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.

This is a transcript from our podcast episode published November 8th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, related 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. Kate Grandbois:  We are so excited for today's episode because we get to basically hang out with two authors of literature that we have read many times over. We're so excited to welcome Cathy Binger and Jennifer Kent Walsh. Welcome Cathy and Jennifer.  Cathy Binger:  Thank you. It's such a pleasure to be here.  Jennifer Kent-Walsh:  We're we're super excited about this. Amy Wonkka:  Um, you guys are here to discuss language development and AAC, which are two topics near and dear to our hearts. Um, before we get started, can you please tell us a little bit about yourselves.  Cathy Binger:  Sure. I'm Cathy Binger. And, um, I, my history, I won't [00:03:00] go through all of it, but briefly, um, I went straight through school to get my master's degree in speech language pathology, thanks to career counseling, figured out what I wanted to do fairly early in my college career. And, um, after that, I spent eight years in lots of different places doing lots of different things, but a lot of that time spent in preschools and that's really, my love is doing, working with those little kids, birth to three and three in the preschoolers. And then, um, I returned to Penn state eight years later, where I got my PhD and where I met Jennifer Kent Walsh. And we have been working together now, since that time. So it's been, we've known each other for, um, over 20 years now and have been close colleagues and good friends for all that time. Um, and so we really, we focus on two main lines of research. One is partner instruction, which I know is another topic near and dear to your hearts, Kate and Amy, and also language development and AAC, which is what we're going to talk about [00:04:00] today. And clearly those two lines of research overlap, but the studies we've been working on are, um, some are more focused on one and some more focused on the other. Um, and that's where we are right now.  Jennifer Kent-Walsh:  Cathy set things up. Well, um, as she said, I did start to roll back the clock to think. Yes, that's right. 20 years that we've been working together in one way or another. So we're excited to be here together today.  It's a little bit on my background. Um, I started out as a public school classroom teacher, um, and then became a speech language pathologist. So my clinical work before, uh, returning to school to do my PhD was in public school and preschool settings. Um, and as Cathy said, I met her at Penn state when we did our PhDs, uh, overlapping in the same time period. And that was really an opportunity, um, for me to start delving into these [00:05:00] topics that we're going to be discussing today in much more depth. Um, since coming to the University of Central Florida, I've been here for what is getting close to 20 years now, um, as well as which is hard to believe. So we do actually, house, uh, house an assistive technology demonstration center with which is associated with our communication disorders clinics. So I'll have the pleasure of collaborating with many clinical, um, faculty and instructors, as well as students as we're providing, um, AAC services and other assistive technology services to individuals on a, a daily basis. So lots of, um, informed opinions and, um, input that we're able to get in that content. Kate Grandbois:  That's awesome. This is going to be such a good conversation and I'm like chomping at the bit to get to it. Uh, but before we get into the good stuff, the powers that be require that I read our learning objectives and, um, financial disclosures. So let's get that over with as quickly as possible, uh, learning [00:06:00] objective number one, discuss the importance of applying a developmental model to aided AAC language learning; learning objective number two, list the language domains that should be considered when providing AAC language intervention; and learning objective number three, describe evidence that supports an early focus on semantic and grammatical development for preliterate children who use aided AAC. Disclosures, Cathy Binger’s financial disclosures. Cathy is employed by the University of New Mexico. She receives grant funding from the National Institute on Deafness and Other Communication Disorders that support her work on the topic that we will be discussing today. Cathy does not have any non-financial relationships to disclose. Jennifer Kent Walsh, financial disclosures. Jennifer is employed by the University of Central Florida. She receives grant funding from the National Institute on Deafness and Other Communication Disorders that supports her work on the topic that we will be discussing today. Jennifer 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 [00:07:00] 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, Mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis special interest group.  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, SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for Children. All right now onto the good staff. Um, Cathy and Jennifer, why don't you start us off by telling us a little bit about the first learning objective. Why should clinicians consider typical language development within the context of AAC interventions? Why is that important?  Jennifer Kent-Walsh:  Sure. Well, that, that is a very broad topic. Um, lots to think about here, but I think as, as [00:08:00] clinicians, sometimes we can get separated from that concept, um, and really, uh, focus on more about what might be different when we're working with kids who are using, uh, aided AAC to communicate as opposed to what is similar to any child that we're working with, uh, and looking at helping them with a communication disorder. So as opposed to focusing solely on the actual, uh, technology perhaps, or whether it be high-tech, whether it be low tech, et cetera, um, we need to focus on what are we trying to accomplish. So how are we trying to help these kids be able to communicate? So if we even track back to if we were looking at a typically developing child and when we would be excitedly anticipating their first words, um, and supporting and encouraging that and moving on from there to starting to put words together into short phrases, moving up to [00:09:00] sentences, et cetera, all of that can remain and should remain within our framework. As we are setting goals and looking at where we want to go with these kids and how we want to help support them, get there step-by-step, to be able to be independent communicators who are able to put together their own thoughts, their own sentences and their own wording so that we know their personalities as well. Amy Wonkka:  I think you make such a great point as somebody who has worked in the, in the field as a clinician, um, with folks who have complex communication needs for such a long time. Um, I think you're right. I mean, often we do, we kind of turn AAC into this special, separate different thing and disconnect from everything else we know about language development, um, and you know, clinically that's not serving the best interests of our clients. Kate Grandbois:  And I see that throughout, I agree, Amy. And just to piggyback on that thought, I see that as a common thread, [00:10:00] across a variety of different aspects of AAC. So I see it as part of the evaluation process. I see it as part of, um, implementation, um, as part of my job, I train a lot of SLPs in AAC implementation. And often a question I get is so, so how do I do this? How do I do language therapy like that? Because there's this extra thing. All of a sudden it becomes a different task that we, you know, well, I, I'm a speech pathologist. I know how to do language intervention, but not with AAC. Well, it's still language intervention. A lot of the skills that we have as SLPs still apply. But for some reason, because there's this extra tool, there's extra thing. It becomes this very intimidating foreign alien activity.  Jennifer Kent-Walsh:  I think that's a really good way of putting it. When you mentioned the extra thing, that that's where we tend to shift our attention for, for whatever reason and, and get a little [00:11:00] hung up on that, as opposed to really looking at how are we setting up this interaction or how are we helping to facilitate an interaction between the child and someone else? What is the purpose of this, as opposed to just, what do we do with this tool?  Cathy Binger:  Yeah, those are all excellent points. And one of the things I, um, when I give talks, one of the things I tend to talk about a lot early on in my talks is what are your goals and objectives and are your goals and objectives that the team has set for the child? Do they look like the same kind of goals and objectives for the other children on your caseload who don't use AAC? And if they look wildly different, that's something to re-examine. Um, because the focus is, should be like big C on communication in AAC, right? Like I even put that in my PowerPoint notes, I do two small A's and a giant C, right. The focus is communication. And to just remind SLPs that we know a lot about communication, we know a lot about [00:12:00] language and that I think that can help be a doorway to help them kind of get over the technology a little bit. Like it's not about the technology, it's about communication. It's about language in whatever ways we can put together to help make that happen. But, you know, for starting with goals and objectives that are similar, or, you know, even exactly the same with possibly the addition of in whatever communication mode versus, you know, via speaking, right? Like the child will do such and such with her speech rather than the child will do such, or will do you know, will do you can accomplish this language goal using any form of communication, um, rather than just spoken language, then hopefully that helps keep that frame and that focus for the whole team on the language itself. Um, which is where it's all about.  Kate Grandbois:  I can agree. I couldn't agree more. And as you were talking, I was thinking about all the different aspects of technology and how they [00:13:00] sort of remind me of a phrase my husband says all the time, which is don't be distracted by the shiny penny, meaning, you know, the technology that we use might be capable of a whole bunch of different things that we want to participate in, or we want our student to be able to access. And that distraction might not be in line with the, I'm just thinking about, you know, this idea of the developmental language and the developmental model, those shiny pennies, those features might not be in line with the what, with what exactly what you said. The C the big C the communication goals and the goals and objectives and example that comes to mind is something I see a lot, um, where there might be an objective written for a two word utterance, because the way the buttons are programmed, you have a, you know, the initial words such as eat automatically directing you to a second page. So there's this, there's this feature of linked icons that are going to, [00:14:00] auto-generate a two word utterance, but is a two word utterance actually appropriate from a communication objective? Or do you have it in there because the technology is programmed that way. I'm not sure if that's a decent example, but, but the shiny penny can be really difficult to ignore. Amy Wonkka:  I was having kind of similar thoughts where.  Kate Grandbois:  I feel awesome. It's very validating for me. Go on buddy.  Amy Wonkka:  One obstacle, I think for, for clinic, I mean, I've been doing this a long time and one thing that's challenging for me is that depending upon, you know, thinking specifically, I guess, about high-tech aided systems, right? So for people who are listening, you know, those are kind of what you think of as your, as your standard communication device, you press an icon or a sequence of icons and a device speaks out loud. Um, I think one deviation from using a system like that, like an aided system is that it does have capabilities that are, you know, [00:15:00] natural or oral speech doesn't. You don't necessarily have, you know, a two-year-old who's able to generate a multi-award phrase. Motorically, they're just not doing that yet, but with certain aided systems, you can do that. So I think that can also be a confusing factor, um, for the clinician. And you're trying to balance all of these different pieces in your therapy, trying to think about the pragmatic piece. You're trying to think about the reality of these like operational demands, which, you know, kind of talks about needing to push the buttons or do different things to make the device say things, you know, those are things that are kind of unique to an aided system that's using something external from your body, but you know, it is kind of confusing because you can do that. You can, you can ha I guess maybe it's the shiny penny example, but there are some shiny penny aspects to speech generating devices.  Cathy Binger:  Yeah. That's I think all of that, um, that's one of the [00:16:00] reasons why we just come back constantly to a typical developmental model because for most of the kids we work with, if not all, I mean, even, yeah. Okay. I mean, yeah. Well they'll just say all kids we work with, I don't know the better model that we have to work with and to look at what is it that happens in typical language development and what is it that's going, where, where does this child I'm working with, where are they fitting into this? And this is getting into the second learning objective a little bit. Where does this fit into in the semantic domain and the syntactic domain in the morphological domain. And let's not forget narratives too. I mean, little kids start storytelling really early on. So getting beyond that utterance or sentence level and into how the sentences linked together. Um, you know, again, we're all of us here. We're all speech, language pathologists. And focusing on that language piece, we need to understand where they fit into all that. Now is that [00:17:00] easy with a kid who's got all kinds of stuff going on. The may have motor issues, sensory issues, cognitive issues, et cetera. No, but, um, there are certain things that I think we can do to help us figure that out. Um, one of the things that we do all the time, and this is what the giant caveat that I know you can't do this kind of thing with all of the kids who need AAC, but whenever it's possible, we always test their receptive language. Um, now you have to think about whether or not, those test results are going to be valid, right? Like some kids, you may be testing behavior more than you're testing their language. So they, you know, using standardized testing, isn't going to be valid for all kids. But whenever we can, um, actually for every kid who walks through our door, we at least attempt and we usually finish, um, attempt, uh, testing their receptive language. So, um, this is like, there's a thing out there in the world with people who've gone through [00:18:00] masters programs of don't use age equivalent scores. And I think that the reasons why we shouldn't be using those scores and reports and, um, for other purposes, those are really valid reasons. However, I think there's one really, really valid reason for using age equivalent scores. And it's for the purpose of helping us figure out where approximately should we be aiming for, with expressive language. Okay. So let me pull that thread and explain that a little bit. So, you know, let's say I test a child with down syndrome and test that child's receptive language and the child is six years old and his receptive language is going to come out at, let's say, you know, below the first percentile you use the usual scores, the standard scores, and they're all going to be way, way, way low, right? They're going to be less than first percentile and a standard score of, you know, whatever they're going to be really low and not, and everybody's going to say, yeah, this kid's really [00:19:00] low. What did that tell us? But if you look at the age equivalent score that child's age equivalent score, who's below the first percentile, it could be at a two year old level. It could be two and a half year old level. It could be three-year-old. It could be three and a half. Right. So because their raw score is different, but there's also low compared to a normal six-year-old with normative table that there's still like there's variability in that functioning. And that's really useful information. And the age equivalent score pulls that out for you and helps contextualize that. So if that child is a six year old, who's got the receptive language skills of a three-year-old. I'm like jumping up and down for joy, because think about what a three-year-old does. Right? And again, we're going back to our typical model of language development. A typical three-year-old is using approximately a thousand words expressively. A typical three-year-old is putting together grammatically complete sentences, [00:20:00] simple, but not always simple. A typical three-year-old has a range of early grammatical morphemes. Some of which are mastered and some of which are emerging and, you know, establishing, but most of them are coming in, if not all of them by then. So there's this, you know, and then if I look at, okay, so then what does a child actually dom child with down syndrome who's relying on his speech? Well, he may only be speaking in two word utterances. Well, that's a total mismatch with where my expectations should be for that child. Um, given his receptive language ability. And so, you know, we know with Down syndrome that kids tend to have speech skills that are significantly lower than their cognitive skills. And that's really getting in the way, it's not just their cognitive skills that are driving that limited language. It's also on top of it additional speech disorder. That's probably keeping [00:21:00] that kid from reaching their expressive language potential, and that's where AAC can really come in and fill that gap semantically and grammatically, when I say grammatically, I mean, both semantics and syntax. So all of those things are like that using that developmental model, using your tests for the particular purpose of helping you frame, where you are in space and what kinds of language goals you should be setting all that kind of stuff. It's really useful.  Kate Grandbois:  I think that's true for a variety of different, if you're looking at, you know, the student that you're working, whether the client that you're working with, looking through that lens is applicable across the board, too. So thinking about our more emergent learners, um, who may or may not have complex needs, they may or may not have complex presentations of how they're communicating in terms of behavior or in terms of, um, persistently asking for the same thing. You know, I think a lot of times our, you know, these [00:22:00] kinds of students can get miscategorgized. As, um, you know, because there's an AAC device there, we're not really looking at it through that developmental lens. When in reality, an emergent, typical peer is going to tantrum and they are going to persist and, and ask for the same thing over and over and over again. And I think we often forget, at least, you know, in my, in my clinical world, forget. Oh, but you know, constantly having that backdrop and comparing to the backdrop of what you would expect in typical development at a certain level can really change the way you problem solve when, when you're trying to either write goals and objectives or train communication partners. Um, it's a really good check and balance. At least I think for me in my clinical work, in terms of problem solving, when, you know, there are other ancillary issues related to the expressive language stuff,  Amy Wonkka:  I just wanted to comment on the receptive language [00:23:00] piece. And I'm going to say I'm one of those people who was, who was told don't use the age equivalent. And I think that that's such an interesting point number one. So that's probably going to shape my practice moving forward. So thank you. Um, but, but also just don't forget about receptive language and that's something that I have been guilty of and I'm sure there are other people listening to this podcast who, when we, when we focus in on AAC, it becomes like 80, 20 expressive emphasis. Right. So, so kind of back to Cathy your earlier point, look at your goals and objectives and see are they in line with what you would be targeting? You know, if you, if you didn't have this AAC layer on top of it. And I think that's another piece where we may see that mismatch. We might see, oh geez. Of course we would have receptive goals and objectives because when we did our receptive language assessment, we identified all of these areas that, you know, we [00:24:00] want to target. Um, and we sort of forget to do that. So I think that that's another piece, just kind of back to that first learning objective. It's not a developmental model, just in terms of expressive communication. It's a development, it's a developmental approach for language umbrella.  Jennifer Kent-Walsh:  I think that time that's taken and really looking more depth at the receptive language. So whether that be through a standardized test or further probing, um, et cetera, that that really can push us away from just focusing on the vocabulary, excuse me, that the child is using for example, and really forced us to think about all of those domains of language and how we're going to help these kids transition and continue to progress. So if we just take it from, for example, sometimes what, um, might be shared with us about these are the words that the child uses, for example, which is very helpful, but that's not the full picture. So if we take that [00:25:00] time to delve in a little further, as Cathy was mentioning, in terms of the actual assessment of the receptive language, we start to immediately sort out and look at, okay, what are some appropriate goals? And next step in all of these different areas.  Cathy Binger:  And just to piggyback off of that, um, the, there are lots of ways to look at, as Jennifer was saying, there are lots of ways to look at receptive language. So I talked a lot about those normative, the not using normative data, but yeah, there's all kinds of, you know, you can make your own probes up. You can use dynamic assessment which you guys have talked about in the podcast a few times previously, and we've done a little bit of work in dynamic assessment as well. And it's really informative to do that. You know, basically using a teach test, teach, test approach, to see and get a feel for where kids are. And you have to be really careful with that with our kids who use AAC. I mean, we need to do it, but there's gotta be teaching in there and not just the testing because. [00:26:00] You know, kids, aren't walking around seeing lots of people using AAC all the time and it's, it's new to them. And even if it's not new to them, it's still, they're not getting the same kind of input. You know, it's just, there's a lot of different stuff. So we need to be doing teaching with them to make sure that again, like, are we measuring behavior? Are we measuring unfamiliarity with symbols or are we really measuring receptive language and expressive language? So having enough exposure, interactions, prompting, et cetera, and taking the time to, and, you know, using it, not just as an assessment session per se, but throughout intervention that we're constantly assessing. We're constantly learning something new about these kids, these complex kiddos, um, to see where they are and make sure that we're have a good understanding. And how many times have we all been surprised at, oh my gosh, I had no idea this kid could do this. Right. But we need to be open to that and looking for that, um, all the time. Kate Grandbois:  And what you're saying is making me think about you sort of going back to an earlier point in the [00:27:00] conversation, the, how this ties back to our goals and objectives and how we write our objectives. Um, in term, you know, objectives are really that connection between our measurement, our assessment and our intervention. And, um, you know, how looking through that lens again, having that extra thing there on the table, how is that going to impact your objective writing and your goal writing for both short-term and long-term Thinking about goals and objectives and our second learning objective, what are the language domains that you think really need that clinicians really need to reflect on when they're considering both short-term and long-term goals and objectives?  Cathy Binger:  So one of the things that, um, we've seen so much, and I think others have as well is the fact that, um, there tends to be a really heavy emphasis on pragmatic skills and, you know, and all those [00:28:00] social skills and those, those things are really important. Things like turn-taking and, um, and all the rest. And, um, and the, and that's both in clinical practice. And we also see that in the research literature, that there's been a lot of evidence showing, you know, different ways that we can enhance those social interactions using AAC. And that's all really important. And there are also, again, going back to that typical model of language development, um, the other domains come in really early on. Right. Um, so pragmatics comes first long before kids say their first words. They're refusing things by throwing things they're, um, showing interest in things by smiling or reaching out. They comment by holding things up and vocalizing, they hold up something fun and look at dad and want to, you know, as they have early joined attention and want to have a shared point of reference and kids do that [00:29:00] sort of stuff, um, without words, and then also requesting of course, too. And that's probably the, the, um, pragmatic area that people tend to hit up the most in AAC. Um, I think for lots of reasons, um, but that's just one piece of things. So, you know, within pragmatics we need to be looking beyond requesting very early on for a lot of the kids we work with. Because again, in typical development, kids are doing those things before they ever even say their first words. So one point of it is blowing up the pragmatic realm. Um, and then, okay, let's look at the, at the next domain that comes in. Well, the next domain that comes in is semantics. When kids start saying their first words or, you know, understanding their first words, we were talking about receptive language and then using their first words. That's the semantic domain and this amazing, amazing vocabulary explosion that kids have. Again, both in terms of receptive and expressive language. Um, kids just [00:30:00] love learning words. It’s so fun and exciting to have new words for things. Um, I used to have this great video of this kid who was going through a grocery store, just like pointing and everything, and he's in the cart and mom's pushing him and he’s saying, what that, like, what's that what's, that what's, that what's that and wanting labels for everything. They want to know what these things are called. They don't just want to use general words. Um, you know, kids playing with vehicles and the two cars are running into each other. Is it fun to just say go, no, it's fun to say crash, like crash is a really fun word and being able to have that word and use that word is really inherently motivating for kids. And they're just sponges for vocabulary. And, um, it's easy to, you know, so, so that's, that's a whole do-, huge domain in and of itself. Like all the different parts of speech and kids are using all the different parts of speech very early in development, even things like articles. [00:31:00] Um, you know, people tend to throw those out and not worry so much about words like a and the but the next book you read, try either deleting every, a and the, in the sentence or switch the words a and the, in the sentence, and you will realize very quickly how important the articles are. They're very important to communication. They specify definite versus indefinite references. Um, and kids use those super early in development. Um, so you know, so that's semantics. And then when do we hit syntax? We hit syntax and typical development at about 18 months. When kids start combining words, 18 months. Right. We're talking about babies here and they’re combining words. And, um, so that's, and then very quickly learning, you know, that kids tend to combine words and rule-based ways very early on. I mean, right away, they, they, they are using rule-based utterances. They don't tend to mix up word order and spoken language and they get that and they start learning [00:32:00] those underlying rules of how can you combine words? And it means something different to use these two words, three words in this order versus that order. Um, I'll give you a quick example from a study that Jennifer led where, um, we taught kids to use sentences such as, um, she's in Orlando, so they were Mickey mouse characters. So like, um, Mickey pushes Goofy versus Goofy pushes Mickey. Those are two completely different things. Two completely different propositions there. I think they were. Um, is Mickey singing. Mickey is singing. They're the same three exact words, but one's a question. One's a statement. That's syntax. Like you're not, if you have the same three words, but you order them in different ways and it means something different that’s not semantics anymore. The kid knows is and making and sing, but learning that when you put words in a different order, it means something completely different. That's really important. Like again, kids are doing that really early in development. So focusing on [00:33:00] syntax early, um, is important. Okay. So we've got pragmatics, which we need to look at broadly. We've got semantics, which is super exciting and really important with all parts of speech. We have syntax, which is building those utterances and learning how words should words behave and what they mean in different placements within the sentence. And then we have, um, morphology and specifically gram, um, specifically grammatical morphology, right? Um, bound grammatical morphemes in English like plural S third-person singular S possessive S progressive ING past tense, E D and then the ones we don't talk about as much, ER, and EST like fast, faster, fastest. Those kids are using those really early in development too. And, you know, they are super important, like the verb morphology in particular, it sets a place in time. Am I talking about now? Or am I talking about something that happened in the past? Am I talking about something that's happening? That's in progress or something that's more [00:34:00] static. And though that verb morphology or is huge, those are huge cues. And the thing I think about one of the things I think about a lot, is why is it the kids get these so early in development, they get them because they're useful, right? Nobody's teaching them on a meta level. Oh, you just use a present progressive ING now that's, you know, like, no, like that's not what a two and three year old is doing. They're using it because they hear it. It's meaningful and it's important. And it shares critical information. And again, when we're having to make hard decisions about what words we're giving kids access to, what morphology, we're getting kids access to when there's limited real estate, right. And limited number cells on a display, they're hard decisions to make. Like there's no two ways about it. If a kid's got motor, motoric issues and it's only cognitively so far and can't have access to a hundred pages navigate, you have to make some hard decisions with the team. And we also have to keep all these things in mind while we're making those choices. And, um, just blanketly saying, [00:35:00] oh, like we don't have room for any of that. So we're not going to deal with any of that. I think we really need to get away from that and keep these domains in mind, keep normal language development in mind and keep constantly. One of the things I've been talking about a lot recently in talks is I'm never going to get it all right, I'm going to miss something. I'm going to be missing something a hundred percent of the time. The thing is, I want to know what I'm missing. I want to be referring to that normal developmental model, know exactly where the strengths are of the approach that I'm using, know exactly where the weaknesses are and be thinking constantly about how am I going to start plugging in those things in the missing, how am I going to plug in those things that are missing and not just get stuck in one approach? Um, you know, one approach is always going to get you into trouble in the long run. Um, so that wasn't one, but there you go.  Jennifer Kent-Walsh:  Well, I think you're, um, if we just go back to earlier in the conversation, when we were talking about not [00:36:00] getting distracted by the shiny penny or the technology, et cetera, but what, what you're getting into there, Cathy is really the magic of leveraging. Then some of those features of the technology to be focusing on all of those domains that you were just discussing. So the technology allows us the opportunity to do that. If we're talking about high-tech and again, I want to circle back to it. We're not always using high-tech, but when we are, uh, we can really maximize, uh, those features to ensure that kids have access to all of that, those useful components of language that inherently make sense to them to use. And in many cases, it really doesn't take that much to get them over the hump to start using them up through the technology.  Cathy Binger:  Yeah. And one more piece to tap on to that is what I call the both and approach, right? Just because I'm using, um, one approach, uh, for a percentage of the [00:37:00] day, because it's easy, it's useful. Everybody knows how to use it. I can train a whole bunch of people how to use this one approach, right? That, that makes a lot of sense from a partner perspective, et cetera. That doesn't mean that's all we're doing. Right? So if that approach is limited, let's say in terms of semantics that their kids only has got at the only kid only has access to so many words. There may be other specific times when we're making sure that we're also working on vocabulary expansion. Right. And giving kids access to those things. So it's again, it's I get worried when I see folks locked into one and only one approach and not using the technology as Jennifer was saying for all its power to bring in all of those other pieces as well. Um, so I just want to make sure we're keeping in keeping an open mind, looking back at normal development, looking where we're doing a good job and looking where the holes are and, and working toward ways to [00:38:00] fund into fill them in. Kate Grandbois:  One thing that I was sort of reflecting on when you were talking, when you were, you know, reminding us of how much development happens in such a short period of time and how these linguistic constructs are being used, because they're useful. Not because someone taught them how to do things. It reminded me of how messy that period of time is and how many mistakes kids make, um, my son would ask me to spoon things for him and I couldn't understand what, what you want me to spoon your, your, your milk. He wanted me to stir it, take a spoon and spoon it mom. Right. It made no sense, but I figured it out and he made that error for probably longer than he should have. But, but it's fine. And I think sometimes at least in my experience when there is a system, we sort of tend to expect perfection. Um, an example that [00:39:00] comes to mind is recently one of my, uh, students who is an emergent learner, um, relatively small vocabulary size, maybe 25 words kept asking for soup and soup meant cereal and soup meant chili. It was the bowl and the team was, This is an error. This is making a mistake. And I was like, hold the phone, guys. Let's think about this where this child is in their development and kids make mistakes. I also think this speaks to the nuance of the environment when kids make when, when they do make mistakes. So I didn't see my son making a linguistic error and then drill him at the desk with a whole bunch of, well, that's wrong. And this is how we say no, I modeled it for him. And we talk, you know, we use natural language, um, discourse and modeling and all of those kinds of things and how some of those components and AAC intervention are so important. Not only acknowledging that kids do make mistakes and that's [00:40:00] totally okay, but using those nuanced opportunities to recast and to model and to create opportunities for exposure and pairing symbols and all of those kinds of things, instead of expecting this perfection, you know, because there's an icon for chili, you should know a hundred percent of the time, the difference between chili bean, chili and beef chili and Turkey chili. Well, that might not be developmentally appropriate. I've sort of gone off on a tangent about my example, but I think I hope that sort of illustrates it.  Cathy Binger:  I think that's a great example and it shows this progression of vocabulary development, right? Kids um using that spoon for stir. They're not using the word filing cabinet for stir. They're using the word spoon for stir. They're using something that is semantic related and they're actively very actively building those semantic networks, which are crucial. Right. Um, you know, linking all those words [00:41:00] together. And how does this word link to that word? Okay. We've got spoon, fork knife, but we also have bowl and we also have eat and we also have lunch and breakfast and dinner. And we also have mom and dad and sister, cause they're usually around when I'm eating like that, you know, are just so many ways that, that we're we're and we have to, you know, find those contexts, link those things, et cetera. When we, um, don't give kids access to rich vocabulary. And I'm talking, you know, rich forbs, rich nouns, um, as well as the closed, um, parts of speech, like the articles, um, we're potentially stunting their growth, like stunting their semantic development, um, as well as making them want to sometimes, you know, throw their device across the room because they just know they just don't have access to the word that they actually want to say. Um, so you know, all those things are, are really important to, to keep in mind. Can we, again, the [00:42:00] expectation is not perfection it's expectations. Not that we're going to get it all right. We're not going to get it all right. We're not be able to do everything at once. Um, but knowing where, knowing that the importance of those things, remembering that and seeking ways to bring that into our practice and using the way that, like we see this so much, right. With our kids who are over, um, using, uh, it's showing, um, good capacity when a child is using a word, that's not quite the right word, but they're still trying to tell you something with their AAC device. Right? You guys you're both have big smiles on your faces. Cause this happens to you all the time. That's like, ding, ding, ding. Here's a word I need to make sure this kid has. I hadn't thought about this before, but I need to make sure the kid has access to the word stir. Um, because Kate, you eventually, as your child's mom figured out what that was, I mean, you know, is everybody else gonna figure that out? Like, no, they're not. And it may make it's makes for commun, it makes for communication, breakdowns and all that stuff, [00:43:00] as well as, um, not supporting the child's semantic development and there. So I'm going to tell you one quick story about this because this one just like I can get, we'd be thinking about it. One of the, one of the kids I worked with early on, it was actually my dissertation. Um, he had, uh, yeah, and, um, uh, DiGeorge syndrome. Um, and he was just, he was so bright and he had so much to say, and he just had no way to say it. He was almost completely unintelligible. And his, um, there was someone in his life who drove a tractor trailer truck, and he used to go and he was three and he would go riding around and his relative would talk to him all the time about, about all the trucks. And he, this kid was so interested in vehicles and all the big, big vehicles, the front end loaders and the bulldozers and this and that. So I went home one night and I made him a page. And I tell you, I learned a lot that day. Cause I didn't know, there was such thing as a sleeper car. I made him a page with all these different vehicles and I didn't know [00:44:00] the difference between a front end loader and a bulldozer. And at this point I can't say that I do anymore either, but anyway, um, you know, I had all these other vehicles on it and I took that, that display and to him the next time I saw him, I have never seen a happier child in my life. I mean, I thought he, he just came jumping. He was like jumping around the room. He was so excited and, and his, uh, one of his family members was in the room and he was just like hitting the buttons and, and hitting the cells and making them talk and looking at his grandma and jumping up and down. I mean, vocabulary is exciting and motivating for children. He had been trying to tell stories and wanting to differentiate at age three, between a sleeper car and a bulldozer. And all he had was. Like he couldn't do it. And so it's limiting his narrative development, right. Wanting to tell these stories. So that stuff is so, so, so important,  Kate Grandbois:  But also hats off to you for identifying vocabulary that was meaningful to that little person's perspectives and values. [00:45:00] And I think sometimes we get stuck in this. Well, these are the top 25 words that you need to know, because I say so, or these are the classroom words that you need to know, because I say so, and then we so quickly fall into this trap of, because there's this extra thing that we need to teach you in this really structured way. The thing becomes, becomes equivalent to sitting down and working in my classroom or sitting down and working somewhere else instead of language, which is fun and socially connected. And, you know, I think that at least in my experience, I see, I see that a lot and this tendency to choose vocabulary. That we have assumptions about instead of axle wheel or I don't know, brakes, other, whatever, you know, vocabulary is relevant and reinforcing and empowering to that individual,  Amy Wonkka: Which is what we would do again, just going back to, if we saw [00:46:00] a student and we were working on their oral speech, um, those are some of the same principles that we would use to guide our sessions. So it's kind of just this continuous theme. Uh, you know, I think in listening to everybody. Another piece that's important for me is just thinking, not only in the moment of where you're writing the school and objective for right now, but also part of how we learn and develop these bigger concepts. Like I, you know, I think about just temporal relationships. How do you learn about and develop a construct around temporal relationships? If you don't have any morphology or words to talk about time, how are you going to better able to refine your ability to generate a narrative or, you know, answer questions about time? Um, similarly back. Cathy, you were just talking about the importance of incorporating all of these different domains in our consideration of our goals and objectives [00:47:00] that also connects completely to literacy. If, if we're not working on these skills, now, if we're not teaching you that you can invert your syntax and create a question, then how are you going to be able to do that when we're asking you to do it in literacy, if you can't do it in your oral speech and Kate and I have had a number of really super interesting conversations on this podcast with folks about literacy, but you know, a prevailing theme is that we typically see those skills in oral communication before you're able to demonstrate them through literacy activities. So all of these skills, aren't even just about like the here and now in this moment as a clinician, they're also important for future access for our clients. So just, it's just such cool stuff. Cathy Binger:  Yeah, all this stuff, excuse me, all this stuff builds on each other. Of course it cause, cause that's what happens in development. That's what happens in life and remember literacy development as part of language development. Um, so we, this is just the [00:48:00] progression of, of how it goes in the, if we're going to violate that normal developmental model and leave off something completely, we better have a darn good reason for it because typically, developing kids do all these things because it's really useful because it's really important because it's meaningful to their lives because it's a way for them to connect more with, with everyone. And, um, I think one of my prevailing thoughts when I see a three-year-old kid walk in the door, the first time is how can I help this kid go to college? If he wants to go to college. Right. And that means building those early language skills, um, to the best, that child's ability, helping them to meet their potential wherever they are. We're not just talking about kids who are intact, receptive language and not everybody wants to go to college. So, you know what I mean, though, like really to just help them meet whatever their potential is instead of shortchanging them. Um, and I just time and time again, I just find coming back to that developmental model, being a great driving, [00:49:00] driving force.  Kate Grandbois:  I have a question that's sort of, um, it's, I'm wondering if it's going to transition us into our third learning objective just about the evidence for this. So, you know, I know you guys are researchers, you’re PhD, you know, you've spent the last, however many years reading and submersing yourself in, in the literature for these kinds of things. What can you tell us about the evidence, um, and reasons for semantic and grammatical development? Jennifer Kent-Walsh:  Well, as Cathy was saying, the, the literature is, um, has been far more focused or there's a history of it being more focused on the pragmatic types of outcomes that relate to intervention. But now we're seeing more of an explosion, um, in this area. And we're looking at interventions that really can help these kids to continue to progress in all of these areas. And of course, we're, we're spending a lot of time right now, focusing on, um, [00:50:00] grammatical, uh, interventions and in our research. And we are seeing young kids and kids with varying receptive language profiles, continue to make progress. Um, so we can do this through some focused interventions in working on, and you all talked about all of the different types of, um, cueing and modeling, et cetera. You know, all of those techniques that we use to make sure that these kids are getting illustrations of what is the next logical step, um, in their, in their expressive language development as well. Cathy Binger:  Yeah, we do see this growing literature base and, um, there've been a couple studies done with kids with really significant impairments and teaching them how to combine. Um, Chris and Tom seems done some of this work where she's from South Africa and teaching kids to combine, um, early two word utterances who have really significant impairments and his was really truly complex communication needs and, um, you know, teaching them [00:51:00] the difference between, um, or that it's important to put the action before the object in English, for example. Right. Um, and, uh, and then some of, you know, some of our work doing similar stuff as well, and then we've done some work looking at, um, it was a little bit older kids looking at grammatical markers in particular. We did a study a number of years ago now with elementary school aged kids and teaching them to use each of them to use three different grammatical markers like plural S, or ING, et cetera. And nobody had expected them to do it. So it didn't really take that much intervention to teach them how to do it. Um, so, so a lot of this is about expectation. Um, some of Gloria Soto's recent work, um, on narratives that's come out and just the past few years has really, I was just looking at this literature recently. And, um, to me, one of the underlying messages of that work, where she focuses on kids, I think maybe starting at six up to maybe [00:52:00] 21, I might be getting that wrong. But you know, there are a lot of older elementary school aged kids, as well as middle and high school aged kids. And, um, they're teaching these kids to not just, you know, well, they're looking at narratives, but they're also looking at causal structure and, and to see the changes that these kids. In the short amount of time that they're doing their intervention, just screams to me how these kids have been underserved. If they can do it today, they would have been able to do it yesterday and nobody had this expectation for them. So there's a strong growing literature, including the work that Jennifer and I have done with our colleagues that time and time again, shows that with, you know, we're talking about kids who are symbolic, we're talking, you know what I'm talking about, kids who are pre intentional, who are trying to throw a bunch of symbols at and who don't have joint attention yet. Um, we're talking about kids who are, who are symbolic, um, who have good, you know, um, receptive symbolism [00:53:00] and with access and some instructions, some growing, um, expressive symbolism. So, you know, our three-year-olds with down syndrome who we're working with right now. I mean, these kids have so much potential to learn so much more language than we're giving to them. And we're talking about kids often, especially the kids that, you know, Jennifer and I work with. These kids are a ways from being literate enough to use their literacy skills to achieve these ends. Right? Like, you know, they're a ways from being able to type out a sentence letter by letter saying, you know, Mickey is singing is Mickey singing, but they need these things early on in development. Again, back going back to typical development, kids are doing these things long before they have enough literacy skills and, you know, second, third grade, if they're typically developing to be able to have enough of those skills, to really use language in that flexible way, this is happening way, way, way earlier in development. And what we're finding is that a lot of kids can [00:54:00] use picture symbols and learn what they are and learn, um, I want to talk about the theory here for a, for a minute, cause I think it's really important like that. Um, with a lot of the kids that we're talking about here. And again, I just want to stress, we're not just saying that kids with normal and receptive language with kids with impaired, receptive language as well, who need a, who have profound speech impairments. They have a lot of language in their heads. There's a lot of stuff that's gone in that they have locked inside their heads. And this is in a way as much as the bigger point is look, you know, it's really helpful to go back to what we know about language and using normal language, developmental model, blah, blah, blah, blah, blah. Um, that what we're actually trying to teach these kids in some ways is quite different. And it's much more efficient because with kids with spoken language impairments who have intelligible speech, and we're just working on spoken language, we're teaching them these new structures, right? They're not using progressive ING or past tense D because they have a language impairment. That's your kids with [00:55:00] spoken language impairment. Our kids may well have been using past tense ED and progressive ING, but they're not because they can't say it and they don't have another way of getting out. And so a lot of these kids have a lot of this language in their heads. And so the task isn't to teach them a structure that they don't know how to use necessarily the task is to take the language that's in their head and to give them a communication mode where they can get it out. Right. And if that's the case for some of these kids, if we give them access and proper instruction, they should take off pretty quickly. Um, and, and we've seen kids take off incredibly quickly. Um, we published a study a few years ago, um, where we had, uh, worked with 10 kids who are three and four years old, um, mostly four, but a couple of three-year-olds and we're teaching them these specific linguistic structures. And one of the ones we were teaching was, um, possessives. [00:56:00] And so there was a, you know, there was an S on the display for them to use. And so we would do, you know, I always use, I don't know why I always say mom shoe, but, you know, dogs, dogs, bowl, dogs, shoe, whatever. Um, it doesn't matter. But, you know, the only expectation I had initially was for the kid to say dog bowl, right. And not with the apostrophe S in there. And these, especially the four year olds, they didn't like the way it sounded. They were getting the voice feedback. And it would say dog bowl, they found the S and they started using the S with zero instruction from me, I think all the four year olds, at least once use that S appropriately before I ever showed them one single time, how to do it. And they, and once they did it, they were like, oh yeah, finally, it sounds like what I wanted to sound like that til they have this. Um, notion in their head, this, um, uh, the right term for it, but they, they know what it is that they want to say and that they haven't ever had another way to say it. And now they finally do with [00:57:00] this device and they're seeking it out and finding it and doing it. So now that's unusual. I mean, you don't see that a ton. We do need to do all together instruction with the tons of modeling and all the other great things that we do, but it's just like that story to me, the lesson in that to me was kids want things to sound the same way that everybody else sounds right. They want to put those markers in. They want to be clear. They want to, they want to have access to those things so that they can get their point across. Clearly.  Jennifer Kent-Walsh:  It's another illustration of underlining the expectation for, um, continued growth and in their expressive language use. And just, we can be surprised, um, others who we're working with their, their, um, other therapists, family members, et cetera, they can be surprised as well. Um, and sometimes it'll take more work than others, but we really limit ourselves when we don't have that expectation consistent in our minds.[00:58:00]  Amy Wonkka:  I also feel like for me listening, it just brings back the importance of kind of doing that ongoing assessment component too. Um, you know, as someone who's, who's done a lot of work with AAC clinically. I think that. You know, it, it feels, I don't want to say easier, but it, but it feels more predictable that transition that you're making, looking at those early pragmatic functions and moving from a pre linguistic, um, to early symbolic communication. Right. And, and sometimes what you guys are talking about is like that next step jump is a bit more challenging as a clinician sometimes to remember, oh yeah. Now that we can do all of these things, we need to continue to push forward in all of these different areas, whether that's syntax, morphology, vocabulary, really, it's all of those things. Um, but keeping all of that in mind. And it does, you know, as the communication partner, especially maybe if you're someone who isn’t super [00:59:00] familiar with the aided system that you're using. That also feels a little bit scary. So I think there's, you know, for the clinician takeaway, there's the piece to be aware of how impactful this is, whether your client is someone who can maybe just pick it up and run with it, which is super exciting in your stories or someone who you're going to need to do a little more instruction, but also don't let maybe your discomfort with knowing the best way to navigate the system or knowing where to find those morphological markers or whatever. Don't let that be a barrier either, you know, get comfortable with those pieces yourself. So that once you've made that transition from those early symbolic communication skills, you're ready to move forward with your client into the next kind of phase. Cathy Binger:  Yeah. And, and to me, Amy, um, one of the things I think is really comfort, can be comforting for SLPs is, is that we know language like when we come back to this, um, it takes some of the [01:00:00] pressure, hopefully off of that thing, off of that device. And let's when we have our starting point, the language, this kid in front of me, just like every other kid I've worked with. Right. They're not so different in what we're going to do is not so different. How, okay. I got to figure out the technological stuff. Not, I don't mean to just poopoo that and say like, that's not, that's not a challenge sometimes. Of course it is. Um, but that's the, that's not the point. The point isn't the learning of that is that I really, you know, we know language, we know language development, we know goals and objectives for kids who have language impairments. And so by bringing all of that into my practice with my kids who need AAC hopefully a big part of that burden of this is so different can start to fly out the window and oh yeah, I do know this. We just got to figure out how to access it, but that's an access issue. But gosh, yeah, there's actually a lot here that I do now. And I think that's really, that can be really empowering.  Kate Grandbois:  I, we've [01:01:00] covered so much throughout the course of this episode. And I wonder in our last minute or so, if you have any parting words of wisdom for our audience, I feel like what you just said was very empowering and inspiring. Do you, and I'm 1000% sure you have some more nuggets in there. I just want to make sure you've been given an opportunity to get them out. Cathy Binger:  Well, uh, I guess the last thing I would say it's more in synopsis, which is, um, a framework that I find to be super helpful is looking at what are we doing well in terms of language development right now with this child, looking at it from a broad, developmental perspective across domains, what are we doing well, and what's this child doing well. Where, which domains have we not been thinking about? Where have we not incorporated enough? So where are the gaps? So what are we doing [01:02:00] well, where are the gaps and how can we start as a team to fill in those gaps so that we can provide children with the rich language experiences that they deserve so that they can achieve their full communication potential. Kate Grandbois:  We're air, high-fiving you through the, through the video screen. Um, Jennifer, do you have anything to add?  Jennifer Kent-Walsh:  I think that's the perfect summation right there. I mean, we're, we're really looking at that functional communication as, as the outcome, not checking off boxes on a standardized test, et cetera. It's really, how are they able to communicate in their everyday environments and how are we able to facilitate those every day? Changing in an appropriate way and then becoming increasingly independent in those environments.  Kate Grandbois:  Thank you guys. And more air high fives, just all the air high-fives. [01:03:00] Um, thank you both so much for joining us today. We, as we always learn so much from, from both of you in your written work, and we learned so much from you both again today, um, here. So, um, if you are listening and you would like to use this episode for ASHA CEUs, you can do so at our website, just go on over to www.slpnerdcast.com and find the episode page. There is also a link to earn CEUs in the show notes. We mentioned a couple of studies today, um, and a few, um, bodies of literature. We will have links to all of those in the show notes as well. So if you feel like doing some additional nerdy reading, they will be easily available to you. Um, thank you again so much to our amazing guests and it was lovely to see you guys. Cathy Binger:  Thank you. Thanks so much. We really appreciate it.

This is a transcript from our podcast episode published January 16th, 2023. The podcast episode is offered for .1 ASHA CEU (introductory level, related 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. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is a course offered for ASHA CEUs. 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 nerdcast.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 specified. [00:00:53] Kate Grandbois:  We hope you enjoy the course. [00:00:55] Announcer:  Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEUs 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 to today's episode. During this episode, we had the great pleasure of welcoming Christi Donovan onto our podcast. Christi is a fellow speech and language pathologist. She is also a traumatic brain injury survivor. [00:02:00] We really feel strongly that as speech and language pathologists, as part of our professional education and professional development, we need to continually be listening to and learning from the experiences of others. And in focusing on those experiences and listening to those stories, we can refocus our clinical lens and continue to incorporate aspects of person centered care, patient centered care. And one of the three triads of our evidence based practice triangle, which is client perspectives and values. We hope that you enjoy this story that Christie is here to share with us and continue to reflect on your own clinical work and how you are supporting and centering the values and needs of our patients and clients. We are so grateful to have had Christy as part of the show, and we hope you enjoy. Welcome everyone to this week's episode, we are so excited to welcome today's guest [00:03:00] Christie O'Donovan welcome, Christie.  [00:03:03] Christi O'Donovan:  Thank you.  [00:03:05] Amy Wonkka:  Christy you are here to discuss life after a craniotomy, supporting patients and families in the healing process. Now, before we get started, can you please tell us a little bit about yourself? [00:03:17] Christi O'Donovan:  Sure. My name's Christi O’Donovan. I am, um, a speech pathologist. Uh, I own my own private practice leading therapy home on the south shore of Massachusetts. I'm a mom of two little kids, uh, liver of a crazy busy lifestyle. Um, and I have had a brain injury through, um, craniotomy.  [00:03:37] Kate Grandbois:  We've only heard right before I thought we were preparing for this episode. You got halfway through telling us your story. And then I said, this is too good. It's too good. You have to, you have to wait. So I'm, I'm on the edge of my seat. Now, wanting to hear more from you and, um, and giving you an opportunity to tell us your story. But before we do that, I have to read our learning [00:04:00] objectives and our financial and non financial disclosures because ASHA makes me do it. So I will, um, get through those quickly. And then we can hear more about what brought you here. Learning objective number one, describe at least two aspects of the physical, psychological, or emotional healing process following a brain injury. Learning objective number two, identify at least two ways in which a brain injury can impact return to work school or integrating into the community and learning objective number three,indicate at least two non-clinical ways to support patients and their families following a brain injury. Disclosures: Christi O’Donovan's financial disclosures. Christie is the owner of a private practice, Leading therapy home, Christie received an honorarium for participating in this. Christi o’Donovan non-financial disclosures. Christi has no non-financial relationships to disclose. Kate that's me, financial disclosures. I am the owner and founder of Grandbois [00:05:00] therapy and consulting LLC and co-founder of SLP nerd cast. 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 therapy and the association for behavior analysis, international and their corresponding speech pathology and applied behavior analysis special interest group.  [00:05:23] Amy Wonkka:  Alright, Amy, my financial disclosures. Um, I am 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, um, member of SIG 12, and I serve on the AAC advisory group for Massachusetts advocates, for children. All right. Onto the good stuff. Christy, why don't you start off by telling us your craniotomy story?  [00:05:48] Kate Grandbois:  I'm on the edge of my seat. I know I can't. Go for it [00:05:51] Christi O'Donovan: . It's a really interesting one. So my senior year of college studying to be a speech pathologist on the way to an internship and I was in a car accident, [00:06:00] um, minor whiplash hit and behind I went, I had submit neck pain, went for a scan, um, after a while not getting better. And I was sat down and told you have a brain injury. You have what's called a chiari malformation. I probably have had it my whole life. They said, no bungee jumping, no skydiving, all things I've already done. And they said just, no, you have it. And then I moved off to, uh, Thailand actually in between college and graduate school. Got some extra massages for my neck pain, went about my life. So  [00:06:39] Kate Grandbois:  can you define what that is? Can you tell us, um,? Uh, yeah. Yeah. Chiari malformation, a chiarimalformation I couldn't say it back to you. I couldn't remember. that's my, my graduate school neurology failing me. But if you could tell, um, tell us what, what that is. [00:06:48] Christi O'Donovan:  Yeah, I'll do my best. So from real layman's terms that it's a slight elongation of the tonsils of my cerebellum are slightly elongated beyond, Um, so it's often, [00:07:00] uh, uh, causes ataxia and typically you'd see patients with like type two type three who may need surgery to remediate. Mine was mostly asymptomatic. Um, Could have caused some of my kind of clumsiness that, or I walk into walls sometimes. Um, but really it was just something they said, just keep, keep an eye on this. Um, so this isn't how I obviously how the craniotomy happened. So, um, kind of fast forward there, I came back. I was, did my CF as a speech pathologist, um, and a busy outpatient center. Um,  got my C’s working and things were starting to settle down into my life. And I went to my PCP once, um, and said, you know, no one follows me for that brain injury that I have. And she said, oh, I'll send you for some updated scans. And then you can have a neur, uh, relationship with a neurologist up, up here in Massachusetts, because previously I was in Maryland when I first was diagnosed and they sent me for some scans. I did [00:08:00] it. No problem. Um, then I get a call after saying you need to see a neurologist immediately and they wouldn't tell me why. And she said, there's some kind thing widening the arteries of your brain. There's something going on with the arteries of your brain. We need to get you in. So I start calling around, have no idea what's going on. I have a slight understanding of neuroanatomy at this point. It wasn't one of my best college, uh, classes in college, but I bring my then fiance. I'm 26, I'm engaged, I'm working a couple jobs, you know, as we all are as new clinicians, I bring my fiance with me and I'm nervous and the doctor didn't get my scans. She's like, I don't know why you're here. They don't, you don't need to follow up for a chiari malformation. And they never, she never got my stand. She's like, I have to go. She sends me away. We're at the elevator doors and she comes. She's like, I need you to come back in my office right away. I got your scans. Oh, she sits me down. She says you have an aneurysm. I need you to see my [00:09:00] colleague. I'm gonna have my receptionist. Um, put you in touch, but I have to go. So that I, I go back and get on the T. I'll never forget this. I miss my stop. I have three stops and I get a call an hour later from neurosurgery booking me, uh, a consult for the next day or something sometime very soon thereafter. So I go to neurosurgery and I have one doctor who says, yep, I'm quite confident. This is the, the treatment for you. Um, it was a minor treatment going up through my groin. Um, a couple, it was gonna be scheduled right away. Uh, so they can go in, take pictures of the aneurysm, get a better understanding of it and then treat it. [00:09:39] Kate Grandbois:  Okay. So let me just recap this for you. You found an aneurysm by accident after an unfortunate experience where there was a massive pump fake where the neurologist was like, eh, go home, wait, just kidding. You're in my hallway. Also, you're gonna be booked in neurosurgery in an hour. That must have been. a [00:10:00] very intense period of time. Uh, you mentioned that you missed several stops on the T I, I am. I, I can only imagine what must have been going through your mind at that point in time. So you go to, I assume you get booked with a neurologist next for your, for neurosurgery and, and what did they, what did they say? Were they helpful?  [00:10:23] Christi O'Donovan:  He said, You're lucky you found this when you did. Um, I need, we need to take care of this right away because. They're significant. You're at significant risk of an aneurysm rupture. He said, I know I'm going to book you for something. I think it was two weeks out where they go in through my groin, take a picture of the aneurysm to get a better view of it so that they could see it. And then he wanted, I dunno, was it another week later or two weeks beyond that to go in and treat it through, um, again, through the groin to go up, fill it up with coils. And he said, He said to me, you're young, you're a pretty [00:11:00] girl. The other option is a craniotomy and there's much more significant risks and you're gonna be disfigured. And then he said, so I need you to stay calm. I need no don't lift anything over 10 pounds. Um, and let's take care of this right away for you. So this is behind you. And I went back  [00:11:20] Kate Grandbois:  and I a pause for a second and reflect on the insane, the insane advice, stay calm. I understand the neurology and biology behind that recommendation, but that seems, that seems impossible. [00:11:35] Amy Wonkka:  It seems impossible. I, I feel like that is, that is a lot of stress happening.  [00:11:43] Christi O'Donovan:  I remember we stepped out and I was with my fiance at the time and I bursted into tears and he was so panicked because all of a sudden he was worried that I was going to have a stroke right there in the cafeteria,  Kate Grandbois: because you were crying  Christi O'Donovan: the hospital. Yeah. Yeah. Just from the stress. And we were in the [00:12:00] process of moving and it suddenly became a don't lift the box don't bend we're we're worried that we have no idea because that was the impression that the first doctor had.  [00:12:09] Kate Grandbois:  So what, so you, I assume, by the way, you're telling this story, when you're saying the first doctor, something about that experience motivated you to find a second opinion. [00:12:18] Christi O'Donovan:  I was sitting around the lunch table. Fortunately, as a therapist, I was surrounded by very smart therapists who were much more seasoned than I was. And one of my friends at the time said, you'll have to get a second opinion. Yep. I guess I should do that quickly. So I booked myself with another local doctor. We did some research and found someone really good because at first it. I didn't even realize I had to be seen by neurosurgery. This was all happening so fast. So I booked myself a follow up or a second opinion. And the next doctor said, I can see this aneurysm just fine. I don't need pictures for it. And no, what the first doctor didn't tell you was that we've only been coiling aneurysms at the time [00:13:00] for nine years. We don't have a lot of research and we don't have much, very little research on your particular aneurysm in the way it was shaped. He said, craniotomy. You have to, you're the ideal candidate for a craniotomy. We'll go in. You'll be fine. Four weeks. You’ll be back to work.  [00:13:17] Kate Grandbois:  All right. That's a very different message. [00:13:19] Christi O'Donovan:  Wow. Mm-hmm and he said you could live with this indefinitely. We don't know. And you'll be, we can book this out six months if you want.  [00:13:27] Kate Grandbois:  So I'm, I'm, I'm reframing this and thinking about it from the, from, from your experience, but also from, in terms of how you advocate. For what to do next, in terms of the trust that you feel with the medical team that is, is treating you, that's a really big difference. [00:13:48] Christi O'Donovan:  That was huge. It was really frightening. Could be a, what felt like a life or death decision, you know, do I go with one that would keep, that was just this minor [00:14:00] quick fix, but then this other doctor was telling me you actually can't trust that this will be around. That this, that this, uh, that there's enough research on this or that this will be a long, a long term fix, or do I go for the long term fix once and for all that had a lot of risk? I went into a surgery, you know, a really scary big surgery, but it would be taken care of once. And for all, there might be risks associated with it. There may, I was told disfigurement, I was told brain injury, but then the second doctor said, no, you’re fine. You're you're young, you're healthy, you're educated. You're you're the perfect candidate go with this. And to them, it's just, he's an neurosurgeon. It's just another day. Right? And to me, I had to make this huge decision and figure out which one to trust.  [00:14:49] Amy Wonkka:  How do youeven begin to sort through something  like that?  [00:14:54] Kate Grandbois:  Well, you're not allowed to cry. Okay. We've established that. [00:14:57] Amy Wonkka:  You're not allowed to cry. Thanks. You're not allowed to feel [00:15:00] anxious, bend, lift anything.  [00:15:03] Kate Grandbois:  Oh my goodness. Okay. So what happened?  [00:15:07] Christi O'Donovan:  So ultimately decided to take the risk and fix it once and for all the, the thought of at the tennis 26, 9 years, not knowing what could happen in nine years, this colleague said to me, you could still be having babies in nine years. Could you be delivering and could your aneurysm, could the coils dislodge or, you know, there just, it felt like there wasn't enough research on it for me to make that decision. So I decided to go with the craniotomy and I was told you'll be to work for, for four to six weeks. You’ll be back. Good as new [00:15:45] Kate Grandbois:  So science is amazing and wild, but continue.  [00:15:49] Christi O'Donovan:  So I booked my surgery with that second doctor who wanted to do the craniotomy. Um, and I took a, you know, temporary leave from my [00:16:00] job at the very busy outpatient center. Um, I went through the surgery, it, um, what my recovery, I honestly don't remember a lot from right before the surgery and right after my memory loss around that time was really significant. Um, I just, I try, I was barely sleeping. My sleep was really impacted. Um, I had a lot of trouble with my emotions. I had a lot of trouble with noise. My sound sensitivity was really significant. I was not at all prepared for that. If we were, uh, out, we, if we were out to eat, I remember trying to go out to eat a lot because I wanted to feel normal. And if there was any kind of noise, I would be really disturbed by it. Um, I would, if a sudden noise happened, like my whole body would go into sweats. I decision making became. Impossible. Just multistep directions became really hard. I remember [00:17:00] trying to cook a meal. Um, I remember trying to watch television shows. There was this intense show that we, we tried to ever watch breaking bad. We tried to watch that after I was recovered for my surgery,  Kate Grandbois:  I tried but I couldn't, I couldn't watch it. That was too intense.  Christi O'Donovan: I couldn't, I couldn't handle anything. Oh, it was really difficult. So I was just going through, um, I guess I should have mentioned right in the afterwards I did ask if I needed to be evaluated by a speech pathologist, did I need someone to evaluate me? And I think I had a quick screen in the hospital in, in the neuro ICU. Um, and they decided. No further evaluations were necessary and I was discharged. So that's, um, what led me to this point, but I got home and in my early days of recovery, I reached out to my friends from graduate school, speech pathologists, and I, and I asked them to come over and test me. And they brought some, they found some tests from wherever they were working at the time and they came over and did a screen and some of them had specialized in this. So I had another [00:18:00] friend who worked at Spalding and I asked her if she would do an evaluation. And I remember going in and she kind of tried to put together an assessment for me at the time. Um, and, but really no one felt like intervention was warranted. Nobody felt like I needed therapy. Uh, it was just kind of, you need time. Um, so I. Took a little time, couple, think about a month. And I tried to go back to work. I was told, go back part-time for one week, and then you could ramp up to full the following. So I told my supervisor at the time, that's what I was going to do. And she was a seasoned SLP with a lot of experience in brain injury. And she was the only person in my life who was like, sure, you try this. So I went back to my busy outpatient, and I went to work and I tried to treat a couple patients and I had a symptom that I could have never understood before having this surgery. And now speaking about it, it's like it's called brain fog, cognitive, [00:19:00] cognitive fatigue. And I thought that meant you're tired and it's not, you're tired. It's that your brain to me felt incapable of function of like intentional function. I would just stare off into space and I just, I have this, like, I would be incapacitated. I couldn't formulate my thoughts. I couldn't explain myself. I would just cry. And the harder I tried to work, the harder I tried to get back in, the more the cog fatigue would hit, I would just glaze over. But like still try to perform my functions. Right. I felt like I should be able to, and most people wouldn't notice. It was just my husband who was really who had noticed then my fiance or, um, a couple of my colleagues who had known me before the surgery and met me after. So I would try to go into my office and turn the lights off and try to have brain rest, whatever that meant. But all the while, um, it just kept getting harder and harder [00:20:00] as I tried to push myself. [00:20:02] Amy Wonkka:  And this is sorry, this is after you've been screened and you've been told everything's fine. You're good to go.  [00:20:09] Christi O'Donovan:  Yeah, you can go back to work. Yeah. I remember going back to the neurosurgeon. He was like, you look great. You're fine.  [00:20:18] Kate Grandbois: Oh, and I, I also am just imagining. The emotional burden that this, I mean, you're experiencing physical brain fog. I mean, I say physical because it's not a manifestation of something. It's an actual brain fatigue. You're experiencing a physical symptom, but you are in an indirect way sort of expected to just go back to life when. And there, there, there must have been a, a huge toll that that took in terms of, I don't know, feeling, not just from feeling tired, but feeling like you, you should, you said it earlier, you should be able to do these things. You should go back to [00:21:00] work, but not being able to, to the, at the capacity that you were before. Was that was that hard. I'm imagining that for myself as being a really psychologically and emotionally difficult period,  [00:21:12] Christi O'Donovan:  It was, it, you know, we’re, as therapists we’re trained to identify and treat and we all know you can't turn that off. And then all of a sudden you're looking at yourself and you realize I'm not right, but I looked okay. Right. The swelling went down and I was, I was treating patients who had brain injuries, pediatric patients who had brain injuries. And here I am still very much recovering from my own, but I think because I was able to self, I was so self-aware and I was able to self-advocate it almost maybe made the therapist who evaluated me or, um, the doctors look at me differently and they felt it wasn't necessary. Um, so it, it would be subtle [00:22:00] deficits that really took a toll emotionally that I was aware of, that I couldn't quite get anyone else to acknowledge. And just that I wanted to be done with, to be honest.  [00:22:11] Amy Wonkka:  Well, and that feels like when you're approaching professionals and advocating for yourself and they're telling you that you're, that nothing's wrong. You know, I know one of our learning objectives I'm jumping ahead a little bit is around person-centered care. But to me that doesn't, I, that doesn't sound like it's an example of super person-centered care. When someone is coming to you, when your client is coming to you talking about the, the challenges that they're facing. Um, and you're like, Shshsh, everything is fine. You're you're good. Um, I, I don't know. I don't know if you had the opportunity to ever experience kind of the opposite of that, where you felt like you went in for an appointment and somebody was more supportive of you or was that just kind of consistent across the board? [00:22:59] Christi O'Donovan:  Oh, that's [00:23:00] a, um, I think it was more the people that were part of my daily life that some were really starting to notice, speech pathologists. Fortunately, I was around them, you know, my supervisor at the time, or my friends who, you know, my colleagues, they were starting to really notice. And they were helping me to kind of advocate for when I need to be a little bit more. And kind of take the time. I think I really needed that permission that like, you actually do need time to recover from this brain injury. It, it's not gonna be like what you were told.  [00:23:33] Kate Grandbois:  And you mentioned that you got a, you probably had a screening in the, in the ICU or, you know, post, post craniotomy. And you know, I know you mentioned that you have some memory loss from that. Do you remember any other supports that you wish you had had in terms of setting your expectations? So not just to return to work, but you know, this is a resource you can use. If [00:24:00] you are feeling frustrated or sad or you may experience brain fog. Was there any, were there any resources to help you transition, I guess is my question. [00:24:10] Christi O'Donovan:  Oh, you know what, as you're saying this, I wish there were. I really wish there were, I don't know that I was really given many tools besides just, it's gonna take time. I remember I was trying to do like Sodoku. I was trying to find apps at the time that I could work on. And what I was told is really, you're just taxing your brain so much by trying to work by trying to treat that you don't need more. You don't need to tax it any further. What you need is rest, but that felt really hard.  [00:24:44] Amy Wonkka:  In that healing process. I think that's something maybe we can talk a little bit about too, because it sounds like that rest is a really important piece. I don't know if there are other things that you either did or maybe shouldn't shouldn't do [00:25:00] to kind of help facilitate that healing.  [00:25:04] Christi O'Donovan:  Yeah, I, I think there, I, shouldn't sort of certainly been encouraged to do a little bit more and maybe it was me not taking the direction, you know, but just, um, I think I was just, for me, I was focused. I was planning a wedding and I was just focused on getting back to work and bringing an income back. Um, so I just kept going forward. Um, and. Uh, yeah, I, I think I just, it just took a lot. I just remember taking a lot more time than I thought it would.  [00:25:35] Kate Grandbois:  Did. Do you find that you got most of your support from people who knew you best? You mentioned your husband, you mentioned your coworkers and I'm imagining, you know, in reframing this through a professional lens for our listeners who may be treating someone with a brain injury for the first time, or, you know, our scope of practice is so wide. Maybe they're interested in learning more about treating someone with a brain [00:26:00] injury and thinking of these person centered care components. Um, you as a speech pathologist had this sense to self advocate and to, and to use the resources that were available to you. Um, I'm wondering about. For those who are not in that position for the speech pathologists who are listening, how can they help advocate for, for, for patients, um, in terms of either setting their expectations or I don't know, having open conversations about feelings. I mean, even that is something that I, I think tends to be difficult in a, in an intense clinical setting.  [00:26:40] Christi O'Donovan:  Yeah, but as therapists so much, what we do is really counseling and support. And I think that's where we need to focus more, is really getting to know our patients, truly getting to know them and not just their, their scoring on a standardized test, right? Like how they [00:27:00] activities of daily living are being affected by this brain injury, despite scoring really. You know, and how much of a struggle it is and what their specific needs are and goals and desires. My, I was pretty in tune. Um, but I'm sure there could have been work that I could have done or in the, maybe in those early stages and looking back at now nine years ago, had I done more work or had I received some sort of additional supports would I still be facing when I'm facing? [00:27:31] Kate Grandbois:  And I wanna talk about that too in a bit, but I'm also thinking about. What this is a soapbox, we get on almost every episode for different reasons, but it's so applicable here. And that is that our evidence based practice model is three pronged. And one of those one third of our evidence based practice model is client perspectives and values. So even if in, in, as we frame this [00:28:00] through your experience, even if you had been screened, even if you had passed all the tests and for those who can't see me, I have air quotes going here. Right? So you quote look okay. Right? The swelling went down, you look fine. Your experience is evidence. Your experience as a TBI survivor is valid evidence. It is evidence based practice to consider those variables and if necessary design interventions, or, or find supports and resources to help the person as they define their best outcome. as opposed to, eh, you're within the quote average, eh, you passed the, you, you scored, you know, you scored within one standard deviation of the mean on the test. Mm-hmm , that is not always evidence based practice. And as I'm hearing you talk about these presumably subtle quote, subtle differences that only you and your closest, um, family and friends [00:29:00] were able to discuss or identify, it's still evidence. It's still really important.  [00:29:07] Amy Wonkka:  Well, and it makes me think about the importance of a comprehensive assessment, right? So this is yet another soapbox, I guess, that we get on, but you know, thinking about. When we make all of our decisions or 90% of our decisions are informed by norm referenced measures. We are missing all of these pieces. We're missing the pieces that would come out, you know, the client perspectives piece that would come out in a comprehensive interview we're missing, you know, maybe the more subtle deficits that would come out in, um, more informal diagnostic measures. So I think, you know, that's something that I've been reflecting on in hearing your story, Christie is, it sounds like a lot of these decisions were sort of driven by more of that. Like, well, we do, we did the test, we looked here. Good, good to go. You got the right score out the door, you know? Um, and that's unfortunate too.[00:30:00]  [00:30:00] Kate Grandbois:  So you mentioned experiencing some brain fog, you mentioned, you know, experiencing what I have to assume is psychological or emotional discomfort. And in that transition, um, I'm wondering if you can tell us about how else your. TBI impacted your return to life. I mean, across work, across participating in your community, you mentioned you had a wedding around the corner. I mean, those are some really big life events. Can you tell us a little bit about that?  [00:30:31] Christi O'Donovan:  Yeah. So my symptoms were really interesting. Uh, just like I said, working memory, language formulation, um, a lot of executive functioning decision making. Uh, I don't think that was my strong suit before for sure, but, uh, certainly was compounded significantly, but the, and the, um, well, I remember I have a few really unique ones and they're still lasting sound sensitivity. Large sudden sounds still to this day [00:31:00] and at places employment I've had. They'll always let me know before there's a fire drill because if the fire alarm suddenly goes off my whole body, I have a whole body reaction. Or if my kids pop one of those Amazon pop those pillows, those air pillows suddenly, and I'm not expecting it. I, I get so emotional. Like I could actually cry from it. It's really strange sensation. Like I just, my whole body feels rocked. It's a really strange sensation. Um, even like, I'd be still to this day, if I'm trying to have a conversation and I am listening or thinking about something else, I cannot. Oh, that's hard. It's, it's impossible for me. I can't be typing and listening. I'm just, and um, I think it's just the, the. Um, quick brain processes. Like I really needed a slower pace for a while. So I kept building in more breaks at the outpatient center and [00:32:00] hoping that with breaks in between I would be okay. Um, and it, unfortunately I kept ramping up my hours and then decreasing, decreasing, decreasing. It took about a full, say about a full year before I was fully back to work. When I had been told it would be four to six weeks. And  [00:32:16] Kate Grandbois:  I think that just goes to show the different definitions that we all have of, and again, I'm using air quotes for people who can't see me, but the different definitions we have of wellness. Right. So neurologist looking at, you know, your swelling has gone down, you're outside of the statistically significant window for additional complications after surgery, right? So that's the, the neurosurgeon’s threshold, um, and thinking of our audience as SLP, who are supporting people in your position, you know, the threshold for what is well or what is wellness is to be determined by the patient, not by us. That is, you know, that is not where we are in a position to be inserting [00:33:00] our opinions as we support people. Who are experiencing, who have experienced a TBI. It's making me think of, um, we did an interview last year with a woman named Jenna Mary Rosenthal, who is a speech pathologist, but also a physical trainer and a lot of people who, um, she was explaining that people who have experienced TBI and have lost their mobility. As soon as they have some level of independence, they get discharged, but that person might still want to learn to run again. That person might still want to learn to walk with a different level of ability. Again, that person might want to learn to pick up groceries off, off the, off the ground and put them on the counter. You know, and I, I just hearing you speak about the, the difficulties that you faced while your medical team identified them as, eh, mild or whatever, descriptive word you wanna use, they were still really significant to you. [00:34:00]  [00:34:00] Christi O'Donovan:  Yeah. Yeah. It, it was, it was life changing for me, for sure. And certainly, like, as you mentioned before, you know, planning a wedding in this young stage of my life and it just, everything got so much harder for a long time. And I ended up making a career decision to leave that, that busy practice. For a quieter, uh, slower pace. And so I started my own practice  [00:34:27] Kate Grandbois:  um, for those of us who can't see us, we're all laughing because I think everyone knows owning and running a business is not necessarily slow pace. [00:34:33] Christi O'Donovan:  Yeah. My, my grew very quickly too. I mean, this was a few years out, so I started my practice in 2016. My surgery was in 2013. Maybe it's not that much time in between, but it wasn't originally started with the intention of slower pace of life. But I think what I realized more was that patient care focus. And that's why I set out for this. And that's been one of our, our driving forces is can we [00:35:00] make a difference in our community by providing more comprehensive patient centered care, really getting to know our patients and their families beyond just what the standardized scores tell us. Um, because that's what I feel like was maybe missed from my, in my case. [00:35:19] Kate Grandbois:  I love that so much. I wonder if you could, so we've, we've gone over your, um, acute period. So you experienced your TBI, you recovered in those first four to six weeks. It sounds like there was a slow transition through that first year until you really felt like things were back, back to work, as you said for you, um, how, how, what happened after that? How has the long term. Um, how has your long term, what's your long term healing process been like?  [00:35:51] Christi O'Donovan:  Um, that's a really great, it's really nice to think about this. I've just accepted it. Right. And it's hard to understand. I think I still have a lot of the [00:36:00] deficits that I say my language formulation is certainly not what I used to be. And I have these paraphasias still all the time and most people don't know about my brain injury. So here I am, as this educated speech pathologist who owns my own business I'm CEO, you know, who says these words, that just don't make sense. Um, like I'll just in insert or like I'll use the, the person's name, like the wrong name. I've I've referred to my own children with the wrong name and not like, like recently I referred to my child as my friend's kid. I know my little girl. Um, I can't handwrite anymore. Ever since my surgery and they haven't been able to explain this to me, when I am writing by hand, I insert letters incorrectly. So I might be spelling something as simple as, and maybe not my name, but I might be writing a word school. And if I'm [00:37:00] thinking of the next word, I'll put a letter where it doesn't belong. So I might be, if I'm thinking ahead, I'll insert letters incorrectly. If I'm thinking school day, I might put a D in the word school somewhere only when I hand write, not when I type  [00:37:17] Kate Grandbois:  I would, that was gonna be my next question. Is this, does that happen when you type?  [00:37:20] Christi O'Donovan:  No. So I can't provide handwritten notes to my families because I look like I'm spelling errors everywhere. Cause I have to cross out my letters really strange. Wow.  [00:37:33] Kate Grandbois:  That's very, it's a very interesting intersection of executive functioning, motor connection. Phenology. Probably. I don't know. That's a lot. That's a lot of things. I'm I'm just not talking, cuz I'm gonna describe it shortly.  [00:37:47] Christi O'Donovan:  I know I'm sure there's therapists that'll have a field day over that one. [00:37:51] Kate Grandbois:   Oh my goodness gracious. So the point, I guess the, the takeaway here is even if, as your neurologist said, ah, [00:38:00] you're fine. Even if, even when all a lot of indicators are positive, there are still lasting effects that you experience that you have successfully navigated around. Um, but it's important to take that into consideration from, it's important for the professional to take that into consideration.  [00:38:23] Christi O'Donovan:  I think, I mean, there's still a lot, there's, you know, big like decision making still really challenging for me. Um, emotional regulation, then it's funny, I, people recently have described me as really calm as a really calm presence. And like, I've worked so hard on that because internally emotion, like with that frontal lobe injury that I have, my emotional regulation, it, it requires a lot of work to stay calm and steady. Um, there's just a lot of things. And then as. As a mom, as a busy mom of two kids and a working professional, as a business owner, there's a lot of these skills that I can't help, but wonder [00:39:00] had I not had this brain injury or had I had some more therapy afterwards? Would I still be, I'd still be struggling through them or would I have to put all this extra effort into kind of running a company that, that requires a lot of S and, um, am I faced with this additional hardship? Possibly. [00:39:23] Amy Wonkka:  I wonder, I mean, you talk about how you've had to put a lot of work in with your emotional regulation and all of these pieces. And are you just seeking all of that out yourself? You're using your expertise just as somebody in an allied health field to kind of make that determination around what, what would be a better fit for you to help support you on this journey? [00:39:42] Christi O'Donovan:  Yeah, it's been all self-study and I think that that says something because we. As I am able to, I am aware and I'm able to access the resources, but most of our patients don't have a background in this, right. They, they have [00:40:00] completely different skill sets and they wouldn't necessarily have those same tools and resources that I've had to seek out, or they wouldn't even have that awareness necessarily. [00:40:09] Amy Wonkka:  Yeah. I mean, I'm just, I'm just thinking even your ability to identify, okay, I've got a frontal lobe. I've got, I had a frontal lobe injury, which is going to affect my ability to regulate my emotions and respond to this type of stress. These are things I need to be able to do because I'm a mom, I'm a business owner, I'm all of these things. And I just think about how many people who, who must be in your same position, where somebody determined that they were, they were fine. They were good enough, but they don't know even where to go to start looking for this. They don't, they maybe all they know is like I'm feeling really angry. Well that doesn't help connect you with a solution that's gonna help you like move forward, um, on your healing journey. So that, yeah, I think that's a, that's a big missed area right there.  [00:40:53] Kate Grandbois:  And that I was gonna, I was gonna say something exactly in that same vein is that it's making me think of [00:41:00] this intersection between the healing journey, but also the limitations of our infrastructure. So as SLPs, as any clinician, what threshold of eligibility do you have to prove to get services covered? You know, to your point, if, I mean, you're a private practice owner, I'm a private practice owner. We understand the limitations of billing and submitting for funding for the work that we do. Um, and to your point, you know, when you reflected on it and said, what would have happened if you had gotten therapy, just the limitations of our infrastructure to provide therapy for those who might quote don't meet that threshold, even though they've identified areas of need. um, and what SLP can do to advocate in those, in those instances for our patients to either get funding or create documentation that better supports funding, [00:42:00] um, based on the assessment measures they did by focusing on patient centered care. [00:42:05] Amy Wonkka:  I mean, I think even more, more broadly, and I won't go too hard on my soapbox here, but I, I do think it's sort of a uniquely third payer party centered healthcare problem. Um, so that, so that's another piece too, is just thinking about all of the barriers that our healthcare system puts in place, um, to kind of gate keep services for people based upon their unique insurance plan or what they have access to. Um, so those are also things to think about much, much bigger, much bigger  [00:42:41] Kate Grandbois:  I'm wondering, um, what you can tell us about what you wish SLP having had this experience personally, what would you say you would want SLPs to know about treating individuals with brain injury across any phase [00:43:00] of their recovery?  [00:43:03] Christi O'Donovan:  I think cAs speech pathologists we do a lot of talking, right? We do a lot of talking to fill the room and make everybody feel comfortable and show that we know our stuff, but I think there's, we have to really listen. And, and read between the lines and really get to know our patients and how things are going. I think as therapists, we need to put more emphasis on the counseling side of our educations. Um, I think there should definitely be more done, more work done so that we know how to ask the right questions and really understand how our patients are functioning and how they are perceiving their own journey. Um, so I think if I could leave everyone with one me, like one really strong message that would be, uh, that would be it for. [00:43:59] Kate Grandbois:  I, [00:44:00] we, we, I'm just gonna go ahead and speak for both of us. We totally agree. I think that aspects of counseling touch so many aspects of our field, um, and most of us don't get explicit training in counseling. Um, I'm also gonna. Sort of in, in a similar vein thinking about the person-centered care and the counseling aspects, this goes back to something else that we've talked about briefly is the idea of a comprehensive assessment. So comprehensive assessment techniques can involve a lot of listening. A lot of interviews, a lot of collecting the evidence that is rooted in a person's experience instead of just the scores on a test. That is, again, I know I've said it once already, but that is the evidence that we might need. And you can infuse counseling into those aspects to better support someone in the [00:45:00] longer journey in terms of thinking about, um, how they could be best supported to reach how they define their long term goals. [00:45:11] Christi O'Donovan:  Absolutely.  [00:45:11] Kate Grandbois:  It's very important. Um, we did have the pleasure of interviewing, um, for those who are listening. We did have the pleasure of interviewing Dr. David Luterman on the importance of counseling and communication, sciences, and disorders. Um, and it's free. It's listed on our YouTube channel. I was there for the interview and I've listened to it like five times after that the man changed my life. you're listening Dr. Luterman, which I'm sure you're not. Thank you so much for sharing all of that with us. Um, but yes, I, I just seconded all of those thoughts about counseling and how important that is, um, in all of this. [00:45:46] Amy Wonkka:  as somebody with the lift experience of having a brain injury, are there any important pieces that you would wish providers or even other communication partners would understand about what that [00:46:00] experience has been like for you?  [00:46:03] Christi O'Donovan:  Yeah, they, I think there's actually a lot. Um, it's funny. There's so many deficits. There's so many things that are challenging for me now that I'll mention, or I'll try to speak about, and I get such quick responses, all that happens to everybody. So, you know, everyone is forgetful or they feel like they get scattered or they get overwhelmed easily. I get, and it's actually, I wasn't like this before it wasn't to this magnitude before. It it's challenging when it, it is just dismissed as you know, but look what you've done. Look, what you have accomplished, look at where you are. And like everybody gets overwhelmed or everybody, you know, all of these things, but you know, I could be at, or I could be together. We can all be having dinner. And I'm having a conversation with the two of you, if even for a moment to listen to the conversation of the person who's sitting right next to me, I, [00:47:00] I shut down. I can't do them both. And what that looks like then to the people I'm speaking to. Or if I'm in a professional setting and I'm taking notes and someone asks me a question, I cannot shift back to them because I did not take in even a word that they had said. And yes, it's hard for all of us, these are things that are, I think, characteristic, but. This impacts my every single day, it impact impacts my professional image. Um, and so I think it's really important that we all recognize that, um, there are, there's so much happening beneath the surface. There are so many challenges that we are all working through and we can never understand, uh, them all, really, and for what our, our providers to really, again, listen and understand, and, um, kind of dive into and spend some time on, I think would be really beneficial. [00:47:59] Kate Grandbois:  I also think [00:48:00] based on, you know, the story that you're telling, it's really important to remember that your lived experience is different than someone else's lived experience. So you can never truly know what it is like to be in someone else's skin, how they are experiencing sensory information, how they are experiencing life. And as Amy said earlier today, when you're treating a person you're treating them with, what did you say? All their human parts, all of their personness. So that person is a, a wife or a husband or a daughter or someone who is a student. I mean, with kids, without kids, lover of dogs loves to ice skate. I mean, people are, are multifaceted and multidimensional. And when you have an injury, like a TBI that affects so many aspects based on the story that you're telling so many, it touches everything you do, as you said. So taking [00:49:00] a look and actively listening and not making assumptions about someone else's experience or dismissing their experience, um, is so important. And I feel like as a clinician, if you do bring that bias to the table, if you do bring that assumption to the table, you're going to miss really important pieces. Of clinical evidence to help you in your job, you will prevent that person from sharing things with you. You will prevent your client from trusting you to explain that it's really difficult to do certain things because you know, everybody else says, oh, you, oh, it was, oh, it's no big deal. Oh, you're fine. [00:49:43] Christi O'Donovan:  Absolutely. So perfectly said. Yeah. Yeah. It's really, it's really comforting to hear all of this now I'll have to tell you that. Oh, that's the acknowledgement. Maybe I was waiting nine years for that.  [00:49:57] Kate Grandbois:  well, I'm, I'm glad we were able, we were able to do [00:50:00] that for you. That's not really the point, but that's, that's a nice benefit, I guess. [00:50:04] Christi O'Donovan:  Um, But if therapists are passing that message along to their patients, right. That's what it is. Can have that conversation if they could have taken those notes and right.  [00:50:15] Amy Wonkka:   And it shouldn't have taken nine years for someone to have that conversation with you. Um, and I think, you know, it, it's still, I know I've said this a couple of times, I think it, to me, it comes back to when we're doing our client interviews and having that interview process happen on an ongoing basis and really thinking about the questions that we're asking and the way that we're asking those questions. Um, so that, because I could, you know, I could frame a question about going out to eat and switching attention and how that experience is for you in a way that makes it more likely you're going to share your actual challenges and describe those for me. And through that I'll know more about also how it seems like emotionally, you might be feeling about that. Um, rather than, you know, [00:51:00] having you just check a box and having me look and say, it looks like sometimes, you know, switching between conversations, it's hard. So I think that's also a takeaway. Clinically for me is to really try and be thoughtful about what questions we're asking and how we're, how we're opening the door to those conversations, um, with our clients.  [00:51:23] Kate Grandbois:  So to recap in terms of our listeners who, and in, in thinking about our third learning objective and how we can better support patients and families who are recovering and healing from a TBI, the importance of not only actively doing some actively listening, actively listening, you get my point purposefully engaging in active listening. Purposefully infusing per person-centered care and active listening through a comprehensive assessment to really let the patient drives some of the treatment outcomes, [00:52:00] but also advocacy, making sure that there are additional transitional supports in place, making sure that all of those components of the healing process, the physical, the psychological, the emotional, all of those are, um, are addressed and the whole person is being is in the center of, of all of your treatment. Um, I, I, it did make me just think of a question. What were the helpful components of, of the support that you received? What was really posit, what was the positive impact for you across those different domains?  [00:52:41] Christi O'Donovan:  You know, what was a really interesting one? Exercise. Exercise was one of the things that helped me the most, especially when I was having cognitive fatigue and I had never been a runner before, but I suddenly got into running and I found it really helped. Um, so a therapist had recommended that to me, or maybe it was a friend of mine had recommended [00:53:00] trying it. And that, that was a really helpful, um, strategy that I had never would've come, never thought of on my own.  [00:53:08] Kate Grandbois:  Interesting. And again, I'm thinking back to, um, a conversation. We had Amy, for those of us who, those of you who aren't watching, Amy's nodding up and down. She knows what I'm about to say. We did an episode with Jenna Murray Rosenthal that I've already mentioned about, um, recovery and, um, The, the, the connection between fitness and movement and neurological recovery. And there is a lot of neuroscience about the brain plasticity and, and movement and, and neurology. So that makes a lot of sense.  Um, well, we so appreciate you joining us today. We're so grateful for your time. Um, is there anything else that you would like to leave us with? Any words of wisdom for all the SLPs out there, listening who wanna learn more about supporting patients and families with brain injury? [00:54:00]  [00:54:00] Christi O'Donovan:  Yeah, this has been such a great experience. Thank you. I think if the, the biggest thing is looking beyond the surface, right? There's so much of that in our culture right now of things look so perfect. And like that we have it all under control. I shared this with them before I'm in this, like, Fairly professional looking room and right below my camera is my kid's train table, full of a hundred different toys. Um, there's so much going on. I looked like I had a therapist that pediatric therapist was pretty good at her job, and I did a great job in front of my patients. Um, but then beneath the surface, it was still, I was recovering from a brain injury. And so I was able to, sometimes I think, fool, some of my physicians or some of my, the people who are evaluating me. And so looking beneath the surface and really understanding that full picture of the patient and all of their ever changing needs, right. Meeting them where they are, but looking for their future too. I would've never, in my wildest dreams thought I'd [00:55:00] be starting a business, but here I am, I run a company of 14 people and I help I change our community and there's, I have a really important, very privileged role in doing so. But, um, so if, you know, maybe if therapists had looked at me a little differently, who knows? Right. Thank you so much [00:55:18] Kate Grandbois:  So I love that perspective. I absolutely love that perspective. And I have just one more thing to add, and I know we were just gonna wrap up, but I promise it'll be short. The importance of being vulnerable and open with our clients to create an atmosphere of trust. So when you said you were putting on a brave face and sort of fooling some of your physicians, I think that there is a lot of vulnerability that goes into not only asking for help, but talking about. This isn't going well for me, this is painful. I, I, I'm having a hard time and it's really hard to do that in a therapeutic environment. If the therapist working with you, isn't [00:56:00] also creating space of safety for you to have those vulnerable moments. So if you are an SLP or other professional listening, and you have an opportunity to support patients and families, experience, recovering from and healing from a TBI. Not only keeping that person centered that person in the center of your clinical decision making, but creating safe spaces to share that vulnerability and, and allow them to let you look beneath the surface, because at the end of the day, that is something that the patient needs to choose to do. And it's a privilege to, to help someone and support them in that role. Mm-hmm . And that's all I'll say, thank you, so much. Thank you for joining us. This was really wonderful and we so appreciate having you and we hope everyone enjoyed everything today. Thanks so much, Christy.  [00:56:55] Amy Wonkka:  Thank you so much.  [00:56:56] Christi O'Donovan:  Thank you. [00:56:57] Kate Grandbois:  Thank you again, everyone so much for joining us [00:57:00] today, we are so grateful that we had the opportunity to have Christi O’Donovan. Join us. Again, we really encourage all of our listeners to spend the time, listen to the stories of the patients and families that you work with. Continue to refocus your lens on person centered client centered patient centered care. Make sure you remember that patient centered care and client perspectives and values are part of our evidence based practice triangle. And we have so much to learn from the stories and experiences of the people that we serve. A big, thank you again to Christi O’Donovan for joining us today and sharing her story. We learned so much from her. We always learned so much from all of our guests. Um, if you have any questions about anything that we covered today, please don't ever hesitate to reach out to us. You can reach us at info@slpnerdcast.com . We love hearing from our listeners and we are so grateful that you've joined us today for this episode.  [00:58:00] 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 is a transcript from our podcast episode published January 2nd, 2023. 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. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois: Each episode of this podcast is of course offered for ASHA CEUs. 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 nerdcast.com . [00:00:41] Amy Wonkka:  Before we get started, one quick disclaimer, our courses are not meant to replace clinical advice. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise specified.  [00:00:53] Kate Grandbois:  We hope you enjoy the course.  [00:00:55] Announcer:  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 CEUs 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 to season four of SLP nerd cast. Today, we have the great pleasure of welcoming Sydney Bassard. Welcome Sydney.  [00:01:54] Sydney Bassard:  Hi, thanks for having me.  [00:01:57] Amy Wonkka:  Thanks for coming, joining us. Um, [00:02:00] you're here today to discuss how to meet families in the middle when working with deaf and hard of hearing children. But before we get started, can you please tell us a little bit about yourself.  [00:02:09] Sydney Bassard:  Yeah. So I have been practicing as a SLP for, um, around three years. And before I was an SLP I used to work for a reading intervention center, uh, really working with reading disorders and dyslexia. And so that is when I decided to switch my major from pharmacy and go on, um, into public health. My college did not have a SLP undergrad program, or even like a, they used to have a minor, but got rid of it. So I had to like take one com B class. Uh, that was all that was offered at the undergrad level. And then I went straight into my master's because they had a bridge for people that were all non-majors that started in the summer. Uh, so I did that and really loved, um, the experience that I had at the University of South Carolina. But what made [00:03:00] it special was they had a track for people that were interested in auditory, verbal therapy and the research lab that I was a research assistant in, uh, the professor focused on research for children who are deaf and hard of hearing, but use spoken language as their communication modality. And so I was like, wow, like, this is really cool. Plus like I get to kind of specialize while still in grad school. Um, so I did the, ABT track. Learned a lot of those like techniques and principles really was involved with the research. Um, and then after graduation got a job at a cochlear at, not at a cochlear implant hospital at a hospital, um, and was on a cochlear implant team for around two years, worked really closely with E N T audiologist nurses, social work. Uh, we had a fabulous team at the hospital I was at and I loved it. I, I loved seeing the connections of what I did in grad school, into clinical practice, um, and seeing how the [00:04:00] research that I had, like really been right there in the thick of it, seeing how that like directly applied too. Um, and so then probably a couple years after working on that team, I decided to change pace a little bit and move a little closer to home. And so that's how I ended up, um, back here in Charlotte, cuz that's where my family is, but that's been kind of my, my journey with all of this.  [00:04:25] Kate Grandbois:  That sounds amazing. And I, I know nothing about any of the things that you mentioned. So, as our listeners know, I work as a quote AAC specialist. So does Amy. So we love having, you know, people who work in other clinical disciplines on the show so that we can learn from you. So I have lots of questions already, but before we get into any of them, we have to read our learning objectives and financial, and non-financial disclosures to get all of the housekeeping stuff behind us. So I'm gonna go ahead and quickly read those and get that off our plate. So learning objective number one, [00:05:00] list two ways in which the language development of children who are deaf or hard of hearing differs from that of children who are not deaf or hard of hearing.  Learning objective number two, list two roles of the SLP in supporting deaf and hard of hearing children and learning objective, number three, describe two current evidence based practices for, for supporting deaf and hard of hearing children. Disclosures Sydney Bassard’s financial disclosures. Sydney received an honorarium for participating in this course. Sydney's non-financial disclosures. Sydney does not have any non-financial relationships to disclosure. Kate that's me, my financial disclosures. I am the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a mass, I'm a member of ASHA, SIG 12. 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 and the association for behavior analysis, internationals corresponding, speech pathology, applied behavior [00:06:00] analysis, special interest group.  [00:06:02] Amy Wonkka:  Amy that's me. Uh, my financial disclosures are that I am an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of Asha, SIG 12, and I serve in the AAC advisory group for Massachusetts advocates for children. All right. Onto the good stuff. Uh, Sydney, why don't you start us off by telling us just a little bit about the language development of children who are deaf and hard of hearing? [00:06:29] Sydney Bassard:  Yeah, so I think that sometimes one of the biggest misconceptions is that if a child is deaf, um, that their trajectory is going to look a lot different than a typical hearing child. And the reality is that we can introduce language for a deaf or hard of hearing child. Early on, like you would do for a typical hearing child. Um, and so one way that you could do that is by the introduction of sign language. And so really starting like you would with a typical [00:07:00] hearing kid, you know, we wouldn't go from, um, expecting a kid using like full signs to communicate very early on. It would start with one sign, two signs, and then, you know, progress to more complex and using, um, the sentence structure that's used in sign language, which is different. Um, I think that's important to be clear. ASL or American sign language has its own grammar and syntax. It's not like a signed version of English. Um, so depending on where you are in the world, actually the sign language of that country might be slightly different. So it's important if you are going to, um, use any type of signed language that you do understand the grammar, um, and the syntactical structure when working with a child with that. I think the really cool thing as well is that when we have children who are, um, within that deaf and hard of hearing category, but their parents might put, you know, [00:08:00] hearing aids on them, um, or pursue cochlear implantation. Our focus is really going to be, um, that auditory system a little bit earlier on, and it's not to say that you have to do sign or spoken. Oftentimes I think professionals get into a kind of heated discussion about which one people are going to choose instead of really encouraging families. Like you can do both a child that wears hearing aids can sign and, um, and use sign language and spoken. Um, so just knowing what the points of emphasis are. So if we're working and they're really little, how I've traditionally done therapy is we're gonna start without auditory system, because most of my kids have always used some type of amplification. So that would be, you know, detecting of environmental sounds. That would be, um, you know, really just starting to kind of focus on that vocal player that babbling and for most people you would think like, well, why would you do that? [00:09:00] That that's pretty mundane or that's pretty like, that's something that we pick up, but depending on the degree and the severity of the hearing loss, the child may not have ever been exposed to the doorbell, ringing the dog barking. Um, and what we know about auditory development of, for the brain, especially is the starts in utero. There's a reason that mothers have been told traditionally to sing and read to their babies. It's not just because, you know, you, you do establish that connection, but also your child can hear you. Um, so you start hearing within utero. So even by the time a baby is born, even if they get hearing aids like day one, which they don't, it's still nine months that we've missed out on auditory development and listening skills. Um, so that's kind of where I traditionally start and how that might look.  [00:09:53] Amy Wonkka:  Okay. I already have a question. [00:09:53] Kate Grandbois:  I have, I have so many questions. Go ahead.  Just go. [00:09:56] Amy Wonkka:  Um, I guess I'm, I'm the [00:10:00] person who's always asking, like, but what does that look like? Can you just give us like an example of, of how just working on some of the auditory stimulation might look a little differently from what we might traditionally be used to doing a speech language pathologist in terms of, I feel like a lot of us start right with receptive following directions, receptive vocabulary. And it sounds like you're talking about something that's a little bit different from that.  [00:10:24] Sydney Bassard:  Yeah, absolutely. So it just depends on the level of where the child is. So most people that work within the realm of like that listening and spoken language development are going to start with these kids when they are like babies. Um, Really small. So not our traditional, like we're thinking entering school age. Like, no, these are like your three, six month olds. And so what that might look like is, you know, we might just be making that sound or having the parents kind of make that sound and then starting to attach it with the object. So if we have a dog, I might [00:11:00] make the sound for a dog barking. Did you hear that? Really cue them to their listening? Well, let's listen to that again. And then point to the object. Oh yeah. That was a dog. One thing that I do caution therapists with is, um, and this happens, I think across the realm of peds, we see people attach very strongly to animals or, um, farm animals specifically. And while those are great sounds to learn, that may not be the most appropriate sounds to work on for that child. Um, if they don't live by a farm, I'm so sorry, but the child that lives in New York city doesn't necessarily need to know what the cow sounds like, but you know, what might be more functional for them knowing what the taxi sounds like. and what horns beeping are, because those are the things that they would be exposed to, um, quicker than let's say the farm animals.  [00:11:57] Kate Grandbois:  I, I have so many questions. I wanna back up for a second [00:12:00] and go back to one of the first things that you said about how these two groups of children. I'm just thinking about our first learning objective and any developmental linguistically developmental differences there may be between these two groups, um, thinking about an SLP who might be listening and be interested in, in going into this area of practice. So does the research, I had read something that you had posted a while ago. Um, some, some research that you had posted, does the research say that there is a difference between these two groups generally? Or does it depend on a variety of factors, like degree of hearing loss or whether or not they've had amplification at an early age?  [00:12:38] Sydney Bassard:  So which two groups, typical hearing and, yes. Okay. So traditionally what's been kind of noticed is grammatical markers. So what we tend to see is that as our kids with hearing loss get older. We tend to see that some of that complex syntax is a little bit more difficult for them to put [00:13:00] together whether that's directly related to hearing, or if they have true like underlying language disorder that they might have had, regardless of their hearing status that sells something that I think the research is trying to tease apart. But from what we know so far is that they might have difficulty with plural marking or, um, irregular past tense or third person singular. And so those are things that you really kind of wanna pick up for, or even sometimes like past tense ed. I mean, you'd be amazed. They might start picking up these structures. Um, but then certain ones we wanna emphasize. And I think that this is kind of a side, but that's why it's really important. Especially with this population to go beyond the standardized testing. Um, I actually had a study that got published in 2020, where it looked at that. And when we saw these kids that had high IQs on a standardized language measure, they were [00:14:00] doing pretty well. And these are kids with hearing loss. They were doing well compared to their typical hearing peers. But when you throw them in with a language sample, are they matching up the same? No. And so it, like, it's going to show that we have to go beyond just the standardized test, because if we look just at the standardized test, most of them have patterns that you can follow. The example sets the pattern for you and a kid that has decent test taking skills is able to figure this out. But in a language sample analysis and conversation, there is no pattern. It's it like you're having to discuss, you know, whether it's narrative, uh, telling a story, whether it's expository. You know, talking about, um, like facts and being able to retell and provide steps and sequence of things. That's sometimes where we see the holes for these kids really kind of glare. And that's because a lot of times those grammatical [00:15:00] syntax markers are where they're having the difficulty.  [00:15:03] Kate Grandbois:  And I can't not say this. This is only a little bit of a side bar. But anybody who is listening, who has just heard this very important cautionary tale of standardized assessments, we should always be cautious of standardized assessments in our evaluations. We're we're teaching a class on this right now. There's a lot of research about this out there. So if you're listening and you are, you know, looking at this topic through the assessment lens, please just always be very cautious about over-relying on standardized assessments, because that is not a comprehensive way to assess, uh, pediatrics. So soapbox over had to say it gonna move on to my next, to move on to my next question. So I'm wondering about, you know, anybody, any SLP who's listening, our scope of practice is so wide. And so often we are expected to provide intervention and treatment for such a wide variety of clinical presentations. And for any SLPs who are listening, who maybe have a student [00:16:00] or a client or a child on their caseload, who is deaf of in heart of hearing. And maybe this is their first. Time treating someone of this profile. Are there other skills that are, or other differences that are really important to be aware of besides linguistic presentation? I'm thinking in particular about any, any kinds of counseling skills or important awareness around cultural or community, um, components? Um, I remember in graduate school, when I took audiology, there was a really big emphasis on the deaf community. Um, very, you know, as a community that we need to be respectful and aware of. So can you tell us a little, I know that was a very big question with a lot of components um, but is there anything you can tell us about that aspect of things?  [00:16:46] Sydney Bassard:  Yeah. I think that over the past couple years we have seen a big push in the world, but especially in our field about being mindful of inclusion. And so oftentimes, um, I think [00:17:00] therapists get these kids and they're like, okay, well I'm gonna work on the artic because that might be something that they hear. Um, but they might negate or like, forget about some of the, you know, feelings and social aspects behind things. So I always encourage people, uh, find out as much as you can before you see that kid, you know, have books that feature, um, deaf and hard of hearing characters. And I don't think that all of them should necessarily be kids that use amplification. A lot of the books that come out now, which is, which are great, um, feature kids that use hearing aids or cochlear implants. Okay. But let's make sure that we have some representation of kids that sign as well, because a lot of the kids that we see, um, truly to some degree are bimodal, meaning that they use more than one communication modality, which is why their research within this space is a little bit muddy because most of the kids are not [00:18:00] true, like monolingual or one modality. They don't just use one. They might use a combination of both. Um, so, so making sure that we are having those things represented within our materials, but also then like knowing about what your deaf community resources are, you know, if you're able to have the parents connect with the deaf mentor. Um, the one thing about the internet is that you have more access to Deaf people than I feel like ever before. Uh, there are so many people who are very loving and willing to share their stories or share, um, stories that they experience as a parent or stories about their kids on platforms, on the internet, in which they have made it really accessible, uh, to reach out to them, to, you know, ask questions for your kids to kind of connect, uh, even for you, you know, as a professional. And then [00:19:00] really just being mindful that if you've met one Deaf child, you've met one deaf child and one deaf family, the experience is so different for people across the board. Um, some people have gone through very rigorous auditory verbal therapy, and they've loved it. There have been some people that have gone through auditory verbal therapy, and it was a very like difficult experience for their family and their child. So I think always being kind of respectful that there's never one approach or one size that fits all is really helpful. Um, when interacting with the kids too, because they're gonna come with their own experiences and then making sure that, you know, the technology. I know that that sounds kind of. Okay. Yeah, sure. Um, but each implant company, there's three there's cochlear, there's advanced bios, and then there's Medow um, they each have slight modifications. The overall system is the same, but how the pieces are connected [00:20:00] and work might be slightly different. Most schools are going to have a, uh, teacher of the deaf who is either within the school or itinerant. So you can always rely on them, but sometimes you may not have access to them for when a battery is not working or if a magnet falls out or if we're not sure if the processor is working. So being able to just understand the very basics so that you can troubleshoot, um, if needed, I think is always kind of helpful. That was a lot  [00:20:30] Amy Wonkka:  no, I that's a big question. I think those are such good points too. And I think connected with the tech. I don't know if you wanna talk a little bit about FM systems, but that's another piece that sometimes comes into play if you're school based, um, and can be another like kind of scary thing. If you're not like, you know, it's expensive and you don't wanna break it, but you're not sure how to use it. And I, I wonder if there are kind of like basics that would be helpful for everybody to know. [00:21:00] Like you mentioned batter. I think batteries are really big one. Um, I didn't know if there's anything else. [00:21:04] Sydney Bassard:  Yeah. The thing about FMS are, they're so different based on like what the system is. Um, I mean, this is definitely my soapbox, but FMS are beneficial for all children and I really get on it. Get on the soapbox.  [00:21:22] Kate Grandbois:  Yes. Yeah.  [00:21:23] Sydney Bassard:  That's what we're here for. I really wish that people would like stop this notion of they're only good for the deaf and hard of hearing kids in the classroom. Um, like, no, they're good for all kids. We know that schools are noisy. Um, all kids benefit from the boosted sound. I, I mean, they just do. Um, so if you're a school based therapist. seeing if you can make that argument for having a sound field within your speech room, I think is always a good push. Um, but, even like, beyond that, like just figuring out how to work that FM, because they are all so different. So, um, reaching out [00:22:00] sometimes to the companies, some school districts are wonderful and have educational audiologists, some do not. And so that's okay. Um, what I have found as a therapist is it never hurts to ask. So even though I had access to audiologists and ENTs right there by working in the hospital, um, there were plenty of times that I like needed things from the implant companies or I had questions and I would just send an email , um, and just like contact the, the manufacturer myself and say, Hey, like, this is my role in position. And I work with these kids. Can you like, send me a video or explain X, Y, Z, and nine times outta 10, they have already had somebody, um, Create a video because other people have asked this question or they have a rep for your area. And that person is always willing to kind of chat with you quickly or do some troubleshooting with you. [00:23:00] Amy Wonkka:  I think those [00:23:00] are such helpful tips. Um, and the idea that you can reach out to the company is, is a really empowering thing. Just send the email. Worst thing they'll say is no.  [00:23:10] Kate Grandbois:  And most of the time, at least through our experience with AAC is that vendors can be tremendously helpful. I mean, super helpful. It's also a company that's making a sale so most of the time they're pretty motivated to provide good training and customer service. Um, and so I think that's a, that's a really wonderful suggestion. I wonder if you could sort of, I had just Al as you were talking, I was remembering something that I learned in graduate school. That was a really long time ago. So it's probably outdated information, but it made me curious. You were talking about how, when you're working with babies three to six months old, and you, your focus might be tuning them into auditory stimuli in their environment that are maybe non-linguistic are there other early developmental differences that you might see? [00:24:00] So the research that I'm recalling from my audiology class was the, um, if you have a working with a child who is, um, being raised, let's say by Deaf parents and their first language is American sign language, you know, looking at potentially babbling in sign or other, other markers, that language just like, just like you said, language can be introduced at the same ages as our typical hearing children. Is there, are there any other, first of all, I guess my question is, is the babbling with hands true? Am I remembering that correctly? And then are there any other early developmental differences that, that you can tell us about. [00:24:39] Sydney Bassard:  Yeah. So I wish I could comment about the babbling with hands, but I didn't. [00:24:44] Kate Grandbois:  Somebody listening knows you have to write in and tell me I'm gonna have to Google it. Maybe we'll put a reference in the show notes.  [00:24:49] Sydney Bassard: Um, I don't know enough about like early development of sign to know. Like specifically. Um, but I have seen people kind of show that, or like kids will [00:25:00] use like word approximations. They use sign approximations too. So if the sign for more is more, you know, maybe they'll start by like putting their whole hands together and the same motion. So it's the same, um, type of concept. It's just not as refined. And we have to think that a lot of science might require a little bit more fine motor skill, um, than we're expecting kids to have. So if they're able to get an approximation, then I would say like, Hey, like we have it. And, and they're using it consistently, you know, all the things that you would expect, um, and make true for anything else they're using it consistently. They're using it across context. Then we would kind of count. So I think that those are like kind of the, the big things, but I think the sooner that we can make whatever we're doing meaningful to the kid is really where we want to move to. Um, that's why I said like, don't pick environmental sounds that don't work for that [00:26:00] family, but you're also gonna want the family, not just to be walking around making sounds. like we wanna give language input too. So even if they're short phrases or they're narrating as they are, um, engaging in activity, they're reading books, the same is true for sign. Parents of children that sign, you know, they are going to be, um, narrating. They're gonna be providing that input throughout their day. They might be signing the book as they're reading along with it. Uh, so really making sure that the experience is, you know, true of both. I, I really. I know that I used to struggle with, like it had to be auditory verbal, because that was what I learned in grad school. Um, instead of giving honor to like, this is really a continuum and we can be respectful and make sure that people are getting everything that they need in order to set these kids up for lifelong success. [00:27:00]  [00:27:01] Kate Grandbois:  I, I wanted to sort of reflect that back to you, as I heard you say it, because what it sounds to me, it sounds like your, the emphasis is really providing a linguistically rich environment in the continuum of modalities that are right for that child and family. Is that, is that a, a good synopsis?  [00:27:23] Sydney Bassard:  Yeah. Oh, absolutely. Um, so I share, and that sounds  [00:27:26] Kate Grandbois:  like good clinical practice, no matter, no matter what you're doing  [00:27:30] Sydney Bassard:  it is, but it's so interesting. So. I've shared recently, um, how I have stopped pursuing my auditory verbal therapy certification. So if you didn't catch it on my stories, you're now catching it here on the podcast. um, and it was a really tough decision. I mean, it's a lot of training and I pretty much had done all the continuing ed for it, um, was really close with all the clinical hours I needed in order to be able to [00:28:00] sit for the exam. And in like reflecting on my clinical practice, there were just things that just did not sit well with me. And that was part of it. It was how, even though a lot of AVTs that I know that practice say the same things that I do, you know, we give honor to the experience, but when you look at the board who is certifying people to be auditory, verbal therapists, um, That's not necessarily always the message that's reflected and in knowing that so many people have had bad experiences  we know that there have been children that, um, they've had signs withheld. They've had gestures withheld in order for them to like speak it. It's a little frustrating, um, because nobody else communicates like that. I communicate a lot with my hands. My facial expressions will tell a whole story before I open my mouth. So why would we deny that same type of privilege to kids who are deaf and [00:29:00] hard of hearing? Um, so that's why I just was like, you know what, I'd rather spend my energy and time on making sure that we're meeting the needs of everybody on an individual basis, having the training of AVT and knowing a lot about the auditory system is wonderful. And I still think that therapists that are working within the space and working with children, especially those that use any type of amplification need to understand that because there are certain, um, points of emphasis that you're gonna have to make based on their degree, um, and configuration of their hearing loss. But also we need to understand that you don't walk around not using your hands, not using your gestures, not using your facial expressions. Um, we wanna make sure that like we are training these kids to really be able to communicate in the ways that are intuitive for them and authentic for them. [00:29:54] Kate Grandbois:  And so that, so they can choose in a moment. And I know this, [00:30:00] this episode is not at all about AAC, but I hear so much of what you're saying. Reflected in the work that we do in terms of choosing a modality and honoring all modalities that are empowering and, you know, are authentic to the communicator and really continually shifting the focus to person-centered care and making sure that the, the client or the child or the family, um, and their perspectives and values are held at the center of the clinical choices that we make. So I'm, I'm experiencing some joy in these, in these parallels. I don't know if you are too Amy.  [00:30:35] Amy Wonkka:  Yeah. I mean, in, in obviously not having the training sitting that you have and not fully understanding what it even means to be an AVT therapist. Um, you know, I, I, I at least think about the ASHA evidence based triangle, you know, and just thinking about how we, as a field in more recent years have done a better job, giving the weight [00:31:00] and value to our clients and their other and other stakeholders in helping to craft what types of interventions we are supporting them with. Um, and so, yeah, it makes a lot of sense. I also like heard you talking and heard it through my like AAC filter. Um, but I think that it does, it does make a lot of sense, but I'm sure, you know, there's a lot. To be gained through going through that training. I'm sure that there are a lot of pieces of value as well. [00:31:27] Sydney Bassard:  Oh, absolutely. And I think that the big thing is understanding that you don't have to agree. I think that sometimes people and therapists, especially, um, I mean, I'm a young therapist have not been practicing terribly long. Uh, but I had that issue, you know? Well, I'm the professional. You come out of grad school, they instill in you like you're the professional, you have the keys, you know, the things which is true, you know, the knowledge, but you don't know what people are bringing to the table and you don't have to agree. I think that, especially [00:32:00] working in pediatrics, people really get offended almost when parents and caregivers do not follow their recommendations instead of realizing that, they don’t have to [00:32:10] Amy Wonkka:  I agree [00:32:11] Kate Grandbois:  no, for all you listening and you can't see us. Amy and I are just emphatically nodding our heads at like here, here. Yes. Get on another soapbox. It's so true. That was me as a, as a new grad. I think there is so much, you know, wrapped up in us as clinicians being the quote expert or, you know, having this ego just out of wanting, you know, maybe having good intentions, just, just because we wanna help. And we wanna provide that, that high quality evidence, but to, you know, looping this back to Amy's point about continually refocusing the, the caregiver and client perspectives and understanding that that's not you giving in or, or giving ground because it's not a fight, it is evidence based practice. It is part of your evidence based model to hold those [00:33:00] values at the center of what we're doing. Um, and this is, you also mentioned something that I learned from Amy a long time ago, which. You do it, doesn't have to be a fight. You can disagree and be at peace. That is a, that is an option. That is an option. Um, and I learned that from her because I was the one who was like, ah, no, this is, you know, so I think, I don't know if that's something that comes with experience. Um, Or just something that comes from a friend or a colleague who just continually reminds you of that. Um, but for anybody who is listening, who is hearing that for the first time, you're not, you're not alone. Take it, take it to heart. It's, it's very good advice.  [00:33:36] Amy Wonkka:  Um, well inward, like we're all human people and we all have our moments, right? So you catch me on the day that I didn't sleep well. And I, I spilled my tea on the way to work. Like, you know, I mean, I think we're human people interacting with other human people. I think it's making me think though about our, our second learning objective, cuz we've sort of been talking around it. Right. So what are we supposed to do as the speech language pathologist? We, we have [00:34:00] learned, we are not the ultimate prescriber of exactly what should happen rigidly and you know, without care for our clients or their families, but like what should we do? What, what is our role, um, in supporting our clients and their families?  [00:34:16] Sydney Bassard:  Yeah. I think the biggest one is to. The start is you have to be a good listener. Um, oftentimes by the time a family is coming to see you, they've encountered a ton of other professionals unless you work, you know, very closely within this realm. Um, but traditionally, especially if this child. Was identified at birth through newborn hearing screenings. Okay. So they've encountered a newborn hearing screener at the hospital who, um, referred them out. So then they probably encountered a pediatric audiologist depending on the choice that the family makes with the pediatric audiologist. They might have also encountered an ENT at that [00:35:00] at this point and discussed options. So right there alone, you've gone through 1, 2, 3 professionals. And now here comes the SLP that enters the stage. And depending on these interactions that have happened before, it could have been a very beautiful interaction. There could have also been really painful. Um, so your first job is really to listen because there's also a lot of shock. What we know is that most kids that are born with hearing loss are born to hearing parents. So this isn't necessarily something that was even on the cards for a lot of people. When they went to have their child, this wasn't something that they were thinking about. So knowing that going into the situation and really doing check-ins with families up front, how are you feeling about this process? Um, how can I support you? Being able to provide, I think those resources early is helpful. Some people are ready to accept them and some people aren't. And I think if you're encountering, um, kids within the school age realm, [00:36:00] Your role is to really support what the family has chosen. So if the family has chosen that their modality is spoken language only, um, then you wanna make sure that you're supporting that if it is, you know, that they are going to be bimodal, then your job is to support them in that and really make sure that they are having to access to everything within the educational environment being oftentimes we push, well, they need to be doing this. They need to be doing that, but really meeting the kids where they are. Um, I used to work with a lot of kids who they were not your traditional, um, auditory spoken language kids. And when I say traditional, these are the kids that are early identified early amplified, um, using, you know, Pretty strong language skills by the time they're entering into kindergarten, first grade, and they're rolling off the caseload. We're not really seeing them anymore. A lot of my kids [00:37:00] were the ones that got implanted later, due to various different circumstances, or they had comorbidities in other things going on. Could I have pushed them in like you're in first grade and you're supposed to be right here? Or did I meet them where they were? So understanding that like each kid is going to be different and figuring out where that kid is, and what's gonna be most functional. Okay. This kid can't make their th sound, but they also don't know the name of any of their family members. Well guess what, we're gonna be working on making sure that we know the names of our family members long before we're working on a speech sound. We can incorporate that maybe into learning about our family members names, but our focus is gonna be making sure that we have some functional language skills so that we can communicate with the people within our environment. [00:37:47] Amy Wonkka:  Listening to you speak right then was, was making me think back to your comment about, you know, standardized and I think specifically norm reference assessments, aren't enough to kind of give you that information because part of how you're going to find that out [00:38:00] and maybe part of why some of us do tend to focus on the th sound is because we can do a norm reference assessment and it, and it flags that skill right there for us. So I don't know. I don't know if you have any like thoughts or tips for maybe specifically the school based person who has a student who's deaf or hard of hearing on their caseload, like how they can, we know language samples can be really helpful. Are there other pieces of information that you might use to help identify those priority areas as the SLP? How do you, how do you pick out that information? How do you know that they don't know the names of their family members?  [00:38:39] Sydney Bassard:  Yeah, that one's hard. Um, that's I mean, like that's when interactions with the kids come into a big play. Um, but they do have this thing online called the TEGI and do not quote me because I cannot think of the full name. [00:38:56] Amy Wonkka:  Can you spell that for us? Just so we can [00:38:56] Sydney Bassard:  T E [00:39:00] G  I, uh, but it's free. Thank you, FYI. And it was, it comes out of, um, like maple rices lab in her area. It's the test of early grammatical impairment. Um, it's free and it's online and you can download it and it has probes for wanna say it has probes for like phonology past tense marking, um, And with the past tense, there's like irregulars in there as well. And then third person singular probes. And so you can, like, when I say you can really download the whole thing, you can download the whole thing it has, um, where kids should be like by criterion. I wanna say don't quote me, but either way it is, um, it's a really great tool that is available to SLPs. It's pretty quick to give, you give the kid a word. Um, you give it in like a [00:40:00] sentence. And their job for some of them is to like conjugate it to third person or conjugate it to past tense based on the context that's given for them to fill it in. Um, so that's like a really good one because then right there, you can see like, Hey, our third person, singular killers are really difficult or we did pretty good with some past tense marking overall, but I'm really seeing that we're having a huge difficulty with irregulars. [00:40:28] Amy Wonkka:  That's awesome. Thank you for that.  [00:40:29] Kate Grandbois:  One of the things that you said earlier, I, I absolutely loved, and that was about taking the time to thoughtfully and carefully choose targets and objectives that are not only functional, but meaningful. You've mentioned it a couple of times through, you know, identifying sounds in an environment or choosing targets, you know, family names over random speech, not random speech sounds, but you, you get what I'm saying. Um, and I find that that's a thread that's common [00:41:00] across all of speech pathology as, as a fundamental, you know, something that is important that we do as clinicians. I'm wondering if you have any strategies for how clinicians can go about, um, developing, how clinicians can go about choosing those targets, um, for this population. Is it an interview style that you find to be the most helpful? I'm just thinking about the SLPs listening who have caseloads of 140 and are eating lunch and crying in their car. Like what can we actually do to get more information, to help us choose these functional, meaningful targets?  [00:41:34] Sydney Bassard:  Yeah. So let's break this down into like, setting and think of it that way. So if you're working in the early intervention setting, you have access to parents. So asking interviews, um, but also really being observant. So people tell you a lot without telling you a lot, by looking at their environment. And even sometimes when they have like offhanded conversations that you're like, okay, this has nothing to do with your child. [00:42:00] They are telling you so much about their life, their emphasis, their stressors, um, what's important to them, even in those conversations that aren't directly related to the child. So kind of making notes of those things, um, especially in that early intervention or even outpatient, pediatric private practice setting are really, really huge. And then being mindful of the cultural differences that might be, um, influencing some of their decisions and their thought processes. For my school based people. Um, it's a lot harder because you don't have access to families as much. If you have a kid that is even like remotely , um, able to communicate, I would kind of follow their lead. And I feel like that term gets overused truly. Um, but really trying to see where they're going, see what their interests are. And that's when you use the people in your school as your team. So find out from their teacher, like, [00:43:00] how are they doing? You know, what are they seeing as interest? Um, I feel like at the beginning of the school year is a wonderful time to kind of get to know the kids. And I know that SLPs loved us in those, like meet the SLP and like have people know about you stuff, which is great. Right? Like parents should definitely know about you as a professional, but have you ever flipped that around. And maybe like, you know, especially if there's kids on your caseload that are new or you know, that they're coming from somewhere else, um, I've done this in therapy or I've sent parents like kind of a, I wanna know about your child. And I think when we frame it in the framework of like, no, this is not just another sheet of paper you need to fill out in order to get the school year started. Like this is going to help me to be able to make sure that therapy is meeting the goals that you want to accomplish. Making sure that your child is engaged and interactive in this [00:44:00] learning process and making sure that we are all on the same page for our common objective of making sure that little Johnny X, Y, Z. I don't think I've ever had a parent that's been like, I'm not gonna fill that out because they, they want to make sure that they are feeling a part of the school team. It establishes the relationship with the caregivers up front, and then it's giving you a better insight as to what is going to be like really important for them. We obviously know sometimes that parents' goals are all the way up here and we might be right here. So, you know, maybe you're gonna have to explain that of like, okay, mom really wants them to be, you know, halfway up this ladder. And we're really kind of starting at the bottom of this ladder. Um, but at least, you know, where the parent's coming from and what you can kind of work towards to get kind of in that space in realm. [00:44:54] Kate Grandbois:  I, I think there are, so everything that you're saying, I'm coming back to something that you said [00:45:00] earlier about being an active listener, um, and you know, re centering this as, as person-centered care. And I know for anybody who's listened to this podcast, I think we talk about counseling during every single episode, no matter what we talk about, because it is such an undervalued underutilized, um, but critical piece of being an SLP. And it's obvious from what you're saying, there's no difference here. And I'm wondering if you have any thoughts about how counseling, how counseling skills can be applied, um, by SLPs to this, to this particular clinical presentation.  [00:45:39] Sydney Bassard:  Mm-hmm so there is a book, I think it's called counseling and speech language pathology, and I love that book. Kate Grandbois: Is it David Luterman, Sydney Bassard:  uh, no, I don't think so. I don't think so. I don't remember. It's been a while. Um, we used it in my counseling class in grad school and [00:46:00] it was, or maybe it's like counseling and communication, sciences and disorders. I don't know something along those lines.  Kate Grandbois: We'll put the, we'll put [00:46:07] the link in the show notes. [00:46:08] Sydney Bassard:  Um, but it's a really good framework and kind of talks about. How we should interact with our clients. Um, I think the biggest thing is that active listening piece. So oftentimes, and I do this, I'm a terrible person at this with my family. Um, but I am like 10 steps ahead in the conversation. So I already have planned out in my mind what you are going to say before you even like, say it. And I  [00:46:39] Kate Grandbois:  you're, my husband have my response. That's my husband. You're my husband. It drive me crazy [00:46:40] Sydney Bassard: . And it's a terrible habit. It is so awful. It's so awful because you're not really listening to what the person is saying.  [00:46:49] Kate Grandbois:  That's what I always say [00:46:52] Sydney Bassard:  what you've done is I really kind don't care what you're gonna say. I already know what I wanna tell you,[00:47:00]  As a therapist, not, not want to do that. And oftentimes we do, we do it, um, subconsciously, especially if we're nervous and we're not sure how we are going to be perceived. We are already like planning because we don't wanna be caught off guard. So really allowing families to, um, say what they need to say. And one thing that I learned, uh, from someone. Really on like early on in my career during my CF is that she told me to ask the parents how things were going. And I thought, why would I want to do that? Who wants to sit there and ask people for their honest opinion? Because that's, nerve-wracking like, you're already feeling like, oh, maybe I'm not doing the best job. And then you ask somebody and they confirm it. And it's like, oh, this is not great. Um, but what it allows is for check-ins, it allows for people to really take ownership of the whole process and [00:48:00] open the doors for communication, and then counseling's gonna look different. Um, a lot of parents are going through the grieving process when their child is diagnosed with a hearing loss, whether they're early on in the stage, Whether they have gone through all the way to acceptance. Um, it's important to realize these stages are fluid. And so even though somebody may look like they've gotten into acceptance, they might go back like to step one in the grieving process where it's really difficult for them, especially as different social situations might arise. You know, so being mindful of those things and sometimes being prepared ahead. So let's say this kid's been doing well and they're entering preschool moms and dads might start feeling a little bit, you know, tight with their emotions again, as they go into kindergarten opening those doors for conversation. How do you feel about so and so going to kindergarten, [00:49:00] let's have a conversation about it. Can I connect you with this group or this parent who their child is a little bit older, but they've been exactly where you are. Um, and then recognizing your boundaries. We are not mental health professionals. So when you see something and you're like, you know what, this is outside of the realm. Um, it's time to refer out and there's no shame in that. And even with that, making it a conversation with, um, the families, I don't, I don't necessarily see myself referring out with pediatrics. I just haven't had to. Um, but sometimes when it's the adults that I work with with hearing loss, that's when you tend to see a little bit more referring out for mental health, only because the majority of them are, um, what we would call post lingually deaf. So meaning after they had language and speech, they are now losing their hearing loss. And so their journey tends to be a little bit, [00:50:00] uh, rougher for them as the person, as far as emotions, just because they are losing a sense and a skill that they once had and having to make adjustments, which is difficult and can be tough. [00:50:13] Kate Grandbois:  I would imagine that's a very different journey and a very different approach as a clinician. That makes a lot of sense. I'm wondering if, and I'm sure this would change through, you know, depending on your work setting, but I'm wondering if there are collaborative relationships. You've already, men mentioned referring out to other mental health providers, but are there other collaborative relationships that are really important for the SLP, such as an audiologist or another medical professional, like an ENT, um, who do you find to be one of the most important, um, team members or collaborative relationships to, to better support persons with hearing loss.  [00:50:56] Sydney Bassard:  Yeah. So, um, love the ENT that [00:51:00] I work with. So I, uh, contract and work with an E uh, not an ENT with an audiologist two days a week, um, out of their office. And it is wonderful. We are able to really provide our clients with like interprofessional holistic care right there from the office. So if you have a kid, um, or even an adult, that is deaf and hard of hearing, really collaborating with that audiologist early on is gonna be key. Now that can be a little bit tricky. So if you're in like the private sector and you're connected with them, then you'll be able to do that a lot easier. Versus if you're kind of in separate entities, that might be a little bit more difficult. Uh, but in the school settings I'm telling y'all school, school based, people fight for these educational audiologists. They will make life a lot easier on you and make the like treatment that's available for these kids a lot better because they sometimes are able to [00:52:00] provide, um, mappings at the school or they're able to, you know, Fine tune hearing aids or change tubing or, um, all of the things that like are gonna be really important for the kid to be successful within the academic space, oh words are hard. Um so that would be, um, my biggest thing. And so I love working with the audiologist. I think also too, like getting to know the teachers of the deaf teachers of the deaf are our best friends. And sometimes they are very underutilized tools, um, within the school districts and systems, getting to know them, making sure that you become their friend. They oftentimes have a lot more training with the equipment aspect of things that SLPs just don't, especially with our field being so broad, but their field is pretty narrowed in. They like that is who they work with. So they have a lot more training if you're having questions about goals and where to go and you know, you're [00:53:00] not really sure. What you should be doing with this kid, ask them. They probably know they have resources, they will collaborate and help you and be of assistance. Um, and then if you're working with the older population, um, especially if you're in like a sniff setting and you're like, you know, this person has hearing aids. I'm not sure, work with nurses. Um, I cannot tell you the amount of times that people experience, um, what looks like mental health kind of disabilities or challenges or cognitive impairment. And sometimes it really is their hearing. What they're needing is they need someone to put their hearing aid back in, or they might need adjustments. Um, and so making sure that, you know, the nursing staff is trained on how to put them in that we're keeping them in, uh, cuz it's gonna take some adjustment for the brain. And so those things are all helpful to making sure that we are, [00:54:00] um, giving people holistic care, but also it prevents us from misdiagnosing people. Can you imagine if grandpa gets diagnosed with like cognitive impairment and then what we go on later to find out is like grandpa had a severe hearing loss and wasn't able to hear half the stuff. Um, and all he needed was someone to put his hearing aids in. Yikes. Like that's crazy, poor, poor, poor grandpa. Um, so that's not to mitigate and say that like, you cannot have both, you can definitely have both, but sometimes it definitely helps if we are, um, making sure that we're having access to all of our equipment and things that we need early on. [00:54:39] Amy Wonkka:  And making sure our clients have access to all of their sensory aids that they may need. Um, I think you make such great points about collaborating with other professionals and learning from other professionals. And I feel like it sort of brings us into the last learning objective and just thinking [00:55:00] about what are evidence based interventions for supporting children, um, who are deaf and hard of hearing and supporting their families. So I was hoping you could tell us a little bit more, um, about what some of those best practices might  be. [00:55:13] Sydney Bassard:  Yeah. So the work of Dr. Emily Lund, out of TCU is really phenomenal. Her work centers, a lot on, uh, vocabulary intervention research. And so she talks a lot about how we should best be introducing vocabulary with our kids who are, um, deaf and hard of hearing. One of her studies that she published with, um, Michael Douglas basically talks about how explicitly teaching vocabulary and then pairing it with, um, experience is going to be best for our kids that are Deaf and hard of hearing. So you can't just introduce a word and give vocabulary , but [00:56:00] we need to make sure that we're explicitly teaching it and across the board, that's, what's found to be the best with this population. Um, some people talk about embedding instruction. That can be nice. But what tends to happen is if a child is already having difficulty with understanding and processing language, you've just made what you're trying to teach way more complex. So if you can be very direct with what you're doing, you know, we are explicitly teaching, um, this concept. We are explicitly teaching this vocabulary skill. We are explicitly teaching these words. It's going to go a lot further. Um, so I love her work. Um, another researcher is, I love Dr. Crystal Warhol. Um, she's at a Boystown national research hospital. Her work in this space is also really great. Um, Mary pat Mueller has published a lot within the realms of deaf and heart of hearing. And basically all of the [00:57:00] research that's boiling down to is that we need to be direct. We need to be explicit in our instruction. Um, so those are researchers. And then if you're looking for strategies and like, what techniques can I use? Um, so one of the ones that's really good is, um, it's like Milu teaching and essentially what that is, is it's parent coaching. So you would model what your expectation is. Um, Then you would explain it, you'd have the parent do it, and then you would review how they did together. So you would follow that kind of step in sequence, especially when you're working with like the little ones. I also tend to adapt that when I'm working with older kids and do the same type of thing, I might model what my expected behavior is. I'm gonna have them do it and then we're gonna review it together. Is that right? Is that what you heard? Is that what we're supposed to be, you know, doing? Um, so really [00:58:00] kind of tuning them into, having a little bit more ownership in the process of learning instead of it just being, um, you directed. And then, um, there is a handout it's actually free online and it's called toy talk, um, by Pam Hadley and colleagues, and that one is great for if you're working on, um, kind of those grammatical structures. So we can always do, um, re casting, which most SLPs have heard of, but why I like this one is because you can really like make the toys or the games or whatever you're using really involved. And so, um, the research is on one side of the handout. And then on the back, it gives examples of like how you would use this. [00:58:47] Kate Grandbois:  This sounds like an amazing handout. We will put a link to it in the show notes for anybody who's driving or running or folding laundry. And you would like to look at it further. We'll, we'll pop a link in there  [00:58:57] Sydney Bassard: and these skills are not like, I think [00:59:00] sometimes people go, oh, well, what do I do for deaf and hard of hearing kids? Like these, these are not just for DHH kids. These are good resources and strategies for all children. Um, and like the differences may not be in like how you introduce the intervention. The differences might be is we know that these kids will need more repetition with a particular skill. Um, we know that they might need different acoustic emphasis in order for them to hear and fully detect all of the sounds that you're saying. We know that, you know, they might need the supports of visuals and not just visuals with pictures, but maybe visual signs in order for them to fully understand a message. Um, so those are where I really see those differences come in.  [00:59:53] Kate Grandbois:  That that all sounds very applicable. Like you said, to across a variety of, of [01:00:00] children on your caseload. And again, you know, thinking about SLPs who are listening, who maybe this isn't their area of specialty, but they're curious to move into this area of specialty or they have a case. They, you know, this is represents one child on a caseload of X number of children. a lot of the strategies you're talking about could be very easily applied across the board as just good as good quality, good quality intervention. [01:00:25] Amy Wonkka:  I wonder if in our last few minutes there was anything else that we didn't have a chance to ask you or anything else that you wanna get back up on a soapbox about like sound field amplification in more broad environments in the school system or what have you. Um, but we have a few minutes left where we can review any key pieces. You've already shared a number of awesome references. And I know Kate and I have been taking notes and they'll all be available, um, to listeners on the, on the website. But is there  [01:00:56] Sydney Bassard:  anything else. Um, [01:01:00] I think that we just have to realize that, um, people are going to bring their experiences, um, and that's with anything, but especially with this population. Um, so I caution therapists that are listening to this, like, don't get into these nasty debates that you see on the internet. Um, because parents are watching, parents are watching to see how the professionals are doing and treating each other. And so even though you might think like, well, I'm just really passionate and I need to share, um, we can always share with kindness because you never know the parent that's really just trying to search for answers so that they can do what's best for their kid or the adult who, you know, is now finding themselves is maybe con considering themselves as hard of hearing. Um, And they were never seen as that before, because they had typical hearing, you know, whatever the case may be. They're also watching you [01:02:00] too. And there are people that are just genuinely looking for help without feeling as though they are going to get beat over the head. Um, so that's my kind of like big one is let's all kind of be mindful about these conversations you don't have to, and that doesn't mean that you have to agree with everybody, but I think that there's a way to have, um, respectful discourse. That's not always in agreeance and then no, there's a lot of discussion sometimes around, um, should we be using the terms Deaf, hard of hearing. Um, and there are other terms that I personally don't like, um, that people choose to go by. The reality is that that is a choice um, if somebody chooses to identify as Deaf or hard of hearing, or however else they choose to identify, um, that's their right. And you don't have to like what other people's rights are and what they choose, but you [01:03:00] can just respect it and you can agree to disagree. It does not have to be a fight and a battle  [01:03:09] Kate Grandbois:  here, here. I feel like I feel like saying that again, but that would just be redundant. It's just so important across everything. [01:03:17] Amy Wonkka:  I think there there's such good points. And as someone who, who is like medium old and has been doing this for a while, you know, I, I reflect back and I'm, I'm always learning. I'm always, you know, sort of to your point about. Being a person and carrying yourself with respect and professional humility, um, and engaging in discourse with other people who may have different ideas from you. You know, I mean, I think most of us, if you do something long enough and you are thoughtful about your practice, you can look back on it and think, Ooh, I did that. And, and that's how we learn and that's how we grow. And if we don't, if we don't have the ability to do that, we sort of get stuck where we are.[01:04:00]  Um, so I think there's always this balance of, I don't know, this is, this is like a bigger now you've like thrown me on like a bigger, a bigger social media piece. But you know, we also are sort of controlled by robots who tell us more of what we, what they think we want to hear and what they think we wanna know. So it's also helpful sometimes to listen to things that you don't necessarily agree with. And then just think about that and take some other perspective. And like you said, Sydney, you may still decide that you don't agree with that. Um, but it doesn't hurt to sort of, feed your brain, some different perspective type too. [01:04:33] Kate Grandbois:  And I think learning to be, and this is true for this is a piece of professional maturity that I think isn't really discussed enough, but being comfortable in your discomfort. So learning requires vulnerability. Vulnerability can be very uncomfortable. It can mean that you're wrong. It can mean that you've made mistakes and learning to be more resilient and comfortable in that discomfort [01:05:00] can give you access to so many new learning opportunities and ultimately make you a much better clinician. I mean, it can make you a much better person, but this is about clinical work and really trying to continually shift to person-centered care and evidence-based practices. Um, and that is a really big piece of it. That again, you've sort of kicked us up on the soapbox by accident, but it is relevant. It is clinically relevant. It's a huge cornerstone of professional maturity and good clinical practice. Um, and I really appreciate you bringing that all to light through this lens.  [01:05:38] Sydney Bassard:  Anytime ,  [01:05:41] Kate Grandbois:  We've so appreciated having you here today. Um, all of the references and everything that you shared is all going to be listed in the show notes, along with, um, some research that I'm sure you can provide for us, for anybody who wants to do a little bit more nerdy reading, um, or nerding out on any of the information that you've [01:06:00] given. We're so grateful. Thank you so much for teaching us so much today. You're welcome back anytime.  [01:06:06] Sydney Bassard:  Oh, thank you guys for having me. This was fun.  [01:06:10] 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 is a transcript from our podcast episode published October 31st, 2022. The podcast episode is offered for .1 ASHA CEU (intermediate level, related 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. S4 Brandon Seigel [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 Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois: Each episode of this podcast is of course offered for ASHA CEUs. 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 nerdcast.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 specified. [00:00:53] Kate Grandbois:  We hope you enjoy the course. [00:00:55] Announcer:  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 CEUs 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:  Hello, everyone. Welcome to today's episode. We are really excited to welcome Brandon Siegel onto the show. Brandon, thank you so much for being here.  [00:01:53] Brandon Seigel:  Thank you, Kate. I am so excited to be part of all our S L P nerds [00:02:00] and beyond it. It's really exciting for me.  [00:02:02] Kate Grandbois:  You know, you, can't not mention the name I've had so many people be like, oh, interesting name. It's you're in the right place. I feel like you're, you're a business nerd. You're a medical billing nerd and, and here we are. [00:02:12] Brandon Seigel:  Absolutely. I I've got, literally when we, we started this, you saw my little Doppler twin of me, which is basically a nerdy kid with glasses. Um, the only thing that was missing was the beard, which, uh, came later in life. [00:02:27] Kate Grandbois:  That's. That's wonderful. That's great. Well, we're really glad to have you here. I know you and I have touched base multiple times before we hit the record button. Then you've taught me a lot and I'm really excited to share your knowledge with our entire listener base. You are here to discuss funding options in private practice. So selfishly I'm in private practice. I'm very excited to learn from you today, but before we start, why don't you tell us a little bit about yourself? What, what brings you to the world of funding in private practice? [00:02:54] Brandon Seigel:  Well, couple things first and foremost, everyone should know that my wife, my mother-in-law, my [00:03:00] brother-in-law are all therapists and, um, I've always been a business person, even though if you talked to me as a child, I would tell you I'm not a business person. My parents kept telling me until one day I had that awakening. And so when I had that awakening, it just, it's a natural muscle for me. And I really have found that, although I was bad at math as a child, later in life, I really became just great at, uh, communicating numbers. And I say, it's one thing to understand numbers. It's another to communicate. And so, as I started recognizing the importance of a business algorithm in a private practice, I recognize that I could help solve problems. And so it started with my mother-in-law's practice that had more money than I want to share outstanding, um, with major insurance headaches, and basically she was working for free. And, um, it turned into me saying I have to solve this problem. And so throughout that process, I not [00:04:00] only learned how to medical, to bill all the insurance, but I really navigated the funding sources from all different ways of funding, more than you can imagine. And I kind of came up with this business algorithm of helping private practices, diversify their funding and solve their funding issues in creative ways. [00:04:21] Kate Grandbois:  I'm so excited to learn more about it because as many of our listeners probably know, funding is a huge headache. We don't go to school for this. I won't share the abomination of my personal math skills. I live in Google sheets and Excel, um, and we're clinicians by training and it's really our passion. Most of us, to focus on our clinical work. But as many listeners know, if you work in private practice or have a private client on the side, you can't work on your clinical work, focus on your clinical work if you're not getting paid. So unfortunately these business aspects are a critical piece of what we do for a living and. We're [00:05:00] really grateful for people like you to show us the ways, show us the money, so to speak. So you told us a little bit about your background, but you also have, uh, a podcast. You're a fellow podcaster, as people who are watching on YouTube can see with your fancy mic. [00:05:14] Brandon Seigel:  I am a fellow podcaster, so I have a love- hate relationship, but I love it because people love it. And it's called the private practice survival guide podcast. It's on everything streaming, apple podcasts, Freaker, you name it, uh, iTunes or I apple the whole bit. So the private practice survival guide podcast with Brandon.  [00:05:38] Kate Grandbois:  That's awesome. Um, and I know that you are going to get into some pretty heavy duty stuff with us today. For those of you who are listening, if you are not at all familiar with private practice, this episode is likely not for you. I think the content that we're gonna talk about today is intermediate. We're gonna be talking about billing codes. We're gonna be talking about EMR [00:06:00] systems, insurance liability. So if you're already in private practice and either thinking about dipping your toe into the insurance world, or you're already there and wanting to scale your business, then this is the episode for you stay tuned. Um, I also wanna say that we're gonna cover a lot of ground today and you have a conference coming up where our listeners can learn even more. Do you wanna tell us quickly about that? [00:06:21] Brandon Seigel:  Absolutely. So we've got a conference called the growth code conference growth code conference.com . Um, it's designed for occupational physical speech, language pathologists. We have, uh, private practice owners, private practice managers, office managers from coming all over the country to join us February 23rd through February 26th, we've got, uh, tons of content, lots of speakers, general sessions, we're covering marketing. We're covering HR, we're covering medical billing the whole bit. We've got a lot of fun stuff, uh, coming, coming to everyone's way. So it's gonna be in sunny, Florida, February 23rd to 26th.  [00:07:00] Kate Grandbois:  So, everything [00:07:00] that we talk about today is going, is just a little bit of a tip of the iceberg. There is more out there, um, medical billing and in private practice management is a whole career's worth of information. And there's absolutely no way we are going to squeeze it all in. Um, but we'll list everything in the show notes for anybody who's listening, jogging, folding  your laundry. Um, if you are after, after this episode, if you wanna go out and learn some more. Before we get into it, I wanna take a minute to read through our learning objectives and disclosures. I'll get through them as quickly as possible. Learning objective, number one, describe the difference between private pay and insurance models of funding and private practice.  Learning objective number two, describe at least one creative funding solution in private practice and learning objective number three, list two strategies to minimize administrative burden when billing and private practice. Disclosures Brandon Siegel's financial disclosures brandon is the owner and founder of wellness works [00:08:00] management partners, which provides services related to medical billing, marketing, HR services, business, coaching, and consulting, wellness works management partners is the producer of, and has direct financial relationships with the growth code conference, which will be mentioned during this episode, Brandon Siegel's non-financial disclosures. Brandon has no non-financial relationships to disclose. Kate, that's me, my financial disclosures. I am the owner and founder of Grandbois therapy and consulting LLC, and co-founder of SLP nerd cast. 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, mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. Okay. Let's move on to the fun stuff. I'm almost out of breath from reading that, which is horribly embarrassing, but let's, let's get into the first question. So why don't you tell us a little bit about the different types of funding sources in [00:09:00] private practice?  [00:09:01] Brandon Seigel:  Absolutely. So it's so funny because we, we get into this field and all we think is usually three different funding sources. We think of, uh, obviously insurance, which is our medical model. And then we also think of schools because a lot of us will subcontract or work for the schools. Um, and then usually we think of this thing called private pay cash, but a lot of us don't think it exists in our field when it does, but there are so many different funding options beyond that, just to unlock some unique perspectives. Real quick. One is government contracts. A lot of us don't know there's government contracts that will pay for services, um, related to speech therapy. And you might not even know it. And sometimes it's county based, regional based. Sometimes it is, you know, government funding, like early start DBS, D B all that stuff. So, um, the other thing that we're seeing a huge, huge growth in right now [00:10:00] is, uh, what's called self-funded employer contracts, where companies are now investing to say, I want a special SLP benefit for my employee's children. And I want an AAC benefit and all of these things where employers are doing self-funded healthcare coverage, but they're adding in direct contracts with local providers to be on site or in the area to support their employees. So there's a huge, um, market right now in what I call self-funded employer gain, uh, other creative things. Obviously there's nonprofit funding there's, um, you know, different ways in terms of, uh, different types of school contracts. And so we're, we're definitely seeing also subcontracts related to skilled nursing and things that are just not tied to the, the you accepting insurance. So sometimes we think of either accept insurance or [00:11:00] accept private plan. There's nothing else there are different. Um, even just aging and place contracts. Um, there are grants, there are, um, again, I'm thinking on the cusp, but I, I would say that there's at least 25 different funding sources and we only think of three. Um, and so sometimes it's understanding what our role is in the community and aligning with who has budget connected to that. Um, because there are groups that will just pay for your services. Um, and sometimes as a speech language pathologist you'll even get paid cash as an organization from another organization, like an ABA company. Um, there's a lot of creative ways to kind of connect your services so that you're not just stuck in one funding source um, as your solution. . [00:11:47] Kate Grandbois:  So right out of the gate, my mind is blown. I've been in private practice for 12 years. No longer than that. I see. I don't do math. That's fine. It, it, and I, I think up until now, I [00:12:00] probably, I knew about private pay and I knew about insurance and maybe one or two other things like I've done school contracts, for example, but I love the perspective of thinking about connecting your services with budgets who have money for you to pay your services, because it's, it sounds like there are such a wider variety of options to choose from. [00:12:23] Brandon Seigel:  Absolutely. And I had picked on the employer benefit because that is the biggest thing right now that's changing. Um, you know, in terms of employers right now are seeing they're expecting like 50, 60, 70% increases to premiums in the coming year because of COVID. Oh, so they're looking at alternative healthcare services. So what if I could change? And I, I'm going to get Kate's company catastrophic coverage for all her employees. I'm gonna get them a telehealth subscription. And I'm also gonna get a subscription to a local speech provider for their kids, because I know that our families really [00:13:00] value therapy. So we're gonna create a monthly subscription where we do what's called a capitated contract with them versus a fee for service contract. So there's all different ways to kind of think outside the box to help each other out.  [00:13:13] Kate Grandbois:  Okay. So if you're a clinician listening to this episode, you're and your mind is blown like me and you're thinking, okay, well I have a small roster of clients or I'm look, I have a small practice and I wanna grow my practice. I think, would you, is it fair to say that insurance is still a primary or large avenue of, of funding or something that's at least worthy of our attention to get credentialed and set up  [00:13:41] Brandon Seigel:  a hundred percent. So. The medical model is a model, especially as we, as we head to a recession, people are going to lean more on what coverage they have than selective private pay. Now it doesn't mean we can't get creative with private pay as we'll talk about later in the episode, but especially with speech, I [00:14:00] think it's a cornerstone and I think speech therapy right now, um, in almost every state, I can say you can be sustainable through insurance as we'll just say, 50% of your funding model. I'm not telling you to be a hundred percent funding model, but I think that there's a, a place for 50%, but the other thing we have to look at Kate, when we look at your business algorithm, like when I talk about your business algorithm, what I'm talking about is your employees, your overhead, all the pieces, what comes in and what goes out in expenses. There's a big difference if I'm talking to Kate and Kate has 50 therapists versus Gina who has two therapists. When Gina only has two therapists, there is a supply and demand thing here where we, we have more control. We might not need insurance because there's less of us to go around. But when we've got 30 therapists that want full-time work, we're gonna need to play in the insurance game. It's not a matter of if it's when, unless we're really [00:15:00] a school contracting company, insurance is gonna play a big part. So what I wanna say is that when we have a lot of therapists, we're gonna lean on government contracts, school contracts, insurance contracts, that's our primary cash flow of our practice. And we're gonna utilize private pay and creative funding sources for some of our unique outliers and identifiers of what separates us as an organization.  [00:15:25] Kate Grandbois:  So to say that back to you, it sounds like it's fair to say if you're operating in a business model where volume is a part of your revenue stream. So you're not seeing 10 clients a week, you're seeing, I don't know, you've got 17 people working for you and each of them has a caseload of 20 that's when you really start to lean on insurance as a, as a backbone of your practice from a funding standpoint. [00:15:48] Brandon Seigel:  uh, I would say the combination of insurance and what I'm calling government contracts. And I consider school kind of under government because of the government. Kate Grandbois:  Yeah. That makes sense.  Brandon Seigel:  Funded [00:16:00] mm-hmm so I would say those two entities are more of transactional funding. I do it. I get paid. I do it. I get paid. There's a reliability, there's a consistency. I go to the pool, I stick my straw on it and I drink some, some revenue, so to speak. Um,  Kate Grandbois: sounds lovely Brandon Seigel:  So , so those two factors play a part when I've got overhead to support, that's greater than just. A couple couple of us playing, playing in the pool.  [00:16:25] Kate Grandbois:  Okay. This is a wonderful analogy. I feel relaxed, like I'm sipping on a cocktail, sitting on a pool on a pool side somewhere instead of, you know, buried under the horrible paperwork that is insurance funding. So, so let's talk about that a little bit. If we're really thinking about the kinds of funding sources that are available. Um, I, I know so many private practice owners who deliberate for a very long time as to whether or not to start accepting insurance because of the administrative burden that comes along with that. And I know we're gonna get into that when we start talking about our [00:17:00] third learning objective, but let's talk a little bit more about the logistics and structure of insurance funding models. Um, what would you say are some of the key necessary pieces to bring that into your practice? If you don't already have that set up. [00:17:21] Brandon Seigel:  Well, the first thing I, I actually wanna just talk about is when we're dealing with insurance, we actually have two different buckets that we can pull from in network out of network. [00:17:30] Kate Grandbois:  Oh yes. Yes. It's like a decision tree. It's like private pay versus insurance and then insurance is broken up into two of them. [00:17:38] Brandon Seigel:  Or we could also say one is an RV and one is a plane. I don't know if you've heard that radio ad for RVing, but it makes me never wanna step on a plane. It's got kids screaming that you're on the runway and like, it's really awful. So there's what I call air travel. And today we'll call that insurance and then there's RVing, which is out of network. We call that out of network. [00:18:00] Um, there's good and bad in both circumstances.  [00:18:03] Kate Grandbois:  Interesting. Okay. So, but one sounds a lot more like fast and one sounds a lot more luxurious is that, is that intended?  [00:18:11] Brandon Seigel:  Um, depends how you play it. So let's say it this way. We're gonna, we're gonna start with in network. So why do we accept in network? Because we can get more clients. It's a marketing action. I just wanna be transparent when people are accepting insurance as an in-network provider, you have a bigger pool of people that want your services, and you might not have enough of a differentiator to pull outside of that bucket. So you sacrifice pay in order to tap into the pool of in network, uh, clients subscribers. Now we're gonna put that to the side and we're gonna look at out of network out of network allows you to name your price. You have price control. [00:19:00] So a lot of people like out of network because you are not subject to the in network rates. Now within the out of network bucket, I wanna make sure everyone understands. There are three different ways that we can play the out of network game. The first is we accept assignment of benefits and we submit to insurance. So it feels similar to in network because we're waiting to get paid by insurance. And we're submitting the claims on behalf of our client, our subscriber, but we get to name the prices. So we're not subject to contracted rates. We have our fee schedule and whatever the out of network covers they cover and they will pay us and we will charge whatever the responsibility is of the patient. If they don't pay, we will charge the full rate that we charge the client, the, the insurance to our client. And that is what I [00:20:00] call out of network accepting assignment of benefits,.  [00:20:06] Kate Grandbois: AOB I know that acronym, a AOB, AOB assignment of benefits. So just to again, say this back to you so that people are following along, we've got insurance divided into two categories in, in network and out of network and out of network this is where you are billing insurance directly. And, but setting your own fee schedule and assign and accepting the AOB, the assignment of benefits.  [00:20:30] Brandon Seigel:  So that's one bucket.  [00:20:33] Kate Grandbois:  That's one of them, three options, three options for out of network  [00:20:36] Brandon Seigel:  three. So that's just one.  [00:20:38] Kate Grandbois:  I'm gonna guess that one of them is a super bill. Yep. Why don't you tell us about that one next. [00:20:42] Brandon Seigel:  So the second one is, Hey Kate, here it is. I'm gonna take your money. $185. Boom. Give it to me. Here's your receipt, your super bill, your codes, my MPI, everything you do, what you want with it. You submit it to insurance and there's a good chance that you're gonna get reimbursement if [00:21:00] you take the effort to do it. And if you need anything more like copies of my notes or whatnot, let me know. So we've got  Kate Grandbois easy peasy wash my hands of it. That sounds great to me, Brandon Seigel:  polarising energy. So one is, oh my gosh, I'm still responsible, but I'm getting my rates. The other is like, give me my money. Here you go, go have at it, whatever you get, you get and you're on your own. Right? So then there's the middle bucket.  Kate Grandbois Oh, I didn't know that there was a middle bucket.  Brandon Seigel: so the middle bucket is I'm gonna charge you Kate, $185. I'm gonna submit. I know. Everyone's like, why did you come up with that, that dollar amount? [00:21:37] Kate Grandbois:  I'm like, should we have a conversation about setting your rates? Maybe that's another episode. Anyway, keep going, keep going. Don't we're in the middle bucket.  [00:21:44] Brandon Seigel:  So we're in the middle bucket. I charge $185. Kate pays me $185, but rather than me give her a super bill. I'm gonna submit the claim to her on her behalf, but I will not accept assignment of benefits. So the insurance will pay Kate, but [00:22:00] meanwhile, I've saved her a step by submitting the claim for her and I'll know right away if it gets rejected or processed or whatnot. So I am speeding up the process and I'm doing a little bit of work, but I'm not necessarily getting hit by the cash flow, waiting to get paid by the insurance company. [00:22:17] Kate Grandbois:  But you're also taking on some of the administrative responsibility as a courtesy to the family versus the super bill where you're just giving them a bill and walking away with your cash. [00:22:28] Brandon Seigel:  And here's the other kind of curve ball. Are you ready for one more curve? I wasn't prepared for a curve ball. So here's the curve ball. This is I'm giving a disclaimer, this not advice. It's just a perspective. You gotta deal with it and think with it and check with your accountant, lawyer, everything. So don't boy don't hold me to it, but there is a world when we are what I call a private pay practice that offers the opportunity of out of network where we don't accept assignment of benefits that we say, look. Here's your super bill, but if you want us to submit, we have a [00:23:00] subscription price for us to submit on your behalf. So you charge Hey, $50 a month and we'll do all your submissions for you.  [00:23:08] Kate Grandbois:  Interesting. So it's like a, you're charging the family for an administrative service.  [00:23:13] Brandon Seigel:  for, for, to save a, save the energy. And we're not under contract with an insurance company. So it's not looked at a surcharge or anything. It is an elective that, uh, you know, service that we are offering. Hey, you know, you want us just kind of like, Hey, you want us to offer you 30 minutes of childcare while you wait to come back for your child, we've got childcare as well. Um, interesting. It's just an alternative way to say. We know that sometimes the burden of submitting is worth extra 50 bucks a month. And so for you to submit all the claims on our behalf, like it's worth it and it's month to month, you can cancel it anytime.  [00:23:50] Kate Grandbois:  Interesting. That definitely sounds like a, I wanna have a conversation with my accountant and attorney first kind of flavor, but it's really, that's a very, talk about creative [00:24:00] solutions. That's a really, really interesting, interesting perspective. Okay. So we've got our under our insurance umbrella, we've got in network out of network. You've walked us through these three options for operating out of network. I only knew of the super bill. Um, so that's really helpful. But when we start talking about going in network, I feel like that's where a lot of clinicians start to get like hives. Like I, they reimburse sets such lower rates than private pay. You take on all of this additional administrative burden. You become a covered entity, et cetera, et cetera, et cetera. So where do you even, I'm, I'm curious to hear where you're even gonna start going down this road. with, so with the in-network piece. [00:24:43] Brandon Seigel:  So the first step is I think you have to have a vision of what you're trying to do. When you're going in network, usually there's two things that impact that decision. One is what I call scale, the size of what you wanna produce. And the other is accessibility that you wanna make your [00:25:00] services more accessible to those who might not be able to access it. So that's the first, that's the why, let's define the why. The next thing is we have to reach out and find out what fee schedules are current. You would be amazed by how many people go in network and don't know what the rates are. And I literally just had a meeting last week. I think it was yeah. Last week with, uh, a client that they reached out and they're like, look, we wanna know how to bill OT PT speech. And they're like, can we find out? And it was one of my 30 minute free strategy sessions. So they went, they credentialed, they contracted, they did everything. I said, do you know how much you're gonna get paid? They said, no. So why would you contract, like, would you sign up for a dinner without knowing how much the dinner's gonna cost you? [00:25:49] Kate Grandbois:  but how do you find out? I always, and maybe this is wrong, but we're gonna be vulnerable here and having have a learning moment for the entire audience to understand something better. How do [00:26:00] you even find out? I was always under the impression that contracts between insurance payers and providers were under lock and key. Once you had that contract, you, you, weren't supposed to talk about insurance, not to mention talking about money makes people uncomfortable to begin with. [00:26:13] Brandon Seigel:  So technically speaking, yeah, and in network providers should not be sharing their rates with you and what they get paid might not be what you get paid. So what you need to do is part of your utilization management process, which is where you're connecting with that, is you need. So I always say, um, the more power that you have, the easier it is to get what you want.  Kate Grandbois: Touche. Brandon Seigel So if a client comes to you and says, I love for you to work, my insurance. I have the client call their insurance and say, I have a provider that I want, I can't find anyone in the area. Can utilization management help me connect you with this client? And that might sound weird, but like, literally I start in that way, cuz I've got the power. Now it could be that the, what they do is they come [00:27:00] to me and they say, Hey, the, we need you as an in-network provider. My first thing is I need your fee schedule. Show me your fee schedule. Sorry that fee schedule won't work. Well, then they may do a letter of memorandum or a memorandum of understanding, which is like a single use contract in which you can name your price for that client. And then upon, depending on how many people they end up meeting you, they may grandfather you in to that in network contract at the rate that you want. That's the first thing to understand that sometimes when you hold the power, you actually can negotiate. And so sometimes a patient saying, I don't have a provider of the quality I need within your network. I found someone, can you work with them to either create a letter of understanding or whatever you wanna call it, a single use contract with this provider. Um, and sometimes they'll also just bring you [00:28:00] into their end network. So that's one thing. The second thing is you can contact the insurance and I get, you were like, I never get a call back. I never got an email. It might take you 60 emails and calls. You've gotta be persistent. You doing it once, twice, three times. Do I seem like someone that lets you drop the ball? No, I'm like, I'm gonna chase you down. [00:28:20] Kate Grandbois:  Your little avatar was very intense. I will, I will give you that  [00:28:23] Brandon Seigel:  very intense. And I'm currently, so I'm currently contracting with someone right now that I said. Literally like every other day, I'm like, Hey, I haven't heard back. Where are we at? What's your timeline? Who do I need to talk to, et cetera, because we know staffing is hard, but I also throw my patient minions on the insurance to say, I need you to contract with Brandon. I need you to contract with Brandon. I need you to contract with Brandon. It works. Um, but,  [00:28:49] Kate Grandbois:  but you have to create that leverage because we don't have that leverage,  [00:28:53] Brandon Seigel:  create the leverage. If you don't have that leverage, then you have to be a squeaky wheel where you call and you say, I [00:29:00] understand you sent me a contract. I need to know the rates do not sign a contract. Is it based on CMS? What is that? If they say to you, well, you need to sign that contract before we'll share the rates with you. Don't do it. Don't do it.  [00:29:19] Kate Grandbois:  That's really great advice. And I think that many of us feel beholden to whatever the insurance company dictates. We don't see ourselves in positions of power, or we don't see ourselves as, as being individuals who could create leverage or create more of that position of power. So that's, that's tremendous advice. I'm wondering.  [00:29:40] Brandon Seigel:  just so that everyone understands, because I work with insurance throughout many, many states, Medicaid only works in very few states and I just wanna be very transparent. And this was the mistake that the, this other group did is they contracted with Medicaid, not realizing it's $32 and 50 cents [00:30:00] for a visit. Okay.  [00:30:02] Kate Grandbois:  That is, That is not clinical staff rates. So that is not clinician rates that's horrifying. [00:30:06] Brandon Seigel:  But then I can go to Texas and get 86, 50 or 88, 50 or whatnot for 9 2, 5 0 7. So each state is different. But what I want you to understand is the majority of states Medicaid. There's a reason why people don't accept it. So if you're like, no one takes Medicaid, so I'm gonna go take it. There's a reason why, well, Brandon, there's this underserved. Then they need it. I go, you're gonna lose money. You're gonna lose money. Well, how do the hospitals do it? How do the healthcare systems do it? Totally different contract. It's not the same contract.  Kate Grandbois:  Wow.  Brandon Seigel: So first and foremost, it's very hard. If you're not in Texas or a couple other states, it's very hard to work with Medicaid, California, New Jersey, Florida. Good luck, uh, Florida, you can do it, California, New Jersey. I have yet to find a private practice who's not a nonprofit who does not have grant money or other things to offset it. [00:31:00] Who can do Medicaid now by and far, I'm gonna throw this out there. A 9 2, 5 0 7 reimburses for commercial insurance or, um, some HMOs, usually between $55 to $98 is the average for that 9 2 5 0 7, just so we know that language code. Now, what wear speech is able to optimize is a lot of speech are getting into feeding and they're pairing a 9 2 5 2 6 feeding code for myofunctional. And myofascial all that with a 9 2 5 0 7. Well, now all of a sudden they're doing that untimed code. They're doing two units within whatever they decide is needed. 30 minutes, 40 minutes, 45 minutes, whatever they dictate. And now they took quote, unquote, let's just say $55 and $55. Now they're getting $110 for that visit. Right? That's how they're making in network work, just so we know, [00:32:00]  [00:32:00] Kate Grandbois:  right. Combining different codes. And if you're listening and you haven't explored the different combinations of different CPT codes, uh, the American speech and hearing association website does have a good, I'd say gateway, uh, website into how the different codes can be used, what the different codes are for. Um, but that's, that's a really, really awesome suggestion. And I, I think as I mentioned, so many of us feel beholden to what the insurance companies say we can do. It's a very intimidating, particularly if you're a small practice trying to grow, um, you know, you sign, sign away in blood on the dotted line and cross your fingers that you don't commit some sort of break some sort of rule or, or, you know, infringe upon some law. Because once you sign that contract, you do become, uh, become what's called a covered entity, correct me if I'm wrong and you are beholden to additional laws and regulations. Can you tell us a little bit more about that?  [00:32:57] Brandon Seigel:  Yeah. And I'm gonna jump to that, but I wanna [00:33:00] just finish one thing on, on the code thing. Um, just because there's codes does not mean you can use the codes, does not mean that just because you can use the codes does not mean you'll get paid for the code. Just because the codes are approved as a benefit does not mean that insurance has to pay for that code. So there's a lot to understand in terms of exclusions and evidence of coverage and all these factors, whether it's in network out of network and whether you can code things together. A lot of times I'll see people reference ASHA and there's a lot of great info in ASHA, but there have been some management codes that were misquoted and are illegal to be used. So please check. Kate Grandbois:  Interesting.  Brandon Seigel:  Please check, because some of these management codes should not be used depending on insurance and location and all those things. So a lot of the times what a coding professional will do is they will check their AAPC. Again. I'm gonna say it one more time. AAPC is a coding professional association, kind of like [00:34:00] you have your Association. It is, in my opinion, the elite of medical billers, they've got certifications that you take crazy tests for and et cetera, they have a product called codify. And in that codify, you can check codes together as what's required, what the requirements are, et cetera, just in terms of coding regulations so that everyone  [00:34:20] Kate Grandbois:  I'm laughing because I was in there this morning. there you go there, you, I didn't know I was using an elite database or an elite service, but that's good to know. Um, they have some info, they have a paid service, but they also have some good free information on their website as well.  [00:34:37] Brandon Seigel:  They have both. And I think that even everyone always asks me, like, where should I go to learn how to bill? And I say, there's not a direct, here's how to bill as a speech language pathologist. There's not, but there are some good classes and courses and things that you put together. And sometimes it's about understanding Medicaid and Medicare. Which there are some great [00:35:00] resources out there for that. And sometimes it's going to ASHA and sometimes it's going to private practice specialists, and sometimes it's going just to the coding world, like AAPC and codify. Um, so all of that is helpful, but let's get back to your question, which is kind of the liabilities of being in a network provider and kind of doing that. So we find out, you know what, Brandon, I'm going in network. I'm gonna make the pricing work. Um, so you need to make sure that you're paying your staff correctly. You need to make sure that you have that business algorithm of how much should I pay for therapy. So I'm gonna give you one nugget real quick. I know this is kind of a, I just wanna give a lot of content for you all.  [00:35:43] Kate Grandbois: I I'm, I'm here for it. Do it,  [00:35:44] Brandon Seigel:  your revenue that a therapist generates, they should never take more than 60% in total cost of the revenue they generate.  So if you accept a rate in this case, that's [00:36:00] $55. Okay. And of that $55, you say, you know what, Brandon, I don't wanna do a 30 minute visit. They need an hour. Okay. So at the end of the day, if we were to say, what am I paying them? You're total cost taxes, benefits, everything cannot exceed $33 for that visit. [00:36:18] Kate Grandbois:  I think that's great advice. And I, um, I joked earlier with the, with the margins comment, but this is something that I learned sort of on the road. And when you do math by looking at the percentage of visit, it's a really, at least for me as a practitioner who is not a mathematician, uh, it's a really nice way to keep your profits and your revenue in check. As you build things along to make sure you're not accidentally cutting into a budget too steep, or, you know, you, you have enough room for overhead. And I, I think that that's, that's very sound advice.  [00:36:51] Brandon Seigel:  Yeah. So we wanna know. So when people say what's my, what should I pay my therapist? What's my productivity. It all comes down to the revenue they generate and I'm getting 60%. [00:37:00] And us just basically financially modeling what that looks like. Here's what 60% productivity looks like. Here's what 70% looks like. Here's what, 75% productivity. So sometimes we build a base payoff of 60% productivity and we bonus of both, there's all different ways to play the tricks. But getting back to in network insurance, we accept the prices. Okay. I'm, I've, I've made a deal with the devil, so to speak and some of these insurances are the devil. So then we need to understand what does it take? We need to make sure we're credentialed. We need to make sure that we have software that allows us to submit electronically. And ideally, we also set up electronic payment, the ERA electronic remittance. Um, and so these are all factors that we want to structure. The other thing we need to understand is how long it takes to get credentialed. And how does it work in terms of if someone's not credentialed, um, what are our rights and what is right and what is wrong? [00:38:00] There's a lot of great areas. So like, one of the things is, can I, bill, can I have this, uh, therapist, bill under me because I'm credentialed with insurance, that's a gray hole that is an abyss. And it's like, well, I do that for my CF. So can I do that with someone? Depends. All I'm gonna say is it depends. There are insurance companies that, that will tell you under no circumstances, can the rendering provider not be the credentialed provider.  [00:38:31] Kate Grandbois:  Interesting. So there's a, and it's really a case by case basis. You really have to know exactly what your contracts are, what your payers will and will not allow [00:38:37] Brandon Seigel: . And you have to ask the right questions, not set them up for the answers that you wanna hear. [00:38:47] Kate Grandbois: I love that. It's not manipulation. It's smart communication. Yep. Yep. It's wise. It's good question asking. Okay, so, so let's say, pretend you've, you've gone. You've made a deal with the devil, as you said, I [00:39:00] love that expression. And not only now, are you beholden to being credentialed and using an EMR, but there are other requirements as well. Can you tell us [00:39:07] Brandon Seigel: , so we're credentialing, we've got the EMR system. We gotta verify eligibility. We gotta make sure we're getting authorizations. We need to make sure that we're disclosing. Um, obviously what the, the out of pocket max would be for them. Um, it's called a good faith estimate. Ironically side note, my mother-in-law called me and said that she was chasing down all her providers for one of my father-in-law's procedures, asking for a good faith estimate. I'm like, you shouldn't have to ask for it. They should already provide that to you.  Kate Grandbois: Right. Right.  Brandon Seigel: You know, things like that. The other thing I wanna make sure that everyone knows is that when you are in network with an insurance company. You are not most contracts. I'm gonna say it this way. Cause I don't like to talk in black and white. Most contracts will not allow you to see a client unless it is through their funding source for a [00:40:00] medically covered service. So if Kate has blue cross and I accept blue cross and Kate says, Hey, Brandon, I just wanna come to you private pay. I don't wanna use my insurance. The minute you hear she's a blue cross subscriber. It is blue cross or nothing, honey. Like they have no middle ground there. So you have to recognize that there is this component where I said, Kate, I'm an in-network provider. It is, you have disclosed that you are a blue cross provider. I must treat you through your insurance. I have, I I'm obligated by my contract. Now, if something's not medically covered and it is not a medical necessity. Then you need to have a release form that helps 'em understand that they are signing up for elective services that are not part of their medical benefit, that they understand that their insurance will not be held liable in any form. And that I like to say, this is recreational and elective solutions that you are choosing to sign up for [00:41:00] and that they sign it really clear because you do not want that receipt going to the insurance and the person saying, I thought, I'd see if they'd cover it. What do I have to lose? Right? No, you can cost me my contract. So it's very important that you have that agreement so that you say NA NA NA NA nah, I had them sign this. They knew it was not medically necessary because insurance has two objectives. And I mean, no disrespect when I say this, but it may offend insurance companies who are listening. One is they wanna only cover what they have to cover. Yep. And I'm gonna say that again. They only want to cover what they have to cover and what's the second thing? They do not wanna get sued.  [00:41:44] Kate Grandbois:  Yeah. Well, nobody wants to get sued, but I think, I think that the, I think the point you're making is such a wonderful one and really, really important because so many of us are so afraid of the, the big, scary [00:42:00] insurance fraud, right? So like what's covered and what's not covered. And I am gonna take this moment to get on a little bit of a soapbox that almost all of our listeners have heard me get on. I wanna say every single episode, because we talk about it so often. Indirect service. There is such little coverage for indirect service, and I complain about it all the time because indirect service is a critical part of providing high quality evidence based interventions. Right? So these are things like consulting with classroom teachers, consulting with parents, providing training, um, reviewing documentation, working on generalization while the client or the patient isn't isn't physically present. And it's my understanding that these indirect services are generally not covered by insurance funding  [00:42:47] Brandon Seigel:  hundred percent. They're not part. So I'm gonna take everyone into a sandbox right now. We're sitting in this sandbox. Okay. And all these grains are all the sand [00:43:00] grains represent the needs of one person to reach their best selves. Okay. So. Have you ever seen those turtle sandboxes? I love them. Green launch. Oh yes. Sand in everything. [00:43:12] Kate Grandbois:  That was like a, that's a call back to my childhood right there. They were all so  [00:43:15] Brandon Seigel:  hot visually we're in this green turtle and all of the sand greens represent, represent the needs that we have to be successful in life. Functionally, healthwise, everything, all of those sand grains for the sake of this analogy could be benefited by speech therapy. But guess what? Only one handful from that entire sandbox is considered medical ness, which is  [00:43:44] Kate Grandbois:  horrifying back to what did you say? Deal with the devil in thinking about our healthcare system and, and the red tape and the, and the funding issues. There are that many grains of sand that there are that many needs to only be [00:44:00] provided coverage and funding for these medically, this medically necessary handful of grains of sand. Um, and I think, I wonder, go ahead. Do you know why? Because they're not medically necessary or because the insurance company doesn't wanna pay for it and doesn't wanna get sued  [00:44:17] Brandon Seigel:  but, well, that's true, but the reason why it's only one hand truly one hand versus two or three or a bucket fold is because the benefit that we operate in is a very specific bucket called a rehabilitation benefit. And because it's a rehabilitation benefit, it provides such a narrow lens of need for the medical function of person, a child sector  [00:44:46] Kate Grandbois:  that just leaves so many grains of.  [00:44:49] Brandon Seigel:  Exactly. So many. So why, why isn't speech therapy also part of a, uh, behavioral benefit? Why is it only in the re the rehab benefit? I don't know [00:45:00] why you're the expert. Tell me so some person or people came up with this idea of medical necessity and they've segmented, functionally what people need. So you tell me, you know, back in the day, when I say back in the day, 20 years ago, we could get someone weeks and weeks of rehab for a stroke rehabilitation. And now you're lucky if you get maybe two weeks, if you're lucky. So, uh, the, the, the grains are changing based on utilization. And so this comes back to we've put our livelihood in the hands of an insurance company. Yep. And that's the mistake we as a society have done because. The insurance is a for profit. Yes. They will make profit before they make well on your policy. They're betting on you being healthy. They're betting. So when we spend, let's just throw out a number, [00:46:00] uh, we spend $9,000 on our premium. Let's say a year they're betting on you spending less than $9,000 on your healthcare company. That's what they're betting on. Claiming  [00:46:14] Kate Grandbois:  simple, making the point or reminding us that they're a for profit company is, is such a sickening lens. Really. I mean, it, it's, it's sort of bothersome, but I wonder if we could get back to this, all of these other grains of sand in the turtle sandbox, because it's sort of touching on our second learning objective, which is creative funding solutions. So if you are a provider. You are, you know, looking at the one grain of the one handful of, of services that you're able to provide. 9 2 5 0 6 9 2 5 9 2 5 0 7 9 2 6 0 9. I'm just like rattling off the ones that I happen to use all the time. You know, that they're covered services. You have the family sign, a contract, knowing that if you provide any indirect [00:47:00] services, you have them sign an agreement that they understand it is not covered by their insurance, et cetera. How do you go about getting funding for some of these indirect service that as a clinician, you know, is critical and necessary for their wellbeing, for their progress to make gains for good patient outcomes. But to your point before, it's a matter of accessibility, not all families are sitting, you know, they're not the Scrooge McDuck diving in their basement with gold coins. If you don't get that reference, then you're not as old as I am. Yeah. But, um, I, you know, I wonder what other, what other, um, Funding solutions a clinician could employ or at least counsel their, their client about when they're in that position.  [00:47:43] Brandon Seigel:  Yeah. So I almost sang the ducktail song, just so you know but, um, I won't because you want a thing you can, you're allowed, I I'm close to it, but I will, I will digress. So the first thing is, is you need to play the game to [00:48:00] understand that on this buffet table only the medical necessity is connected to insurance. We have to stop trying to fit a 16 meal buffet to one plate, and that's what we're doing. How do I get insurance to cover? How do I get insurance to cover? How do I get insurance to cover? So if I'm trying to get 10,000 grains of sand into one funnel, it's not possible. So I have to play the game by saying, what is part of this rehab benefit? What can I cover under this rehab benefit? And how do I tap into other resources to support this person, this child, this family, whoever it may be, depending on your demographic. So creative things, just so we can think out outside the box, first thing first, and you have to check with your lawyer, check with your CPA. Please don't take my word for this, but there is a world where you have two different companies, two different tax IDs, two different NPIs. One is [00:49:00] Brandon Siegel rehab, and I focus on the rehabilitation of yourself. And I only focus on that medical necessity. I'm an in-network provider. Here we go. Boom. But then I have this neighboring company that's called BCS concierge, where we are out of network focused on wellbeing function and elevating the way that you walk through life. Okay.  [00:49:24] Kate Grandbois:  and that was a very smooth commercial to fly right off the top of your head. [00:49:29] Brandon Seigel:  See, you would never know that I was creative solution. My Brandon single before I went to business school, Brandon was in the performing arts. Oh, that's funny. Yeah. Um, so anyway, we could have a concierge care that works on things that are outside of the medical model we could work on. Um, and then we have the medical model. That's one thing just sometimes we'll do in network and out of network. Also, there are some things that we see as in network [00:50:00] versus some things that are out of network. Again, I'm throwing some curve balls here. The next thing is just in terms of creative funding, we could participate in care. Credit care credit is a funding option, kind of like a credit card. You can offer 0% and it might be that you say, Hey, we offer care credit to help offset some of these additional resources services that you need that are above and beyond medical necessity. And you get 18 months to pay that down as a monthly period. So that, that sometimes it's not free money. Sometimes it's leveraged money or time based money that, that you do so that K can get paid by care credit on day one. But then the patient has 18 months to pay that off. And we're seeing that to be very helpful right now, even with those who are in network with insurance, when things are needed. Now, something I did not say that I think is really important that everyone understand if you bill insurance as an in network provider [00:51:00] and you make the mistake and it gets denied by insurance, you are not allowed to charge the patient for that. So if you treat a patient without an authorization and it is denied with, cause you must eat it, you cannot charge the patient. And there are a lot of people out there that think you can charge a patient. Well, I, I held them to it. No. You didn't get authorization. You're in breach of that contract. You have to eat it, not the patient, not the insurance. Just so we're on the same page. I mean, in  [00:51:33] Kate Grandbois:  some ways it's comforting to know that there are all these regulations that protect the patient, but in other ways, it's so disheartening to really take a step back and look at all the red tape and barriers that go in between a provider providing high quality care and giving the patient the treatment that they need  [00:51:51] Brandon Seigel:  playing with insurance reminds me of the board game risk. If you ever played risk, you have to know how to dominate and put all your forces [00:52:00] together to, to win the land because it takes world domination to be at its best when you're working with insurance. So if you like the game of risk, then absolutely. You'll like the insurance game. It's tactical, it takes strategy, it takes mindset and it takes a team. But when done correctly, you're making therapy accessible on a whole nother level. So getting back to creative funding options, another idea, we're seeing a lot of subscription based, um, options. Right now. We're seeing a lot of speech companies offer things as low as Hey, $99 a month. And you get a 15 minute this and a 30 minute this and all these different ways of both synchronous and asynchronous speech therapy to augment and support above and beyond the medical needs. So again, you can combine forces if you do it right, and you stay true to your contracts. The other creative funding source that I'm a big fan of [00:53:00] is partnering with a nonprofit and coming up with sponsorships and saying, look, we wanna work with the same community as you. We're gonna help you fundraise. We know that people need tax deductions. We don't wanna be a nonprofit, but what we'd like to do. It's come up with criteria where we have scholarships that fund therapy for children or families or parents or people. And this is what the scholarship looks like, and this is how we're gonna help fundraise for these scholarships. And that allows us to, um, to really get to that next level. So I think scholarships are a great way, um, to, to get, uh, sponsorship. The other thing going onto it is we're seeing more and more. I had talked about it earlier, employer funded models. How do we contract with employers to fund services through a capitated contract? What does a capitated contract mean? It means you get a certain amount of revenue per month to support their entire demographic. [00:54:00] And you basically are banking that not too many are gonna use it, but it allows you to have like a certain amount of, um, money flowing in for the accessibility of your services. Um, Other things we've got early start D D D money. We've got, uh, grants. If we are a nonprofit, we have some grants that are not D D D are not nonprofit related. I just heard of someone that got $50,000 of funding for being a small business from their local SBA, for them to put into programming for the community. Holy cow, that's a big check, $50,000. So have you connected with what, because what is the SBA? The SBA does not require you to be, uh, um, uh, a nonprofit they're trying to help small businesses thrive. So have you connected to your local SBA group? That's free money there?  [00:54:55] Kate Grandbois:  That's such a good suggestion. I also love the idea of, [00:55:00] I mean, I guess I'm looking at all of this through my clinical specialty, which is AAC, which as we know from the literature, AAC, interventions are really only as successful as the. Uh, indirect service provision that accompany them, right? So you can have the best advice in the world, but if you're not getting trained on it, if you're not, you know, carrying it out into the community and, and using it in places and your communication partners, aren't being trained, it's not gonna be anywhere near as effective. Um, and so the idea of embracing some of these creative funding solutions through care credit, or through a nonprofit through scholarship, it really is, is opening a very different perspective into how to really support those individuals. Mm-hmm , but I'm sure that's, that applies to all aspects of speech pathology. I'm just selfishly looking at it through my own lens.  [00:55:47] Brandon Seigel:  well, and, and what we're also seeing is we're educating schools on how to better budget, where they spend their money. So I'm finding school districts that are specifically [00:56:00] budgeting tens of thousands of dollars on just education of teachers related to AAC. Yeah. How are you tapping in to also. There are some schools that every three years they get to revise their budget. How are you creating partnerships in the community above and beyond just an IEP based need? Okay. So  [00:56:20] Kate Grandbois:  looking back at our learning objectives, I'm just sort of zooming back out. You've given us so much information and I'm thinking again about the clinician. Who's listening to this and has a small practice where is trying to grow and scale and is maybe playing the insurance game, but they just have a ticket to the game. They're not in the stadium. You know, they're not embracing the components of mindset and strategy and risk as you, as you so eloquently described. I'm wondering if you can give some advice to those clinicians listening on how to minimize that administrative burden, right? Because some of the, at least when you first get into the insurance game, it is [00:57:00] very overwhelming. I mean, you've got the claims you've got, you know, All million acronyms AOBs EFTs. It's, there's a lot that you have to sift through. So what advice can you give clinicians on how to minimize some of that administrative burden at the outset, but also throughout the growth of your clinic?  [00:57:23] Brandon Seigel:  So, first off, I think you need to hire for skill sets that you don't have. And so whether you're bringing in someone with that expertise or you're outsourcing, I think when you are committing to the most important part of your business, I know you don't wanna know this, but it's fuel. And I, I say it this way, we're a vehicle of change. Our purpose is not to make money. It really is not because if it is, you're gonna be unfulfilled, but we have a purpose that we're trying to achieve. Greatness, change in community, all this stuff. But in order for our vehicle of change to reach our optimal destination, we need fuel. And the more fuel, the farther we can go, the more change, the more [00:58:00] purpose, et cetera. And so when we're investing in a fuel line, Don't just read a blog and think, you know how to medically bill hire consultants, hire people, hire, hire, uh, a billing agency, a credentialing agency, uh, someone who can set up the infrastructure. Now what I want you to know, and I'm saying this, honestly, this is in no way a plug to me because I'll be honest. I'm very particular about the practices we take on because it's a huge investment when you invest in a company the right way. But what I am saying is 90% of billing agencies out there are garbage, the garbage. So you wanna measure who has AAPC certified coders who are on site, on the ground in the United States. People that you can talk to people that will respond to your text, people that are co-creating with you, that you know, are gonna believe for you and recognize the smaller you are, the harder it is to find quality support.[00:59:00]  So you may find a contractor if you're using the contractor elderly. Correct. But you may find a billing agency. You may go and look and go to a conference and meet people every time you hire a billing agency or a specialist. I want you to get five references. Five. I don't want five. That's a lot of references for billing. Yes. Because,  [00:59:24] Kate Grandbois:  well, I guess if 90% of them are garbage, you're gonna need five.  [00:59:28] Brandon Seigel:  You want five and you want five industry specific. That's you said a high bar. I do, because this is our lifeline. This is no you're right.  [00:59:39] Kate Grandbois:  I think the analogy of the fuel line is  [00:59:41] Brandon Seigel:  fabulous. So what do I do for a living? I put out fires. I'm trying to prevent you from needing a firefighter. And truly I say this, I, I see I'm working with a speech clinic right now that just had the worst billing experience possible with one of these agencies. They over promise they [01:00:00] underdeliver, they don't spend enough time really helping. And then they justify like, what do you expect? We're just, you know, trying to get through and bill and blah, blah, blah, blah, blah, find high purpose, high, intentional people that have an emotional response to doing right by you. And that takes references. And that takes people. And that takes the right fit because there's a lot of, we'll say wolfs and sheeps clothing, so to speak. And it's sad. And that's why I hate to say it Kate. But the number one thing, I go home and tell my wife is people stink. And it's because it's really hard to find that was very  [01:00:34] Kate Grandbois:  pagey version of I'm sure what becomes out of my  [01:00:36] Brandon Seigel:  mouth. yeah. And so find high intentional people that want to really support you. That really care that are willing to put their reputation on the line to co-create with you. And that are willing to say, Hey, if this doesn't work, you have an easy out, you never want someone locking you into a contract ever, ever, ever, ever, ever. So, um, [01:01:00] so the first thing is you have to find people that can help you get to that next level. The second is you need the right systems in place. You need solid EMR co uh, EMR system. You need the right policies and procedures that protect you. You need, um, artificial intelligence is so crucial today. Now there's new software and systems, and I don't have the name off the top of my head, but there are softwares out there that will do your eligibility and authorizations and tell you what you need to pay. Really invest in measure twice. Cut. Once a lot of the times, we try to grow too quickly. And again, I saw another client recently that said to me, Brandon, I'm losing cash flow. I'm losing cash flow. I need help. I need help now. I'm I'm I don't know what I'm doing. And the problem was, was they said, I need more clients. I said, you don't need no more clients. You need to find out where your lost leader is. You've done something wrong in the algorithm. Your fuel line is wrong. Marketing [01:02:00] allows us to find future destinations of how far we can go. But if the fuel line, you know, we could be running on empty for a long way. And so just make sure that you really tap into understanding what you're doing. Start small, grow smart, don't try and out, create and get, oh my gosh, I wanna grow so fast. The people that are the most successful that I meet are the people who said, I never envisioned having 10 therapists. I just wanted one or two. And then it organically happened. And it felt right versus the person that. I wanna be a million dollar private practice I wanna sell for the big money you're in it for the wrong reason. Then start with your purpose, grow smart, slow and steady wins the race. This is a triathlon,  [01:02:50] Kate Grandbois:  you know, we usually end our episodes with a, what are your parting words of wisdom, but I think you just nailed it. I mean, that was, that was so inspiring and so [01:03:00] well done. And I'm, I'm so grateful. Thank you.  [01:03:04] Brandon Seigel:  I tried you,  [01:03:06] Kate Grandbois:  you succeeded. It was wonderful. Um, to everybody who was listening, um, all of the references that we mentioned throughout this episode are going to be listed in the show notes, um, as well as where you can find more information about the conference and about, um, Brandon's company. So if you have any questions, please don't hesitate to write in Brandon we're so, so, so grateful, um, for having you with us today. Thank you for sharing  [01:03:32] Brandon Seigel:  so much. Thank you, Kate. It's been so much fun. Don't get discouraged. The opportunity is there. You just have to play the game, right. That's awesome. Thank  [01:03:41] Kate Grandbois:  you. 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 [01:04:00] 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 is a transcript from our podcast episode published October 3rd, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, related 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. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech language pathologists working in the field and co-founders of SLP nerdcast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is a course offered for ASHA CEUs. 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 SLPnerdcast.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 specified [00:00:53] Kate Grandbois: . We hope you enjoy the course.  [00:00:55] Announcer:  Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEUs 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 nerdcaster10. A link for membership is in the show notes.  [00:01:44] Kate Grandbois: Welcome to today's episode everyone. We are so, so, so excited for today's conversation. We're so excited. In fact that we got very sidetracked before we hit the record button and had to stop ourselves from going down a rabbit, a million different rabbit holes. We're here today to discuss [00:02:00] dosage and frequency of treatment and we are, we have the great pleasure of welcoming Dr. Mary Beth Schmidt onto our show. She is a researcher who is an expert in this area. Welcome Mary Beth. [00:02:12] Mary Beth Schmitt:  Thank you. Thanks for having me. [00:02:18] Amy Wonkka:  All right, Dr. Schmidt, you're here to discuss a very, very exciting topic. Um, how much therapy do children need to make progress and what we know and don't yet know about prescribing speech language therapy in schools. I'm really excited to have this conversation, but before we get started, can you please tell us and our listeners a little bit about yourself? [00:02:40] Mary Beth Schmitt:  Sure. So I am a speech language pathologist. That's um, that's my background. I work, have worked with children and families, um, for a lot of years now. uh, but I've worked in the schools. I've worked in university settings. Um, both as a supervisor, as an instructor, went back [00:03:00] later in life to get my PhD focused on clinical research, um, with a specific goal of supporting SLPs, um, specifically in the schools, right. Trying to equip them with, what do we know, um, about what works, um, and what doesn't work for children with language disorders, um, in a very kind of naturalistic setting. And so I am currently, um, a assistant professor at the University of Texas at Austin, where, um, I do some teaching and mentorship and get to partner with SLP and school districts. Um, around the country to promote what we know about kids with DLD, um, from a research perspective,  [00:03:44] Kate Grandbois:  we're so excited to have you here. I cannot wait to read our learning objectives and disclosures so that we can have this conversation. Okay. So learning objective number one, describe the role of dose and frequency on children's outcomes. Learning objective [00:04:00] number two, describe how student engagement relates to learning outcomes. Learning objective number three, identify at least three strategies for implementing the key findings from dosage and frequency research in your current practice disclosures, Mary Beth Schmitz financial disclosures. Mary Beth receives salary support from NIH for a current study related to treatment intensity. She receives compensation for her role as EBP brief editor, Mary Beth is employed and receives a salary from University of Texas Austin. Mary Beth also received an honorarium for participating in this course, Mary Beth's non-financial disclosures. Mary Beth is an ASHA member. Kate Grandbois financial disclosures. That's me. 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 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 and the association for behavior [00:05:00] analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. [00:05:04] Amy Wonkka:  Amy's financial disclosures. That's me. I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA. Um, I'm a member of special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right, Dr. Schmitt, why don't you start us off by telling us a bit about our first learning objective. Tell us a little bit more about the role of dose and frequency on children's outcomes because that seems like something we should know a bit about.  [00:05:39] Kate Grandbois:  Wait, tell me everything.  [00:05:43] Mary Beth Schmitt:  right. How long do we have? So, um, okay, so to nerd out a little bit, it, I think the relevance of what we're gonna talk about is really grounded in where these data came from. So if I might let me give a little bit of background. [00:06:00] And so this study was funded by the department of education, um, institutes of educational science, um, and included 300 kids approximately just shy like 294 kids with language impairment who had already been diagnosed in the public schools and were being served by school based SLPs. And why that is really, really important is well, and then one other piece, we, we went in with the intent of, of really kind of capturing business as usual treatment, meaning we didn't ask the SLPs to do anything different. Nothing at all. Um, because we wanted to capture out of the hundreds of decisions that LPs are making for their students, which ones are driving outcomes for their kids. So we're gonna call that like an active ingredient, like which decisions are actually really important for us to be thinking about. And then maybe which other decisions we don't find any [00:07:00] connection to their outcomes. And so it was really important that, that we kind start with, well, what are you already doing? Like before we go in and say, Hey, SLP, do this different, do this different. We need to know like, what are you already doing that we can capitalize on? Um, in a way that advances outcomes for our kids.  [00:07:21] Kate Grandbois:  I just wanna pause right there and soak up how important this question is. How important is it for us as clinicians to pause and or for you as researchers to ask this question? What is it that we are doing that is working? What is it? That's our whole jobs. Our whole jobs are to do things that work. Yeah. And I, I can't wait to hear the answer to the question. I just, I just wanted to take a minute to talk to just to important this question is. So, and thank you for doing the research, but keep going, keep going. [00:07:52] Mary Beth Schmitt:  Absolutely. Absolutely. We had a running joke with our team that like, what is at the end of the day, the thing that [00:08:00] matters is like flannel boards, right? FLA not really. That was it captured, I think the true openness, right. Of we're gonna go in and gather as much data as we can, um, across all of these metrics. And so, um, what we asked then the SLPs to do and like, Kudos to these SLPs. So there were 75 school based SLPs that signed up for this. And we will, as a field, like never get over thanking them because here's what they did. Right? Like they agreed to follow up to five kids on their caseload, who again were already diagnosed with language impairment. And so within this, it also captured the great heterogeneity of kids on our caseload, right? Because we relied on them. Who on your caseload, have [00:09:00] you already determined to have a language impairment? It wasn't our definition. Right? These were school based kids. And so they were already diagnosed. So then every week they filled out a log that captured what days the kids came to therapy, how long they were there. So a literal start time. And end time, this wasn't what the IEP said. This was the actual, this week. How often did I see the kid, whether or not they, um, were absent that day, we had to cancel therapy. How many kids were in the therapy session, um, where the therapy session was, whether the kids involved were typical peers, um, or if they, uh, were other kids that had an IEP, a ton of information, right. About their therapy sessions every week. And then in addition, the SLPs videotaped five therapy sessions over the academic year. And again, it was literally like set the camera up and press record and do your [00:10:00] awesomeness, um, without any finangling of what we just asked them to capture kind of a representative day. And so from that data, then we were able to capture literal dose and frequency. So for this, and I've learned this talking with different groups across the country, I think sometimes our definitions are different. Um, Amy you're nodding. Yeah.  [00:10:25] Amy Wonkka:  Maybe if you could just give us and, and our listeners, I guess would give me sort of an idea of what, what your definitions are for those terms. That would be helpful.  [00:10:33] Mary Beth Schmitt:  Yeah. And our definitions, um, came from the research, but you guys let me know if we need to be using different terms that would align better to what school-based SLPs are doing day in and day out. Or if this varies across districts like this is I think an kinda an interesting semantic question, right? Um, dose. Well, let's start with frequency. Frequency is literally like how often do the kids show up? [00:11:00] So are you seeing them once a week, three times a week? Like what, how literally, how many times are they in your presence and you are in their presence dosage then can be defined a couple of different ways. Sometimes you'll see dosage in the, um, in the literature referred to as like numbers of opportunities, like how many opportunities did they have to work on a specific goal or that type of thing? Um, the way we coded our therapy videos, we were actually able to capture time, not time in the session, but time where language goals were being actively targeted and we know this to be true. Right.  [00:11:48] Amy Wonkka:  So I was gonna say as a school based person, and particularly earlier on in my career, I did a lot of groups and sometimes you have this really eclectic mix of students in your group, and you may [00:12:00] have four or five students who have really different IEP goals, but that's how the schedule worked out. Um, so yeah, saying that they have a 30 minute session is maybe not exactly fully capturing the amount of time on task. So very cool. [00:12:16] Mary Beth Schmitt:  Yeah, absolutely. And the way we did it for this study is we, we didn't parcel out for every child, but just looking at the session as a whole, how much time was spent on a language goal, defined as you know, if they were working on grammar, they were working on vocabulary, narratives, literacy, um, phonological awareness type things, just kind of literacy. Um, like how much of it was language, how much was spent on articulation and then coding, how much was spent on somebody had to go to the bathroom, you're having to manage conflict. You're switching out activities. Maybe you're reading a book, but the kids are not really being asked to do [00:13:00] anything right now, except for listening. And so we separated out all those components of the therapy session, regardless of how long, and then extracted out of all of that, how much of that time was spent on language and for this study, that represented dose.  [00:13:21] Kate Grandbois:  So to say that back to you. The active participation a time that was spent in active intervention, where goals were being actively addressed. Cause I'm think I'm just reflecting on my own treatment session. You know, my clients under the table running around the room, avoiding work,  Mary Beth Schmitt: absolutely  telling jokes with me, telling me about their weekend. I mean, there's a lot. I wanna call it fluff or like stuff it's rapport building. It's important, but it's not necessarily active intervention. Right. So what you're talking about is time spent during active intervention.  [00:13:56] :   Mary Beth Schmitt That's right. Okay. That's right. Um, [00:14:00] and so with that, then you can tell, like we kind of ignored what the length of the actual session was. Cause the theory was that, well, it's not just being in the speech room that, oh, you know, language is part comes down upon the child, you know, but it's, it is that active back and forth. And so we captured how much time was spent in that. And so from our research, what we found is that on average, on average, there was about 11 minutes, again, not per child, but per group. Right. So 11 minutes spent on language therapy. The average session length was about 22 minutes long. So about half is what we found on average. About half of these therapy sessions for kids with language impairment were actually spent on language goals. And we could probably pause there just for that take home.  [00:15:02] Amy Wonkka:  And I think, sorry, go [00:15:00] ahead. Nope. You go ahead. I, I think I, it raises questions for me about did you get, this is just me being nosy, potentially get details about what those groups were working on. Like, was that a group where half the kids had articulation goals and half the kids had language goals? Um, it's, it's always because every group is unique, right? It, it must have been very hard to get a good feel for. Why that amount of time was that amount of time? Was that the amount of time? Because it was a group who just had a lot of challenging behavior as a group in their dynamic was a lot of redirection. Did you get any of that information or was that a two? [00:15:40] Mary Beth Schmitt:  Yes. Yes. Great question. It varied. Right. As you might imagine, there were some where you know, that 11 minutes was the average, so it could have been a lot less than that. I think it was like zero up to like 22 minutes. Um, some of the, so then you're looking at, well, what [00:16:00] were the other 11 minutes? Right? And sometimes it was articulation. Um, sometimes it was what we called management. So a lot of redirection, whether it was somebody off task or just somebody chatty, right. Wanting to talk about whatever, you know, their experience with grandma over the weekend or what they're seeing outside the window, or, you know, whatever the case may be. And then other times what we call null where. It literally was quiet for a minute in the therapy room and the SLPs were changing out materials or they were, um, you know, needing to reference their lesson plan or whatever the case may be. And we go back to the original goal of the whole study, right? Where there wasn't any judgment, right? Like, is this good? Is this bad? Is this irrelevance? Why that half of the therapy session, for kids with language impairment is focused on language. We don't know whether or not that mattered  [00:16:59] Amy Wonkka:  [00:17:00] because we also aren't robots and children aren't robots so it also, would've been surprising, you know, to consistently see, yes, all 22 minutes, we are just, boom, boom, boom. And nobody ever tells us a story about grandma and we never look outside the window, you know? So, so yes, I think if you work with children, that's. That also makes sense because children are people and other people are people and, and we are not on task all the time.  [00:17:23] Kate Grandbois:  And some of those softer non-active intervention minutes are also really important for developing a flow of a session or, you know, making a connection with a student because maybe grandma just passed away or maybe it was a, a super fun weekend and they wanna share it with you. I mean, there are so many softer things that go into relationship building to create safe spaces and get work done. But anyway, keep going, right. Keep telling us what's happening. I, now I can feel myself going another rabbit hole  [00:17:51] Mary Beth Schmitt:  right. Well, and I, and I think a different rabbit hole for a different day. But part of like, when we think about to our last learning objective and like, what does this matter? [00:18:00] And I'm trying not to give the ultimate spoiler alert here, but right. But I think as a profession, we need to be thinking about like how, how we're talking about the therapy we're providing. So if we're saying we're gonna see kids for 20 minutes, Twice a week. There's kind of that assumption that 20 minutes are spent on goals. And what, what we found is that that's not an accurate reflection. Right? And so again, maybe that mix is what's supporting kids. Maybe it's not that, that we really need to be thoughtful of how are we talking about this when we're talking about how much therapy kids need or don't need just, just that, right? Like maybe, maybe we need to be thinking about it in a little bit of a different way and so that, okay. So frequency, literally how many sessions dose the time spent on goals, not the session and then duration. So for how long are we gonna look at [00:19:00] this to kind of get a snapshot? And for us, we followed an academic year. And so for most kids that meant about 36 weeks worth of those therapy logs that the SLPs filled out. And what that means is that not only did we get frequency every week. We got the sum total, literally how many sessions did each individual child receive over the entire academic year and how much dose was represented in all five of those videos? And so this is another important methods point. We looked at the, the therapy videos that we coded, cuz we only coded three of them. One at the very beginning of the year, one in the middle one at the end and the, the correlation. So when we looked at the statistics, the dose was crazy related to each other. And so what we found in that is like, it seems to be pretty representative of what the groups are. We didn't see vast variation. We [00:20:00] saw a lot of variation between kids. We didn't see a lot of variation for each individual child's experience. Does that make sense? So like the dose captured in the first video, the dose captured in the middle video and then the dose captured at the end was pretty similar. And so we felt pretty confident then making that assumption of like, okay, then each child's experience is pretty similar. And so we can use that as a representation then of how much dose did they get throughout that academic year.  [00:20:32] Amy Wonkka:  That's interesting too. Right. I think as a clinician, that's interesting. And back to my sort of side question about, well, what were they doing in that other time? It's interesting to think about. All right. Well, maybe part of that was because it was a, it was a mixed group and part of your time was intended to be spent on articulation. And part of your time was intended to be spent on language. Or perhaps we, we just have a real chatty group of friends,[00:21:00]  And we’re just doing lot of grandma chats. So that's, that's interesting. That's interesting to hear.  [00:21:10] Mary Beth Schmitt:  So we were curious then to know, does any of that matter, does. Frequency or dose matter, or is there a relationship between the two, cuz there's a little bit of research really from education more than we hadn't seen it done yet in speech pathology that looked at the interaction between the two, meaning there's been tons of research in speech pathology, looking just at dose or just at frequency, but very little looking at what they call the cumulative intervention intensity, looking at the, kind of the multiplication of both dose and frequency. Um, and so that's what we did in this research and we controlled for their language at the fall. And what that means is that we, we controlled for any possibility [00:22:00] that our findings were related to severity, right? Like maybe kids who had more severe language had a different frequency and dose than kids with more mild, um, language impairments. We took that into consideration. And so we're looking at all areas of language. So looking, um, across, um, content form, mostly content inform and, um, and looking at that both at the fall and the spring, so that we were able to see children's language change over that academic year, and then looking at dose frequency in the combination of the two in respect to their outcomes. [00:22:40] Kate Grandbois:  So I'm gonna say respect to you and sort of, and sort of paint this picture of where we are in this story, right? Yeah. Cause so much like this is, is storytelling. Yeah. You took a boatload of data. I mean, it sounds to me like you had so much information at your fingertips to analyze and [00:23:00] look at to see what variables again, going back to this original question, what are we doing? That makes a difference. What are we doing that is working? And you looked at all these variables sounds like I am not a researcher by any stretch of the imagination, but to sort of reflect back something that you mentioned before we hit the record button, it sounds like this is very sound science. Like the science of this is, is very good in terms of what you controlled for is that, I mean, I feel like that's an important piece of this story. [00:23:28] Mary Beth Schmitt:  Absolutely. Um, Jessica Logan was our methodologist in this study and, um, she just does phenomenal work. And so we had this team of researchers who bring kind of the more content knowledge. So those of us with experience in the schools and understanding language and understanding the dynamics they're in and then, um, methodologists and statisticians that can really oversee the, um, both the design as well as the, the numbers. Right. And the, the mathematical component of it. And then it's all done [00:24:00] in teams, right. We're we're talking about it, we're wrestling with the data, um, and making sure it, it all aligns and then it makes sense. So, yeah.  [00:24:11] Kate Grandbois:  So not only is this an incredibly important question, but what you are about to tell us these findings was done in a way that we is valid and reliable and we can trust it. Yes. Excellent. Okay. Don't tell us this [00:24:25] Mary Beth Schmitt: . are you ready? And I'll tell you that too. We're it out? Just one more, more when we first ran these's analysis, right. And found what I'm about to share. We did not believe it. We were like, we did something wrong. There was a glitch in the data, like, go again. So that, and like more to your point, Kate, like we, we were doubtful. We interrogated the heck out of this data, out of the analyses because [00:25:00] what we found was that dose mattered frequency mattered. When we looked at the combination of the two, they mattered differentially. Meaning when children had more dose and more frequency. So the high, remember I said that there was a lot of variability and that's awesome because where we see variability, we can explain something. Some kids with number of sessions received 15 therapy sessions over the academic year, which translates to about one session every other week. Some kids received upwards of 90 or more sessions over the academic year, which translates to about three sessions on average per week. And everything in between some kids dose was as little as like zero to two minutes. We'll talk about the two minutes, right? Two minutes per session. Some had that [00:26:00] average of 11 minutes and some had dose up to like 22 minutes on average, across those therapy videos. When we look at the outcomes, kids who receive like using all my hands, right? I'm like visual. I think the, the graph when kids received the higher number of frequency. So they were coming to therapy three times a week. And every time they came, the dose was towards 22 minutes. Their outcomes were quite poor,  Kate Grandbois: poor?  Mary Beth Schmitt poor, their, their outcomes were,,  [00:26:41] Kate Grandbois:  is this the moment where you had, no this is wrong. We have to do this differently. Is this the moment? Do, what is this the moment where you looked at the data and said, this is, this is wrong. Something is wrong. [00:26:50] Mary Beth Schmitt:  Yes. Yes. Like our scales wrong. Like, did we flip the, the graph? Like what, what happened happened? [00:27:00] Kids were receiving more therapy relative to their peers did worse than so here are the two groups that did better. Okay. Kids who either got high frequency. So they were towards that three times a week over the course of the academic year. But when they came, they got these short bursts, right. Their dose was like two minutes. They rocked it in terms of outcomes, Kate Grandbois:  joking. You’re a research researcher, you don't joke. There's no joking here with data.  Mary Beth Schmitt: We don't have humor.  [00:27:43] Kate Grandbois: Right.  uh, I, okay. Okay. Keep going. I mean, there's a million thing, more things. I, more questions. I know.  [00:27:48] Mary Beth Schmitt:  And like, I wish I wish so much that I could like paint a picture for your listeners. Right? So, so it's dose in frequency working in opposite directions. So kids with high [00:28:00] frequency, three times a week, but low dose, these little spurts, like two minutes, they did great. Um, and by great, like let's define that, like let's. Let's be a little bit more specific they, they gained more in terms of their language growth or language change over the academic year than the kind of the average average amount. Cause overall here's another take home, sorry, I'm going a little bit overall kids who get therapy do better than kids that don't get therapy. Like our therapy overall is effective. What we're trying to figure out is what pushes kids a lot more than just kind of the average. This is in general, what we expect to see in terms of language change for our kids, with language impairment. There are some kids that are gaining a lot more over this academic year, and this is one piece of it that we are associated with or, or found associated with those changes, [00:29:00] high frequency, low dose, or, or the other split. The other side of that coin. Low frequency. So they were only coming once every other week, but when they came, their dose was high, their dose was more that 22 minutes of therapy, those two kind of profiles of kids, for lack of a better word. Those, those two experiences for kids with language impairment was related to more gain over the academic year than the other two extremes kids who got low frequency and low dose. And that's intuitive, right. If they only came once every other week and they only got about two minutes of therapy, shocker alert, like they didn't do very well by the end of the year. But, but the real big story though, is the other extreme. When they got more of both high frequency, high [00:30:00] dose, their outcomes were equally poor.  [00:30:03] Kate Grandbois:  This is insane. I have brain explosion, emojis, right?  [00:30:06] Mary Beth Schmitt:  Adjust. I still have brain explosion. And we've been talking about this for a while now. So, so to say the brain explosion back, yeah. [00:30:15] Amy Wonkka:  In general, receiving therapy helps school, age children. That's good thing. You have language disorders. It's good. But when you pull apart the progress that those different students are making the patterns that you see, the associations that you see are surprising because the students who are getting the most frequent longest amount of concentrated therapy are not the ones who are making the best progress that is being seen by either frequent, shorter duration or infrequent, relatively infrequent, longer duration. [00:30:53] Mary Beth Schmitt:  That dose dose dose. Yep. Yeah. And dose meaning not about [00:31:00] session length, right? Yes. I know. That's hard. Do, yeah.  [00:31:03] Amy Wonkka:  So it's not about what the session length is on paper. It's about the amount of time in that session spent on the language targets. You got it. That does kind of blow my mind little bit. Right [00:31:14] Kate Grandbois: .Well, and I know I, what I'm about to say sort of touches a little bit on our third learning objective, and I don't wanna go there yet, but it's, I'm reflecting on myself as a clinician. And I know that if I only have five minutes, uh, if, if my, if I have a short, if, if I have a short dosage of time, that's allotted and, and I, I have to be more efficient. Right, right. I have to spend more of my concentrated time, actively engaged in intervention. And I might not, I might not have an elongated chat about grandma. I don't know. I, I just, there are so many practical and I know we haven't gotten to the practical applications here yet, and I'm really jumping the gun, but this is just mind blowing. It's making me think of so many additional things,  [00:32:01] Amy Wonkka:  but there are other places I remember reading about, you know, the idea that these short bursts of articulation therapy can be really effective. Right, right. Or that, you know, if you are working with somebody on motor speech goals, you might be better off doing frequent, shorter duration. So as, as a school based person, I wish that there was more of this research out there because it would really help me in thinking about recommending service delivery. Right. But it's, it's it like blows my mind, but then also kinda makes sense. Cause I feel like we've. Things sort of like this about other areas. [00:32:37] Mary Beth Schmitt:  Absolutely. And you know what, that's what we went back to. So we reran the data. No, the science was sound. The analyses were sound. Um, we went back to prior literature and cognitive scientists have been saying this literally for decades. Like since the [00:33:00] 1960s, maybe even earlier, if memory serves across all content areas with reading, right? The, they call it spaced versus mass. So spaced when you're spacing out, you're learning opportunities versus massed it's the idea of cramming for a test, right? Like we all had that experience in college. You can do it. Your brain will show up. Usually you cram the night before you get as much in as you, can you go take the test, you pass likelihood that you're retaining that information. Slim to none, right? It's like cram, take the test done with that. I'm moving on in life versus when you spend time in it a little bit at a time over and over again, across they're showing it in math. They're showing it in reading. They're showing it in the arts, learning a musical instrument. I was sharing this before we hit record. Like I'm working with a physical trainer right now on my wrist and ankles. And she said it the other day, she was like right up [00:34:00] doing 10 reps, five different times throughout the day is better for your muscles and really retraining than, than doing one set of 50. Right. That's spaced learning. That's dose across multiple frequency, right? Low dose high frequency. That's exactly what she was prescribing of me too. And so it's. When we go back to then other disciplines and we really rely on like cognitive science, who's been studying the brain forever. We are just learning. We know this to be true about learning, whatever it is you're learning our brains do better with space opportunities rather than mass. And what our study suggests is that kids with language impairment follow the same pattern.  [00:34:53] Kate Grandbois:  So before I, I, I, the application of this, again, the, the brain explosion emoji. But before we start [00:35:00] talking about that, I wonder if you can talk to us a little bit about how engagement factors into all of this.  [00:35:06] Mary Beth Schmitt:  Yeah. Great question. So in a separate study, not related to this actual paper and these analyses, we looked at some of the videos of kids and specifically we narrowed in on how actively engaged are the kids during therapy. So we took those language, you know, how looking at their language goals and the dose of language. And we went in and coded in 15 second intervals. Are the kids off task, meaning they're talking about, you know, grandma and the squirrel outside the window, or they're doing circles in their chair, or they're running around the room or they're underneath the table, or like they are literally doing something other than related to the task. Are they passively engaged?   Meaning that when we look at the kids. Right. Um, from what we can tell, cuz we [00:36:00] can't see inside what's going on, but they're sitting still, they're looking towards the activity and or the speech therapist or the peer that's talking like the outward, um, appearance is somebody who's focused and attending to the task capacity, but they're not actively participating. Right. They're just, they're there they're present. They seem to be attending and then actively engaged, meaning that they are either verbally or non-verbally responding to a prompt so that maybe, maybe they're answering the question or maybe they're following a direction, right. That can be nonverbal. Um, maybe their, um, whatever the, the goal or the prompt was, they're responding to it. And so that was actively engaged. And so again, then we looked at, okay, does the, if we were able then to, to summarize. Or sum rather, how many intervals across a [00:37:00] therapy session were kids off task, passively engaged or actively engaged? We did have a fourth one that was kind of a mix, right? So like over 15 seconds, it was a little bit of this and a little bit of that. And what we found was that it was active engagement that related to outcomes. And there was a wide range. We had some kids who were actively engaged zero during their therapy session. We had some kids who were actively engaged for the majority of their therapy session. And so what we found is that the more actively engaged the kids were the better their outcomes and the better their outcomes to quite a significant, um, degree in terms of changing their, um, the gain, the overall improvement of their language from the beginning of the year, to the end of the year, compared to kind of on average, what kids are, are receiving or benefiting from. [00:37:57] Kate Grandbois:  So to say this back to you [00:38:00] encompassing all of this, I I'm thinking about myself, any of our listeners, our jobs, what we want is to do things that work, that move the needle yeah. That have a positive impact for our clients. When we're making decisions about service delivery or planning our sessions. We wanna think about this intersection between dose and frequency. Right. So either having a high frequency with a low dose or a low dose with a high frequency. Yeah. But also thinking, considering those idiosyncratic variables in our clients to try and get them as actively engaged as possible within that combination of dose and frequency. Is that an accurate summation? [00:38:47] Mary Beth Schmitt: Yes. Yes. And again, like I heard this analogy once I didn't come up with this. Right. But. They liken active engagements to riding a bike. Like if you're learning to [00:39:00] ride a bike, you gotta get on the bike and balance and learn how to coordinate with pedaling and all the things like you have to be on the bike and try, you can sit on the side and you can have somebody narrate to you. Okay. Here's how you ride a bike. You're gonna sit and you're gonna balance your body and you're gonna hold your hands on the handle. Like you could listen to that all day long, but guess what? You're not learning how to ride the bike until you actually get on and try. I think it makes sense for us when we think about articulation, right? Like we need kids to actually attempt these sounds to get better at producing the sounds themselves. And yet when we think about it with language, you know, we've gotten feedback from SLPs before too, of like, but I was trained that they need good lo good language models first. Right. They need to listen to a lot of input first, before they get a turn. And the [00:40:00] data suggests that that's not actually the case.  [00:40:05] Amy Wonkka:  There are so many interesting pieces here. So many my mind is getting so blown. I have a long commute. I listen to a lot of audio books and the theme this summer has been attention and I can't help, but make a connection between the findings of both of the studies that you're talking about. Right? Yeah, because there, I believe is a fair amount of research also out there showing that our attention is better. All of us kids, grownups when we are actively interested in the activity. Absolutely. Right. So when we are able to have those higher rates of engagement, those kids are probably paying more atten like your operational definition of engagement is you know, you're seeing those things probably more often. And if I reflect on my therapy sessions, I'm seeing those things more often when I'm able to pick an activity that's motivating or meaningful for the student on my caseload. Right. I, if I were to try and collect that data, you collected myself [00:41:00] and code those interactions. I think that I could definitely pick out some patterns yeah. With current and previous students about, oh yes. These activities are way more likely to get me that active engagement, um, as defined, you know, in your study.  And then also our attention span. Isn't infinite as adults or children, and we're always switching back and forth with our attention. Um, so I feel like another takeaway for me, kind of specific to the engagement is for us as clinicians to be really thoughtful. If we think we're going to maybe take that frequent, but low dosage approach to also really be thoughtful about making those low dosage amounts, high engagement, promoting activities, if we can, um, I know you didn't really do that study and I'm sort of extrapolating it, but, um, you know, that's, that's a question that it's raising for me is like, is there some intersection there too?[00:42:00]  [00:42:01] Mary Beth Schmitt:  Yeah, it's a good question. Right. And we haven't done that study. But again, the theory behind it all kind of makes sense. Right? And you, you know, we keep talking about the art, the comparison with articulation, it's that idea of short bursts where the kids are getting a lot of repetitions. I think it was Lynn Williams study that showed like upwards of 75 opportunities is what kids really need to change. Amy Wonkka: It's super high number Mary Beth Schmitt:  and it's so, yeah, super high, but it's achievable if, and forgive me, cuz I'm talking to myself, if we'll stop talking, right. Totally kids can get those opportunities if we kind of take ourselves out and, and do some interesting things in therapy,  [00:42:47] Kate Grandbois:  what is making me think of, again, there's so many, this touches so much of what we do. Yeah. I'm thinking about the planning and organizing to try to [00:43:00] actually make this happen. Right. And how much of this. Comes in contact with the infrastructural expectations of our workplace. So I have worked in places where I was told we do two times 30 here. Yeah. This is, this is the service delivery that we give as like a blanket, right? Yeah, yeah. Or the conversations I've had with parents where let's say the service delivery is two times 30, but they want five times 60 . Yeah. You know, or, or the, or the contentious conversations with other providers who are giving a service delivery. And, you know, if you ask, well, why. Um, well, I, I don't know why now we have a why. Well, because we know that I know that my student needs 10 minutes of a, of warmup to be actively engaged. I know that my student needs X, Y, Z sensory activity to be actively engaged. And it takes this much time. And, and based on this [00:44:00] research, we can also say most effective outcomes will be a combination of all of these variables. This is, this is it. This is, this is everything. I can't believe that I've been practicing for 15 years. And I am just learning this today. I was today years old until all of these critically important pieces came together to form a picture of what I am supposed to be doing as a clinician. It's it's insane. [00:44:29] Amy Wonkka:  It's really hard though. I mean, you raised such a great point, Kate. I mean, I, I have received many outside reports that recommend a very high, um, not dosage, but duration and frequency of services. And so if we map onto it, the findings of Dr. Schitz research, we, we really have more than just kind of our gut and the idea, you know, I mean the time comes from somewhere. It, the time that we spend in [00:45:00] speech at school is coming from some other activity that the student could be participating in. There's a, there's a lot of pieces that go into determining service delivery. Yeah. Um, And I, I hope that this message also gets out to other providers also gets out to, you know, other allied health professionals who may be making recommendations around dose and frequency, believing that to be in the best interest of the shared client. Um, when in fact the research is suggesting maybe not, [00:45:29] Mary Beth Schmitt:  maybe not, maybe not. Yeah. And this is where, um, the type of research done matters, right? Because it absolutely has policy implications, but the, the design of this study that makes it so relevant to SLPs also brings with it some limitations on how far we can use it to make specific recommendations. And so for instance, we don't get an actual [00:46:00] number, right. Like we can't, we don't know at this point that okay, if I actually do schedule my client for 90 sessions over a 40 week period and see them for two minute dose that will improve their lang-. We don't have that data. What we did with this study is called correlational data and it means that we, you know, we just took a lot of information and we looked at patterns. There was a pattern between, um, the inverse relationship between dose and frequency. So high frequency, low dose, low frequency wait, or then high, high dose, low frequency. Uh, I have to give it straight too, um, and children's outcomes and it's, you know, the science would sound it corroborates what cognitive sciences has, has been saying forever. It corroborates what we know from other disciplines, education, motor learning, all of it. But, what my team and I are doing now is [00:47:00] we have funding from NIH to literally test just that. Um, and this is where I really could use the help of your listeners. You know, our study is online, it's across the country, it's even in Canada. Um, and we're looking at what is that, that magic combination and not just how much the, like how much dose versus frequency kids need, but at what point does our therapy stop being effective?  Amy Wonkka: This is so exciting.  Kate Grandbois: This is the biggest question of all time.  Mary Beth Schmitt: It's huge. It, it really is huge. And we're hearing from more and more both. Yes. Like I never felt good about the two times a week for 20 minutes, but I didn't have anything else to go on.  Kate Grandbois: Yes, exactly.  Mary Beth Schmitt: And just the, like, let, please tell me, like, please give us more information. And we've also heard from SLP who are finding creative. Solutions within the current constraints while we're waiting. Cuz science is slow. Y'all like, oh my [00:48:00] sorry, my Texas came through. Um, it's y'all science is so slow. And so it's like, what can we learn from the data that we have and how can we, you know, kind of using an evidence based practice model, how can we take this external research, use our current, um, constraints and barriers and directives from where we're working. Some of our kind of internal pieces collect our own data, um, to really, really decipher ourselves. Like, can we go ahead and optimize this in ways? And. We have some thoughts.  [00:48:40] Kate Grandbois:  Uh, I wanna just quickly, Amy, I know you have words in your mouth. Hold on one second. I just wanna, I just wanna make sure that we give our listeners a link or some information for how we can help you. So is there a link that you can give us that we can put in the show notes just to make sure people if they're listening yes. And they wanna contribute to this [00:49:00] research for a way for them to connect, get connected with you?  [00:49:03] Mary Beth Schmitt:  Yeah, absolutely. Absolutely. Um, and, and I should add to, from the SLPs perspective, we really don't need anything of you. We'll do all the work. We just need to help find these find kids. So we're looking for kids who, same as before, like they are already on your caseload, right? They're they have a diagnosed language impairment. For right now we're trying to keep it just like the language impairment is their primary diagnosis. So they don't also have comorbid diagnoses, um, that might explain the language impairment. Um, and, and then we'll, we'll. We'll do all of it. Like we'll so this is not a burden on you just help us find these kids. And the other interesting thing about this research, I think is that we're using, um, a vocabulary intervention. That's already been proven effective through their research in all the kids get it. So no one's in a control group. All kids are gonna get this supplemental vocabulary intervention for [00:50:00] participating, um, plus some other incentives. And so we're, we're excited about this design. We're excited about the offering that we're able to give kids the fact that, you know, silver lining of the pandemic, it forces us online and kids are responding well to it. Families are enjoying it. Um, and so we can get into more homes that way. And then for our profession, we're really hoping to have some actual policy guidance. Um, For that. And so absolutely Kate, like, I'll give you the links, but I also want your listeners to know too, like we have on the website, the, um, UT Austin's children's language literacy and learning lab CL3, go alliteration and acronym. Um, we have, there's a PDF of this article and we are self, self archiving in the way that is legal and following all the rules of how you can do that, so that, um, so that you can get access to it because this one is not [00:51:00] in the ASHA journals. That's a whole nother story, but the, the, but we have a copy of the article itself, but we also have a PDF. That highlights the outcomes of this data so that you can take this PDF into your IEP meetings. With that family that's asking for more and more and more, and you can show them right now. It's not a matter of, I don't have time. It's a matter of actually the data suggests that that would put your child at a disadvantage. And that, that we're so excited to be able to really empower SLPs with data, without having to like read through the article and pull it out. We've given it to you in just this one, snapshot, take it to your administration, take it to your principles, take it to your lead SLPs, um, and really start a conversation about what could this look like for us. [00:51:55] Amy Wonkka:  And it's, it's so exciting because I think often, especially [00:52:00] school based SLPs, can be very bound into the schedule. Well, this is how we do our blocks and we don't do anything other than 30 or 15 minutes. And we need you to do a duty at this specific time. Yeah. Um, so I think. Even just having that conversation with your administration could allow more flexible thinking. I mean, I'm just thinking about evidence based practice and I'm thinking about the evidence based practice triangle. Yeah. And this is sort of that external evidence piece that might lead a clinician. To gather some internal evidence about their client in with a, with a variable change that we probably wouldn't. I, I wouldn't have even thought of. Right. Yeah. Often if something's not working and I'm looking to external evidence, I'm looking specifically at a treatment approach, right. So what I'm doing during therapy, I'm not thinking about things like how enga, I mean, it's more fun for everybody when everyone's engaged in its fun activity, but not necessarily thinking about [00:53:00] that explicitly as a variable to change and see if it made a difference, not necessarily looking at, or feeling empowered, to suggest a change in frequency or dosage to see if that makes a difference. So it, I think it also just really widens. It, it widens the, the world of things that might actually make a difference for one of our students. Right. And maybe we can, while we're waiting for the slow slog of research to, you know, get us the answers. Yeah. External evidence wise, it's something that we might be able to look at internal evidence for our own clients. So just asking yourself some different questions and being curious to, to steal one, a few words, but being curious about, well, actually, maybe it's not my activity at all.  [00:53:47] Mary Beth Schmitt:  Absolutely. Maybe these other things. Absolutely. And, you know, remember that we gathered these data from SLP, like we didn't know that this was gonna be a thing. Right? So these SLPs were doing [00:54:00] their business as usual. So most of them were in those same constraints of, you know, a couple times a week for 20 minute sessions. But remember it wasn't the length of the therapy session. It was the dose. And so what that does for SLPs listening, is it, it gives you some power while, while you're having conversations with administration and talking about the policies. And can we look at our prescribed therapy in a different way when it comes to the actual IEPs, while you're having that conversation, you could go ahead and experiment with this. For instance, maybe, you know, maybe you have a, um, a client who has a narrative goal and some grammar goals, right. And maybe you do something like a cycles approach, right? Maybe you work on grammar kind of as a drill, the first five minutes of your therapy session. Right. And [00:55:00] then the last 20 minutes or 15 minutes or however long it is, you focus on narrative and then you don't touch narrative again for at least another week. If not two weeks. Right. And then maybe the next day you hit grammar again. Right? So you're doing higher frequency, low dose do a quick burst of grammar, but then maybe you do a longer on, on vocabulary. Right? Find the goals that they need a little bit more. Like you gotta take a little bit more time to get into the depth of them. Then use that like restructure your 20 minutes in such a way that you're intentionally doing some high dose and low dose, if you're not able to be flexible. But you know, then that said, I worked with districts before that they used a minutes per month model. Right. So rather than two times a week for 20 minutes, each it was, we're gonna get in 260 minutes or 240 minutes over the month. That's permission then to experiment with this. [00:56:00] Right. And maybe you don't try it with all of your kids. Maybe there's one group or a couple kids that are not making anticipated yearly progress. Start there. Right and gather your data. And then you've got now both external evidence from our research, plus your own internal data to take to families, to the it meetings, to your administration, to whomever and say, look, look at what we're noticing. Look at what we're seeing here. Um, and so I don't want SLP feeling like, oh my gosh, we're sitting on this goal mine, and now we have to wait for us to do more research. No, no. Use this at, you know, to the extent that it's meaningful and relevant to your caseload, don't feel constrained by your situation. Think about how to creatively use the data. The data had nothing to do with the time of the session. It was all about the dose of the language.  [00:56:56] Kate Grandbois:  And I, I can't help as I'm listening to you talk, I can't help but [00:57:00] thinking about, think about the difficult conversations that you might a listener or a speech pathologist might have to happen have with their administration or with their infrastructure. That is just very used to doing a certain things a certain way. I also think in terms of making effective change and tailoring your message to your audience, there are likely some creative ways that you can apply this to be more efficient. So thinking about a kid on your caseload, gosh, I really don't need to see this kid five times a week. I could probably make even more effective progress by reducing the amount of time that the student is spending outside the classroom or reducing the amount of time to be a more efficient worker. And that's like, those are the kinds of things that your administration might also want to hear, because again, tailoring our message to our audience. And I think that this applies to outpatient centers. I think this, I know your research is about the schools, but when you're [00:58:00] having these conversations with your administration, consider it the budget implications, consider your, your productivity implications consider. And you know, it may be caseload to caseload. This might not be true for every SLP in terms of improving efficiency, but those are also really important variables for how we can be effective in our jobs. Again, going back to this, what's the point, to be effective at our jobs and your administration might care a lot about efficiency and productivity, depending on your caseload and all of these very specific variables. But I think it's definitely something to consider.  [00:58:34] Mary Beth Schmitt:  I think that's a really important point, you know, and, and again, you're not making this up now. Like it's, data and, [00:58:41] Kate Grandbois:  and it's really good data as you already established. This is one of the most, this is good. Good science.  [00:58:48] Mary Beth Schmitt:  Yeah. Yeah. So that, you know, and then you think about the engagement piece. I was working with a, a school district and some SLPs that were, were really looking at it. And the first place that [00:59:00] we started was just take data on yourself. Like some SLPs, literally turn their video camera on. And they watched themselves to see, okay, out of my 20 minute session, how many opportunities do my kids have to attempt their goals? And some who brought in like a trusted peer. Right. Of just like, here's what I, I want you to track, like how, how often, or, you know, time it or what, however they wanted to do it, them talking versus the kids talking versus, you know, off task. And so some of them, it was an eye opener. It was like, oh my gosh, like I'm not doing very much active engagement or my kids don't have opportunity. Great. That's great data start there. Right? Like that's a, that's a toggle that you can make and just make that switch. Maybe you take your own data and you're like, actually I'm doing pretty good. Right. Then that's equally important because you can talk about that in the IEP meetings and with your, um, administration annual reviews, that kind [01:00:00] of thing of look there's data to suggest this matters. And the PDF for this is also on our website. There's there's data to suggest that engagement matters. I took my own data. I'm doing this, right? Like my practice in this regard is aligned to the research. Now there's this other piece of talk, thinking about like the dose and frequency of that active engagement. That's what I'm gonna attempt next. Right? So like, you can really use the external data, not just to inform change to your practice, but then also use it to affirm what you're already doing. Right? Like, look at it. You might already be doing low dose, high frequency or low frequency, high dose. Like some of the SLPs in our study were, and you just didn't realize that's what you were doing. And you didn't realize that that mattered. Awesome. Figure out who you're doing that with and then do try doing more of it and see if that doesn't have [01:01:00] cross implications for all.  [01:01:02] Amy Wonkka:  I want this study to be replicated with all sorts of school population groups. I just selfishly often say that. Um, I think, I think these are such good questions and although the groups I work with most often are not represented in, in your work. I think, you know, as, as somebody moving forward, I'm definitely going to think about these variables in ways that I haven't before, um, as potentially agents of changed for student progress,  [01:01:31] Mary Beth Schmitt:  right. And Amy, I think that's such an important point, right? Of just because different populations weren't represented in the data doesn't necessarily mean it's irrelevant. That's where your internal data comes. Real becomes really important. Try it. Right because the theory behind it and cognitive science data for decades would suggest that it likely does have implications for other populations, but you don't have the same external data yet [01:02:00] to rely on. You can do your own, do your own trial, your own comparison, gather your data and see, and then you've got, you've got that, um, information to help lead you to  [01:02:11] Kate Grandbois:  In our last couple of minutes, I wonder if you have any additional recommendations for SLPs listening, for how to apply this research. I mean, we've, we've gone over a bunch of talking to your administration, bringing the PDFs that you have available on your website, into the conversations to show the data, to show the research. Um, we've even all of that will be linked in the show notes for anyone listening. We've also talked about structured planning. So taking a look at your own caseload, you know, looking for inefficiencies, planning per student, based on what they need for engagement, what do, what combination of dosage and frequency is maybe most relevant to their clinical presentation, those kinds of things. Are there any other words of wisdom or any other really good takeaways that you would like to share? [01:03:00]  [01:03:01] Mary Beth Schmitt:  Yeah, I think maybe two main ones first. Like I would just encourage your listeners to kind of be reflective of themselves. Right. Of cuz we've heard from lots of SLP, some hear this and they're empowered. Right. And it's like, this is what I have known in my bones and I just didn't have the data. And so if that is you like go ye fourth, right? Like use the resources we have, reach out to me if you have questions, get a buddy or two. Right. Who are also wanting to think about this within the constraints of whatever your setting is and yeah. Try it out. But if you are on the other side and you're like, this is still blowing my brain, like I still need a minute to just think about what this means. And this sounds like a lot because I have a huge caseload and I'm super constrained in the, [01:04:00] the frequency and dose that, or at least the frequency of how often I can schedule, then it's okay to start slow. Right. I would encourage you to take a look at our PDFs that are the one pagers. And I would encourage you to take data on what you're already doing. See if there are groups and or sessions where you were already doing this and you just didn't have language for it. Because what that'll do is I think that will give you some encouragement and motivation to be like, oh, This actually isn't completely changing everything I know to be true about service delivery, it's giving language to it. And so I just would encourage people to figure out where they are on that continuum of hearing new information and figuring out how it applies, not dismiss it, but it's okay to be on that continuum. It's okay to just be at the processing side and it's okay to be like ready to dive in and [01:05:00] like have IEP meetings for all of your kids, change every change everybody's schedule. That's okay, too.  [01:05:08] Kate Grandbois:  This has been so incredibly helpful. Thank you so, so much for sharing all of this wisdom and research and great, amazing science that is going to change our field one day. Once we continue to move the needle, we're so grateful for your time. You again, so much for being here. [01:05:27] Mary Beth Schmitt:  You're welcome. Thank you for having me. This is, this is always fun to talk about this. Thank you so much. [01:05:34] 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 [01:06:00] 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

This is a transcript from our podcast episode published March 14th, 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. [00:00:00] Kate Grandbois:  Welcome to SLP Nerdcast. I’m Kate  [00:00:09] Amy Wonkka:  and I’m Amy, and we appreciate you tuning in. In our podcast we review and provide commentary on resources, literature, and we discuss issues related to the field of speech, language pathology.  [00:00:20] Kate Grandbois:  You can use this podcast for ASHA CEUs. Visit our website for other courses, including live courses, webinars, blog posts, and SLP masterclasses available for graduate level credit. SLP nerd cast is committed to improving continuing education in our field through affordable pricing and open access libraries. You can support our work by leaving a review, referring a friend, making a one-time contribution on our website or subscribing. You can subscribe for as low as $7 a month and get access to monthly Q&A sessions, exclusive content, discounts, and a resource library of downloads, freebies, and printables. Want unlimited access to ASHA CEU courses? There's an affordable subscription for that too. For more information, visit us on our website or [00:01:00] contact us anytime on Facebook, Instagram, or at info@SLPnerdcast.com . We love hearing from our listeners and we can't wait to connect with you. [00:01:07] Amy Wonkka:  And just a quick disclaimer, the contents of this episode are not meant to replace clinical advice. SLP nerd cast its hosts and guests do not represent or endorse specific products or procedures mentioned during our episodes, unless otherwise stated we are not PhDs, but we do research our material. We do our best to provide a thorough review and a fair representation of each topic that we tackle. That being said, it's always likely that there's an article that we've missed or another perspective that we haven't shared. If you have something to add to the conversation, please email us. We love hearing from our listeners.  [00:01:39] Kate Grandbois:  This episode is brought to you in part by listeners like you. And one of our amazing corporate sponsors language dynamics. Language dynamics group develops and disseminates evidence-based language and literacy assessments and interventions. They specialize in narrative language intervention for your caseload and for the whole school, check out their dynamic assessments and [00:02:00] visit languagedynamicsgroup.com to download a suite of language screening and progress monitoring tools for free. Language dynamics group did not participate in creating the contents of this episode. We are really excited for today's episode. We have a lot to learn and we're very excited to welcome Tim DeLuca and Kate Radville. Welcome, Kate and Tim.  [00:02:22] Tim Deluca:  Thank you. Thanks for having us. We're excited to be here.  Kate Radville: Yeah. Thank you [00:02:27] Amy Wonkka:  All right, Tim and Kate, you guys are here to discuss the relationship between developmental language disorder and dyslexia. But before we get started, can you please tell us a little bit about yourselves?  [00:02:38] Kate Radville:  Yeah. Thanks Amy. I'm Kate Radville. I am an educator, a speech language pathologist, and a literacy specialist. I actually began my career more than 15 years ago as a classroom teacher, primarily working in early childhood general ed classrooms. Uh, since [00:03:00] then I have been a speech language pathologist in a variety of clinical settings, including with adults and children in healthcare and education. And most recently I spent several years as a clinical instructor at the MGH Institute of health professions in Boston, teaching graduate student clinicians to work with school aged children with reading and writing difficulty and currently, and this is my connection to Tim, I am a doctoral student at the MGH IHP, and I'm studying developmental language disorder and dyslexia with Dr. Tiffany Hogan in the sale lab.  [00:03:41] Tim Deluca:  I am Tim DeLuca. I am also a speech language pathologist and a reading specialist. I started my career working with medically complex children, children with autism who have limited verbal language. Uh, so a lot of AAC. And then over the years, I've [00:04:00] transitioned to working more with children with DLD and dyslexia comorbidities. Over the past number of years, I've continued working clinically, um, done some clinical supervision at universities, a little bit of teaching. And like Kate said, now we are together spending a whole lot of time together, uh, studying DLD and dyslexia and Dr. Tiffany Hogans, speech and language literacy lab at the MGH.  [00:04:25] Kate Grandbois:  I cannot wait to hear about all of these things. As our listeners know, this is an area that I know very little about Amy. You might know a little bit more than me, so we're very excited to learn from you both. Before we get into the fun discussions, the powers that be require that I read our learning objectives and financial and nonfinancial disclosures. Sometimes people write in and ask me to skip this part. I can't ASHA makes me do it. So please bear with us while we get through it as quickly as possible. So our learning objectives for the day: learning objective number one, define DLD and dyslexia, understand how they are related and report on at [00:05:00] least five behavioral presentations across academic and social settings. Learning objective number two, understand the SLPs role in assessing and treating both DLD and dyslexia as members of an interdisciplinary team across the lifespan. And learning objective number three, be able to locate at least five free resources to further explore both DLD and dyslexia and assessment and treatment options. Disclosures. Tim DeLuca's financial disclosure is Tim is employed by private practice and university. Tim's nonfinancial disclosures. Tim is an ASHA member, a certified speech and language pathologist and reading specialist, a doctoral student at the MGH Institute of health professions and a member of the sall lab at the MGH at the Massachusetts Institute of health professions. Kate Radville not me. Kate Radville financial disclosures. Kate does not have any financial relationships to disclose. Kate Rodville is non-financial disclosures. Kate is an ASHA member, a certified speech language pathologist, and doctoral student at the MGH Institute of health professions.  Kate Grandbois that's [00:06:00] me, my financial disclosures. I am 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 special interest group. [00:06:25] Amy Wonkka:  Amy that's me financial disclosures. I'm an employee of a public school system and I receive compensation as co-founder of SLP nerd cast. And my non-financial disclosures are that I am a member of ASHA SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right. We made it through the boring stuff is done onto the fun, Kate and Tim, why don't you start us off and start us off just by giving us some background and the definitions of DLD and dyslexia. What's the difference? And why is that important for a speech [00:07:00] language pathologist to know?  [00:07:01] Kate Radville:  Yeah, absolutely. So, ah, big questions, Amy. I think maybe I'll start by saying that I think, you know, being on the same page about definitions and we have this conversation as probably a theme that will come out throughout our conversation today. I hope it will. So just to kind of get everyone on the same page, let's kind of break things down and maybe start with DLD. DLD stands for developmental language disorder and it is a neurodevelopmental condition. In other words, it, that means it's a brain difference and that children are born with it and just put most simply it's marked by difficulty learning, understanding, and or sort of any of the above, using spoken language. And so we might see in a child with DLD difficulty with vocabulary, grammar, use, some or all of the above. And as you might expect, this can really make [00:08:00] communicating or listening and understanding really challenging.  [00:08:08] Kate Grandbois:  I did not know that. So how is this different from dyslexia?  [00:08:10] Kate Radville:  Yeah. To contrast that I guess, with dyslexia and we'll kind of, let's contrast things first. And then I think we can get into this conversation of how DLD and dyslexia are, are related and what happens when they coexist. So dyslexia, you know, similarly it is also neuro-biological in origin. So children are born with it. It's a specific learning disability, but unlike DLD, which is really characterized by oral language difficulties, dyslexia, um, really involves difficulty with accurate or fluent word recognition. So word reading. Usually this happens because children have a difficulty with the phonological component of language. So the piece [00:09:00] of language that has to do with speech sounds, their phonological system, and this usually happens, um, sort of in this unexpected way, given other cognitive abilities and given good instructions. So really dyslexia is difficulty with word reading.  [00:09:20] Amy Wonkka:  So let me ask you a question. It might be a silly question, but when I'm thinking about DLD, some of those examples that you gave challenges with word finding and some of those other pieces, how do I, how do I tell the difference between that and maybe just a receptive language delay or an expressive language delay? How, how is that differentiated.  [00:09:39] Tim Deluca:  That's a really good question. And I think one that is a challenge in our field, right. I think, depending on where you were trained, when you were trained, where you practice, um, you might see the same child and kind of classify that child's abilities in multiple different ways. So it's almost like a [00:10:00] branding problem for our field, right? Because we're not using common language across different SLPs where not able to translate research into practice because what somebody in research is calling a certain type of presentation, somebody in practice is calling something very different. If you're going from a private practice to a school, the child's going to be classified in different ways. So DLD actually became a term that became more widely adopted pretty recently, there was this really cool conference where all of the powers that be in the field of speech language pathology got together, worked together and, uh, kind of debated how we should classify language impairment. So, um, that was called the catalyst convention and, uh, through a process that they use there, they kind of determined that DLD would be the most appropriate term for us to use to describe this whole body and different presentations of language impairments. And [00:11:00] then I think Kate was going to talk a little bit too about like other terms we might see with DLD. [00:11:07] Kate Grandbois:  That was going to be my question. And also that sounds like an, a very official, very official conference. Like it was like the UN or something like everybody got together and was like, because I've never heard, I went to graduate school 15 years ago. This was not a term that I was at all familiar with. So it doesn't surprise me that as you know, over the last 10 years, as people have dripped into the field one year after another, there it's interesting that it's created this. I don't know, confusion with too many terms, but tell us about the terms. What other names might this go by?  [00:11:40] Kate Radville:  Yeah. So, Tim, I love that you referred to this as a branding problem. This is great. And this is why I said like, you know, I think framing this, um, from the beginning, just getting everyone on the same page, because we're saying DLD, but I hope that as we discuss this, people who work with children with oral language difficulty will be thinking like, oh yeah, [00:12:00] no, I work with kids with DLD. We're just using so many different terms. So, you know, again, we just haven't been consistent defining disorders, but, um, a lot of clinicians may be using or may have heard the term specific language impairment up until recently. And it continues to be used. If you're reading research, you probably seen SLI. A lot of this depends on where you work. You know, if you're in a hospital, maybe you're in an outpatient department, you might be coding this as an expressive or receptive language impairment. Mixed receptive, expressive language impairment. You're probably using the ICD 10, even under F 80.9 or the code that your parole using their whole range of sort of sub categories that you might be coding children's oral language difficulty as. Probably most common. I see SLI language delay, even developmental dysphasia. You know, that's probably the least [00:13:00] common, but really a range of terms. But all of this is really talking about more or less the same thing. You know, these children who struggle with receptive language, listening comprehension, expressive language, or both, and really to varying degrees. No, I know Tim you've worked in the schools as an SLP a lot more than I have. Do you want to kind of talk about what you've some good insights about how this sort of works with IEPs and qualifying kids and what terms are used.  [00:13:32] Tim Deluca:  Sure. And I actually, I worked in schools with Amy for a long time. So Amy feel free to jump in a few extra ideas here. So in schools, we're, we're really our role in a school is not to provide a diagnosis, but rather to identify a category under which a child qualifies for services, right. That's what IDEA asks us to do. And there are 13 different categories that we're thinking from. So we might be, [00:14:00] uh, classifying children as having a specific learning disability or a language impairment under IDEA. And I think that gets kind of tricky, right? Because in schools we want to give good information to families, but we also want to make sure that we are doing kind of what we're guided to do within our school system and kind of following the rules of our school system. So like we talked about with this branding problem and how we're all talking about the same disorders in different ways is so a family might come in for an IEP meeting and hear that their child either has a specific learning disability or a language impairment. And then they're looking for resources. They're trying to figure out, okay, what else can I do to support my child? What is this going to look like for my child across the day inside of school, outside of school? And the families might not be able to find a lot of good support around this, because again, we're all looking for different terms and talking about the same thing in different ways. So. I know that's something that I struggled with in, in schools is trying to [00:15:00] figure out how to best support families and be consistent with the language I'm using so that if this family is going and seeking services at a private practice, we're able to really communicate effectively with one another and coordinate our services so that the child's going to have the best chance at making the most progress. [00:15:16] Kate Radville:  Yeah. And to add, I'm glad you brought that up Tim. I just read this fabulous paper it's by Andrea Ash and what she did was, um, she has qualitative methods to actually find out what affects this poor branding problem, right? This lack of consistent terminology has on families. And they really did find that, um, these difficulties in sharing information, in part, there were other issues, but in part due to inconsistent use of terminology really did have lasting negative impacts on families. They looked at mothers specifically, but mothers felt stressed and confused about their kids' diagnoses and less able to find [00:16:00] resources. Right? Like if you're not really sure what your child's diagnosis is, it's a lot harder to even find useful materials on the internet. You know, you get into this kind of like mess of Googling and not necessarily even the right terms. So this definitely has impacts on both kids and families.  [00:16:18] Kate Grandbois:  That was going to be my next, related to my next question, which was as the SLP, how much does the label matter? Because are you going to be treating it any differently based on the data that you find in your assessment, for example? So there are obviously, can you tell us a little bit about that? Like why as SLPs, should we really care about having a deeper understanding related to the nomenclature around this?  [00:16:47] Tim Deluca:  Yeah, I think you're right, right. Um, DLD is a broad term. It's it's like Kate said it could talk, um, it can refer to difficulties with vocabulary. So word level, sentence level, discourse level language. So as you're assessing [00:17:00] a child, you're really going to be looking at like, okay, which level of language is impaired? Where do I need to put my time with intervention? That's where I'm going to provide my supports. So in that regard, you might say like, uh, why, why does my label matter? And that goes back to maybe you have a child that's presenting in a way, or, you know, their language presenting in a way that you've never worked with before. How are you going to find information about what to do? Well you're going to go look at research, you're going to look at tools online probably. Right. That's how a lot of us are getting information these days, look for good podcasts. And if you're not aware of the kind of language that might be used to refer to this, uh, kind of uh, disability, right? Then you might not be able to find good information and good resources. And then as you're communicating these ideas to others, you might not be doing it justice. You might not be effectively communicating your ideas so that you can pass off care to [00:18:00] another provider effectively. And this might actually be a really good time to, to throw in a few of our resources around, um, how to learn more about DLD. And we'll, we'll send links to these, um, as well, we talked a little bit earlier about the catalyst convention, which is that big kind of like SLP UN conference, where, where they came up with this, this, uh, or agreed upon this term. And there's a great podcast by actually mine and Kate's mentor, Dr. Tiffany Hogan, where she talks with Dr. Dorothy Bishop, and they talk all about that catalyst convention of what it looked like and how they came to the term DLD. The best term for us to use as a field moving forward. And then on top of that, there's a paper by Dr. Ray Paul of textbook fame. You know, I know Amy loves those textbooks. Yeah. Um, so that article is called what's in a name. And Dr. Paul basically walks through the history of our field and how across the [00:19:00] years we've referred to language disorders and talks a little bit about why, how we refer to language disorders matters. So I think those will be two good resources to further explore why DLD should be used in our practice. [00:19:14] Kate Grandbois:  I just want to say for one second, how much I appreciated your answer. That was the most amazing answer because I'm imagining myself as a clinician working in the schools or working anywhere and saying, okay, my, I have this student or client or patient who's presenting with an expressive language delay. Jeez. I'm looking for some treatment intervention. I'm going to go back to the literature, looking, doing a literature search and saying papers for SLI. Well, that doesn't apply to me because that's not the diagnosis that I'm working with. And how, how it really does limit your ability to seek additional information to support you as a clinician.  I think that is just such a good point. And we're going to link all of those resources and references in the show notes. I should just say, so if you're listening and you're jogging or you're [00:20:00] running or driving, whatever, all of those resources will be listed on the page. So thank you so much for those.  [00:20:06] Amy Wonkka:  I do think this is such a persistent issue in our field. This like having a consistent nomenclature for things, because Kate we've talked about this in sort of our area in our scope of practice focus with aided interventions, right? Those interventions are called like 15 different things in the literature and it serves the same challenges at the clinician level. What am I really looking for? How do I find more resources? So I think, you know, it's, it can be hard to shift the way we do things, especially for those of us who are used to calling something one title. Um, but I think that there are a lot of reasons that using a common terminology makes so much sense for clinicians and clients and their families. [00:20:49] Kate Radville:  And I think just to add to that, DLD is really significantly under identified. And I think another negative [00:21:00] ramification of not using consistent terminology is that we don't find these kids. So we know that about 7% of kids have DLD, which is, I think like one or two in every classroom. And it's actually far more common, or I think it's like five times more prevalent than autism, for example, which we know has had a lot of really awesome press, right. Um, but despite that, you know, despite how common DLD is only about half of kids with DLD are identified. Um, so I think this limited public awareness is another sort of impetus to fix our branding problem.  [00:21:39] Tim Deluca:  And that, that makes me think to Kate about how, um, because a lot of people are not necessarily thinking first about language impairment. These children with DLD might be classified in different ways. So if we picture a child who's seven or eight years old in a classroom, and they're in a classroom where their teacher is [00:22:00] using some phenomenal language, modeling complex sentences all day, and this child has an unidentified language disorder. What's the child going to look like in that classroom? They're probably going to be moving around a lot. They're probably going to look like they're not really paying attention. They might be trying to chat with a friend and trying to distract others. And that might look like, oh, the child has behavioral problem. Or, oh, this child may have had, might have ADHD. And we know that our tools right now, depending on how we're using our tools might not be sensitive enough to tell us like, oh, this child definitely doesn't have ADHD. Let's look at something else. Um, a lot of, a lot of. Gold standard for an ADHD tool. Uh, Dr. Shawn Redmond does a lot of work on this. This tool actually has a lot of questions that are more closely associated with language impairment rather than ADHD. So if, uh, that neuroscience or school educational psychologist is not privy to that, not aware that the child's [00:23:00] looking very significant on the set of questions that might actually be more closely associated with language disorder. The child might be ending up getting a label of ADHD or getting a label of some sort of behavioral, social, emotional disorder when really the underlying impairment is language and we're not ever really addressing that.  [00:23:18] Amy Wonkka:  And that right there is why the consistent labeling and looking is so important because it's not just about making sure that we check the right box. It's about providing the appropriate treatment. And I think the example that you gave right there, Tim is one in which the strategies and approach that a team might take to support that student or that client could look really different depending upon the lens and the focus of everybody on the team and what they think is kind of the underlying challenge area. [00:23:50] Kate Grandbois:  This is all very interesting. So can you tell us a little bit more about, you know, we, we started this by [00:24:00] talking about the difference between DLD and dyslexia and how an SLP, so we've covered the difference between those two things, some resources and, um, labeling issues, name issues related to the two disorders. But we have, I think, as a field, I'm just, I guess saying this for my own confirmation, the label of dyslexia is still very clear is that, is that right? So in other words, if you have a student who is, I'm getting some, I'm getting some funny faces from you, Tim. So there's more to the story here and I want you to tell us, um, you know, is there, um, is there more to the story for dyslexia as well? [00:24:41] Tim Deluca:  Of course, there is, that’s what so exciting. Well, well, I think I, I'm going to pass this one to Kate because Kate speaks about this so well, and it's really kind of an area of expertise for her. So i’ll pass this one.  [00:24:55] Kate Radville:  Okay. Well, thank you, Tim. That's a, it's a lot to live up to, but okay. So, you know, we've [00:25:00] talked about DLD and DLD we can think, you know, not to over-simplify but difficulty with oral language, right? So range of kids, range of severity levels, difficulty with oral language. Dyslexia is really a difficulty with written language. So it is, I think what probably more people know about as compared to DLD it's reading difficulty. Right. Um, and it, it really is word reading difficulty. It is certainly very related to language in that most children with dyslexia, like I said before, have this difficulty because of a deficit in the phonological component of language. So one thing we know is that early phonemic awareness, your awareness of the sounds and words and ability to manipulate them is very closely tied to early reading success. In kids with dyslexia, we generally do see difficulty with decoding. So sounding out words, you know, in, in [00:26:00] early readers, we'll see them really struggle through a text. Um, not read as fluently as their peers who are really taking off and accelerating through learning how to read. Um, and later on, you know, if this continues to be a difficulty because they're not reading the words accurately, or as efficiently as we would expect, we start to see difficulty with reading comprehension, especially as that becomes more necessary, right? Little kids start off reading very simple texts. It's not much to understand if they're struggling, we really see it. We're like, oh gosh, you're not reading the words on the page. Older students, um, who struggle, still struggle with reading. They might be able to read quite a bit, but it becomes even more obvious that they're not comprehending what they read because they're not reading accurately and efficiently. [00:26:51] Kate Grandbois:  Okay, that makes a lot of sense.  [00:26:51] Amy Wonkka:  We've had a number of guests on this podcast, you know, I'm thinking of Trina and Doug who have talked just about that relationship [00:27:00] also between oral language and reading and how those two do affect one another and don't necessarily exist in a vacuum. Um, so I think again, being aware of potentially multiple issues that could be at play for your client is super important when you're planning your intervention. [00:27:17] Kate Grandbois:  And for those who are listening, who aren't sure who Trina and Doug are, they have, um, come onto the podcast with us, uh, 3, 4, 5 times. Um, there are researchers in this area. Um, so you can go look for those episodes. It's um, Dr. Trina Spencer and Dr. Doug Peterson. Um, I wonder if we could sort of merge into the second learning objective and start talking about assessment and treatment in these areas. So we've talked about some of the overarching guiding principles, nomenclature, and those kinds of things. Tell us a little bit more about the assessment and treatment process across these two constructs. [00:27:51] Kate Radville:  I wonder if it might be useful. So we're thinking about DLD and we're thinking about dyslexia [00:28:00] and, you know, we do know there's about 30 to 50% comorbidity, so super high comorbidity between the two. So about half of kids with DLD also have difficulty with word reading. So comorbid DLD, and dyslexia, most kids with DLD struggle with reading comprehension because of their oral language difficulty, right? Your oral language, underlies really what you're able to do in terms of understanding print. And you can read all the words you want, but if you don't, if your language system doesn't support it, you probably won't understand what you're reading. So DLD, dyslexia, high comorbidity between the two, I think when talking about sort of assessment and teasing out the two and figuring out, you know, why. Is this child not successful with reading the simple view of reading. And I don't know if that's come up on this podcast, but this model called the simple view of reading is super useful [00:29:00] to think about. Kate Grandbois: Tell us more about it. I don’t know anything Kate Radville:  Yes. It's sort of what it, you know, I I've often joked, I want to get a tattoo of the simple view of reading. Like I just think it's that useful. So, um, originally this model is not new. Um, I think it was same as in 1986, I think  [00:29:17] Tim Deluca:  86, 87, 88, around there [00:29:19] Kate Radville:  another great thing out of the eighties. So I think researchers Duff and Tunmer in the eighties, and really, it says that we think the end goal of reading, right? The equal sign points to reading comprehension. That's what we all want to do. Like the point of reading is to understand what you read. Um, and it's just a simple math equation, listening comprehension, plus word reading equals reading comprehension  [00:29:45] Tim Deluca:  times. [00:29:46] Kate Radville:  Times, sorry, times I used the wrong …So we have these two components, right? We have oral language or written language reading the words on the page equals you know, [00:30:00] basically successful reading [00:30:01] Tim Deluca:  and, and it being multiplication versus addition is important because if you have a zero for word reading zero times, even if your language comprehension is. Your overall reading comprehension is still going to be a zero because you read any of the words and then you flip that as well. So that's why, that's why that multiplication sign is an important one there. And I think this is also a really useful way to communicate these ideas with parents and the rest of your team, right? When you're working on an interdisciplinary team, especially like within a school, you're often, you might be an SLP working with a reading specialist, special educator, whomever else. This is a really great way to explain why your role on that team is really important because that oral language component is half of the equation. [00:30:49] Kate Radville:  And this is why it's important to assess both oral language and written language, right? Like picture your multiplication equation. We don't want a question mark on half of it. [00:31:00] Right? You can't do that math. We want information times information equaling a known product. So we want our number for word reading. We want our number. This is making it seem incredibly simple, but we want our number for oral language. And then we want it to equal this known product of, you know, why are things breaking down for this child?  [00:31:23] Kate Grandbois:  This equation is so simple, but so brilliant. It makes so much sense. It's the first and only time we've discussed math on this podcast and it is absolutely worth every, every minute of thinking about this. And we will have the link to this article in the show notes as well. So tell us more, just tell us more about this assessment and treating lens that we need to think about. [00:31:46] Tim Deluca:  I I think, uh, Dr. Spencer and Dr. Peterson actually talked a little bit about this too.  [00:31:53] Kate Grandbois:  We should probably call them that too, sorry, Doug and Trina, sorry. [00:31:58] Tim Deluca:  They spoke a lot [00:32:00] about screening and one phenomenal thing. That's come out of the past bunch of years of advocacy through groups that advocate on behalf of this, like Lexia, a treatment and support is that a lot of states are now adopting universal screening for dyslexia in kindergarten. Um, and now there's a push also growing for better universal screening of oral language as well, because we know both of those things are going to be really important for a child to be successful in school. Um, Kate, I think you might know a little bit about this too, where right now, so we're in Massachusetts and right now in Massachusetts, the law says you need to do universal screening for dyslexia, but then it kind of stops there, right?  [00:32:45] Kate Radville:  That's my understanding, Tim and I, we can post information with more specifics for the listeners, but yes. So in Massachusetts, we need to screen for dyslexia in kindergarten. I think where things get tricky is that, you know, screening is [00:33:00] awesome. And we do know that intervening early is incredibly helpful. It's exponentially more efficient and effective to teach word reading when kids are younger, right in K and one and two, especially. Um, but what often happens is we screen and then that's it. We don't really have a plan for following up. So good screening involves exactly that, you know, finding kids who are at risk and as your listeners know, you know, a screening is not an assessment. So we want to over identify and find all the kids who might be at risk, but then good screening really doesn't stop there. Good screening also involves having a plan for how we're going to further assess, and then what we're going to do when we figure out like, oh, this group of children is at risk. Um, and I think that's the piece, that's probably the piece that's harder. Honestly.  [00:33:54] Amy Wonkka:  I think that's such an important point. And we talk a fair amount about that on this podcast. Just the need [00:34:00] for not just collecting the data, but actually reviewing the data and having a plan to do something about it. Um, because otherwise it's just kind of, so, okay. We screened everybody what happens next. Right. So part of that's an infrastructure piece too. I don't know if you guys have thoughts about how to work with organizations kind of on a bigger level in terms of maybe making some of that change or what you might suggest as those next steps? [00:34:26] Kate Radville:  Um, yeah. I ha I have, I have thoughts on this as both a clinician and a former classroom teacher. Um, and a lot of my thoughts, I'm sure I have a bias in the direction of sort of general ed and how we support educators, but I think a lot of this infrastructure issue comes back to really, really solid evidence-based classroom instruction because this all sort of breaks down if we're identifying kids who have difficulty or who are at risk, we'll say kids who are at risk for literacy [00:35:00] difficulty. Um, but then we also don't have a strong general ed curriculum, right? So it becomes even harder to tease out, you know, which kids just aren't getting good daily instruction and which have a disability. Um, and we definitely know that diagnosis of dyslexia and early identification are much easier in the context of really good classroom instruction. So really good for those of you familiar with RTI, really good tier one instruction, right? If that's solidly in place, this whole process works better and we have less kids who kind of become at risk because they're just not getting what they need. [00:35:41] Kate Grandbois:  And if you're listening, um, RTI stands for response to intervention. And if you want to learn more about response to intervention and MTSS, we have several episodes published on that topic from Dr. Um, Dr. Trina Spencer and Dr. Doug Peterson, I will use their formal tables, um, and [00:36:00] we can link, um, we can link to those episodes in the show notes as well. [00:36:05] Tim Deluca:  So that, that first step is screening, right? And then we have all these kids coming into general education. We need really good tier one instruction. Like Kate said, sets that we're not kind of creating like human made disabilities, right. Does teach you where, where students are presenting as impaired in a certain way, but it's only because they're not getting good input. Um, so in order to kind of make sure we're doing what we need to do as the professionals in the school after screening, we need to make sure that we're doing our progress monitoring throughout. Right? So a lot of schools have adopted really good progress monitoring for reading and word reading over time. So I know a lot of schools use things like the DIBELS aims web, things like that. Uh, there's a great tool on the IES website that allows you to kind of look, to see which of these kinds of progress monitoring tools are most evidence-based for your purpose. So we can link to that [00:37:00] tool as well. Um, so if you're thinking about, oh, we're really not monitoring how kids are progressing and reading, this might be a good way for you to advocate for your school to monitor that a little more closely when we're thinking about progress monitoring as well, a lot of schools are using, uh, measures that are closely related to basal readers, right? So Kate, you talked earlier about how early on text that’s really simple for children. There's not a lot to comprehend, uh, there, you know, so children. With these really early, early readers might look like really good comprehenders, but it's really just a matter of the picture kind of gives the answer or it's such a common progression of events that the child's background knowledge provides them with an answer. And it looks like they're comprehending, but not necessarily comprehending. So using tools that you know are going to actually measure that oral language progress peace in that simple view of reading. Um, one of my favorite tools is actually the cube assessments that [00:38:00] Dr. Spencer and Dr. Peterson were on here talking about. So another plug for them, obviously a big fan. I think that's a really nice way to continue to monitor children's oral language progress, make sure that we're doing what we need to do within tier one instruction. Um, and then a plug for Dr. Hogan as well. Um, the sale lab is also working on creating, um, a strong screening tool for oral and written language, um, within school. So hopefully there'll be more and more information about that coming out in the next few years.  [00:38:29] Kate Grandbois:  I want to also ask a question about sort of the second half of the second learning objective. So in terms of, you know, I know we're now sort of in the context, talking about a school environment with response to intervention, what does it mean to look at this issue through the lens of an interdisciplinary team.  [00:38:49] Tim Deluca:  Now that's a, that's such a great question, such an important question. And I think one that both you, uh, Kate and Amy are going to be passionate about. So I know you both talk a lot [00:39:00] about advocating more for our field to have more time for a consultation. Um, andYeah.  [00:39:09] Kate Grandbois:  Yes! you heard our memo. I might as well have that tattooed on my forehead. I say it so often. I'm so glad someone was listening. [00:39:13] Tim Deluca:  I gotcha. I gotcha. So, um, I think that is a huge piece there, so, all right. Let's take a step back and let's talk about what Kate presented earlier, as far as what children with either DLD or dyslexia might look like within a classroom. And if we think about how these children represented a classroom, we know that, uh, they might be having trouble with either all of the reading within a day. All of the oral language within a day or a combination of both. And we can all imagine if we are in a setting where things are hard all day, a whole number of things can happen from there. Right. We could get frustrated. So it could look like we have, again like behavioral issues or presenting, like, you know, hyperactive, things like that. We could shut down, [00:40:00] right? Because things are difficult. We also might be having trouble making friends. I'm in a bad mood. I'm not going to be my most pleasant self. I'm missing some of the social cues, some of the idiosyncrasies of language. I'm not keeping up with my peers as well. So I might be having trouble making friends. We also know that there's, you know, if, if you're having a lot of trouble with word reading early on, you might be getting less time where you're actually writing. So you might be getting less of that good, fine motor practice, uh, with early writing, things like that. So. From all those presentations we just thought about, you can imagine that within a school system or even outside of a school system, we're going to need to consult with people, as SLPs we'll need to talk to people who have other areas of expertise that could mean reading specialists, moderate, special educators, occupational therapists, physical therapists, and then counselors, behavior specialists, educational psychologists, you know, a [00:41:00] whole variety of professionals because each of those people is going to have a little bit of, or is going to have a unique perspective and a level of expertise that they're bringing to address one aspect of how the child is presenting across their day. So right now we know our systems are not set up in a way that makes that interprofessional collaboration easy. So what do we do about that? There's not a ton of research yet in the field of education, how we can create interprofessional collaboration successfully within our schools, where there is a lot of practice or a lot of research in this is it more in the medical field. So we know in the medical field, there's been a ton of research done where if I go into my primary care physician with a knee problem, and that primary care physician connects with me and the person, the doctor who handles knee problems, and we all communicate together, you know, that doctor has all my background information on the person actually experiencing the issue. And then [00:42:00] that knee doctors, the specialist with knees, when we all communicate together, the outcomes are better. Right. Translate that to schools and think if all of us are communicating, working together collectively along with the child and the child's family, there are probably going to be better outcomes for that child. One of the tools I really like to start getting us to think about this in schools is a tool that was developed. Um, I forget who was developed by, uh, it's called the working together continuum and it was, I think, first developed by doctors Hall and Accord in 2015 and adapted by Dr. Mitchell for SLPs in 2020. And it's basically just this continuum where you consider all of the different tasks you engage in across your day and think, all right. Is this particular task falling closer to me, engaging in no interaction with others, or is it at the opposite end of the continuum where I'm engaging in shared creation with others? Then if I think about this task, [00:43:00] is it appropriate for where it is on the spectrum? Like, do I need to consult more, consult less with others? So I need to collaborate more, collaborate less with others in order to achieve whatever goal I'm trying to achieve. And I think this helps us to start thinking about, okay, I know I have this role or this goal within my school system. I need to be the one supporting oral language for children and also educating other professionals in the school about oral language so that, that tier one instruction looks great across the day. What am I doing currently to do that? To make that happen. Is there no interaction? Is there a lot of shared collaboration? Does there need to be more, does there need to be less? And then I can start taking data on those kinds of things presented to my school system and say, Hey, I have data to show that our children are not doing well on these oral language progress monitoring tools. I think that I have this area of expertise right now, based on my roles and responsibilities in the school, I'm [00:44:00] not able to engage in shared creation collaboration. Here are some ideas of what I think we can do in order to reach that. And let's try it for a while and see how children start doing on these certain measures. Let's see if there is that distal outcome of improved language performance for children. So that's kind of a very long-winded and kind of complicated response, but that the systems level work is, is really complicated. And we're not set up for it right now in many of our schools. So we need to start getting creative.  [00:44:32] Kate Radville:  Yeah. And Tim, I'm so happy that you brought up healthcare because I think, you know, I've had, my career has spanned education and healthcare in terms of my work as a speech pathologist and working in healthcare was the time, you know, healthcare has its flaws and we know that there's work to be done. That said when I worked in healthcare, the first 20 minutes of my day, which is not a ton of time was dedicated and we never deviate from this to interdisciplinary rounds. So [00:45:00] there was not a day that I entered the hospital when I was working in neuro rehabilitation without talking to physical therapists, occupational therapists, the medical team and social workers. So there was this routine that was integrated and it didn't take, it was a tiny percentage of the work day, right? When you, when you think about it, but it was just known that this is how we structured our time. So I think even just. Short structured interactions are getting those routines in place. This is not, you know, we're not talking about spending entire school days meeting with other professionals. Um, just making it more routine where you are, Tim, like you said, going from this continuum of, I don't talk to other people to, we interact frequently. Doesn't probably have to be that time consuming. It is so, so helpful.  [00:45:55] Amy Wonkka:  Well, and I think to that point, something you just said was that it happened every [00:46:00] day. So there's also this nice piece of, I think sometimes we trade these big chunks of less frequent time, because that's the only way we have a construct to carve it out. When in actuality, if you were able to build something into your system that is a frequent and ongoing thing, you would find that you have these chances to see everybody on an ongoing basis. And your, I did have to Google the continuum cause they'd never heard of that. And that thing's awesome. We're going to plop it up on the website. Um, but you know, you, you really are kind of further down on that continuum of collaboration and sharing just by the nature of like your proximity to other people and it's happening all the time.Very cool. [00:46:38] Kate Radville:  And I do think, you know, this happens and I get why it happens because people are so busy, right. People in schools or no, caseload's tend to be big class sizes tend to be large, but we end up in our silos, right? We're in our offices and we're doing a million things separately. And then, you know, end of the school year, there's a day of PD. So I [00:47:00] integrating this collaboration throughout the school year is just so helpful. And also I think backing up a step even before this, um, just making sure that professionals know what other professionals do. So I can tell you, you know, it was awhile ago, but as a classroom teacher, I did not deeply know what the speech language pathologist did. I know, I couldn't have told you that if a child was struggling with early literacy, I should talk to the literacy specialists and the SLP. And I definitely wouldn't have said, oh, we should all have a conversation together. So you can see how, you know, It go. One of my interest is in teacher training, but going back to this piece of like, our training should involve these deep discussions of what other professionals do and where we overlap and where we don't. And we don't all have to do all the things, but knowing sort of from the start of your career, [00:48:00] who you want to be talking with, I think is just a simple thing. Even walking away from this podcast and saying like, oh yeah, you know, now I sort of know who I would have a conversation with in my school, um, is a great first step. [00:48:13] Kate Grandbois:  I also think approaching that with a little bit of an open mind and curiosity is important because oftentimes particularly with professionals where we share, we might have a shared scope. We think, oh, they do this. I don't need to X, Y, and Z, or the PT, just us strikes. I don't need to do X, Y, and Z. You know, we categorize other professionals and either write them off, or we have decidedly, we have preconceived notions about what they do. And that is a barrier to trying to establish more robust, dynamic, collaborative relationships.  [00:48:49] Amy Wonkka:  So getting back to treating. Again, kind of circling back to this and what the treatment. So we know the treatment involves ideally an [00:49:00] interdisciplinary team. We know that part of our assessment involves screening and then a plan for actual deeper assessment for folks who have been identified, which all kind of comes back to having a nice RTI MTSS system, you know, up in place and running. Um, I know the focus of this talk isn't necessarily on treatment specifically, but how might those, how might your treatment approach look different or the same, um, for kind of the different groups of students who we've discussed. So we've got our students who are maybe presenting just with DLD. We have students who may present just with dyslexia. We may have students, like you said, up to 50%, I think who may have kind of that overlap between the two. Does that look different for you as a treating speech language pathologist? Are there things that you would do differently for a student or a client on your caseload depending upon where they fall in those three groups? Or is it sort of similar intervention?  [00:49:57] Kate Radville:  Yeah, no, I think this goes back to this question of [00:50:00] like, let's say, for example, A new child and they're struggling with reading, you know, and maybe the classroom teacher says, why are they having difficulty with reading? I'm probably going to say, I don't know. And going back to the simple view of reading, I'm going to drill into both sides of that multiplication equation, right? Like, let's take a look at oral language. Let's take a look at word reading and let's figure out if we need to intervene in both areas one or both. [00:50:28] Tim Deluca:  And I think a really important thing to remember there is based on where you are in the world, your roles and responsibilities might look different. So you might not be the one who is able to drill into both. That might not be part of your scope of practice wherever you work. So you really need to engage in that collaborative practice with that.  [00:50:49] Kate Radville:  Yes. And actually, Tim, I would say chances are, I don't know the numbers on this, but you are currently not doing both. I'd say by and large, right. [00:51:00] Unfortunately, and this is part of why these, this collaboration is so crucial is that most professionals are not intervening in both oral language and written language. [00:51:12] Kate Grandbois:  We published an episode, uh, with, uh, Jeanette Washington, who shared a resource, a website for us, where you can go to your state and look up what your state how, how your state has designated interventions for dyslexia. Um, so we will post, I can't remember the link off the top of my head at this very moment in time, but we will post that link as well. Um, and I think just sort of piggybacking onto that thought, that's another vote for developing robust collaborative practices, because if you only quote “own” one side of that equation, but you know, it's a whole equation. You really do need to have time and skills to be able to work with another professional, to get the other side of the equation. [00:51:57] Kate Radville:  Yeah. And we'll take, let's just take a half the [00:52:00] equation, right? Since you asked about intervention, let's take the word reading part of the equation to start, right. This in many schools is the literacy specialist, but in most lots of schools is a special educator, right? So child who struggles with word reading, this is probably going to route to special education. Um, the great thing is when we get the kid there, right to the right professional, because we've collaborated, um, we know that explicit word reading instruction with a focus in phonics, the focus in written morphology with explicit practice in spelling too, which we know reciprocally helps reading, kids can make a ton of progress, especially in the early grades. But what we really need to be doing is being explicit and systematic with teaching word reading. Um, and that's the piece too, you know, it goes back to good classroom instruction where if we are also doing that in the classroom, it [00:53:00] helps all children, right. Practices that help kids with dyslexia learn to read are useful for all kids. This does not harm anyone. It can be very efficient, it can be integrated into routines. And the kids who need extra support are then also benefiting from what's going on in the classroom. So really explicit, really clear, um, phonics-based early word reading instruction. So we have that half of the equation, right. And we hope you found the right person because we've worked together. [00:53:31] Tim Deluca:  And then if we think about the other half of that equation, that's more likely to fall into the lap of the SLP right. Um, and I think we all end up getting good training. Throughout our graduate programs in what good intervention looks like. Um, but our intervention needs to be guided by good data, right? So we need to know which areas of language specifically require our intervention, our skilled intervention. And we also need to think which areas of [00:54:00] language might be well supported in the classroom. If we're able to provide a little bit of collaboration, a little bit of coaching to that individual, who's providing that tier one instruction. And then we also need to start thinking about dosage and frequency. So dosage, we can kind of think about like, if you're taking a five milligram or 10 milligram drug, right. That's your, that's your dosage? So translating that to SLP services, like, am I getting 10 repetitions of a skill versus 20 repetitions of a skill within my session? And then a frequency is how many times per week, month am I providing this type of intervention? So a lot of our research or how this isn't great, but there's more and more research coming out around how to best support children with oral language impairment when considering dosage and frequency and what we're learning is, for word learning children with DLD probably are going to need three times more exposure [00:55:00] than, uh, their neurotypical counterparts when trying to learn new language. However, that doesn't mean that we need to be seeing them five times a week. I have sat in many an IEP meeting where a parent is like, you need to be seeing my kid every day. And, um, I, we now have more data to support that that's not what needs to happen. We know that a really good dosage, like one time a week of really good therapy is just as good, if not better than seeing that kid three or four times a week for these types of supports. And then again, making sure their tier one instruction is looking the way it should look. And there are classroom supports in place to make sure that if there are accommodations needed, those are, those are happening. That's what we can spend more of our time doing as well.  [00:55:46] Amy Wonkka:  Well, and you make the point, Tim, about the frequency. And I think because we are talking about a pediatric population and we are talking about school-based services, you know, it's also an important thing to always [00:56:00] remember any of those services that we, as the speech language pathologists are providing that time is coming from something else. So it's also always that balancing act. And I think, you know, back to our kind of quest for indirect service, but, you know, I think it's very likely that high quality, short frequency or reduced frequency of intervention with some type of consultative piece where you're able to help support the classroom teacher or whoever's in there. It's probably better not only for your client, but you know, kind of to Kate Radville's point earlier, like beneficial for everybody, because it's just good instruction.  [00:56:37] Kate Radville:  And I think too, you like picturing, you know, we've kind of described this child who might have DLD or dyslexia or both, and this impact in the classroom where maybe they're presenting as struggling with attention or having some behavioral difficulties or not engaging with peers. This model too. In addition to freeing up time, we think about interprofessional collaboration is also [00:57:00] perhaps less detrimental to routines. So pulling this child out for services for one high-quality session might be significantly less disruptive and framing it in sort of the positive, let them participate in their school day with their class in a way more cohesive, stable way, which I have worked with a bunch of kids, especially recently where they're, you know, they're getting these pull out services all the time and they're out at this time, they're out at this time. And then at this time, honestly, in my role, working with kids after school, they're exhausted and they can barely tell you, you know, what the routine of their school day was. And, you know, they're all over the place. So I think this is a less disruptive model as well.  [00:57:42] Tim Deluca:  Yeah and I think that's such a nice way of also talking about it with families or, or stakeholders, right? Because, um, stakeholders are probably coming in to a meeting where they're hearing about what's being decided about services for their child and, um, I think there's a lot [00:58:00] of kind of misinformation out there, um, around what parents should be looking for or what might happen within these kinds of meetings. And I think it's on us as the, um, language professionals to be able to, uh, talk not only about the language, but also about how language affects the whole child and the way you put it as, you know, the child needs to be a part of your team needs to be a part of their classroom community. And, uh, if we can support them in that way, it's probably going to be really beneficial. And that also might put those other stakeholders at ease. When we talk about it in this way, when we talk about thinking about the whole child, that stakeholder might buy in much more to the plan and be willing to collaborate on that treatment plan, moving forward, more, more willing to collaborate a bunch of and plan moving forward when they have that understanding. [00:58:48] Kate Radville:  Yeah. And I would even take it a step further and say that this extends to the home too. Right. You know, and this is, I'm a, I'm a parent of two young kids and from a parent's point of view, too, I mean, understanding how you can extend supporting the child to the home environment as [00:59:00] well, um, is just absolutely crucial. So, you know, moving away from this siloed, we pull the kid out, we do our thing. We send them back in to collaborative practice where we're thinking, like Tim said, I love this phrase as an early childhood person originally this whole child. And thinking of them in this sort of developmentally appropriate holistic way is just so important. [00:59:25] Kate Grandbois:  This is such great information. And we have about five minutes left and I wondered if an hour you've already given us so many resources. I mean, you guys have every other sentence has been, you should read this, you should read that. It's been amazing in our last couple of minutes. I'm wondering if, um, there are other additional resources or recommendations that you would have for SLPs who are listening, who want to deepen their understanding of these topics. [00:59:56] Kate Radville:  Oh, I have one. I meant to mention this. I don't think this came up earlier, [01:00:00] but, um, the website DLDandme.org , um, Dr. Tiffany Hogan is a co-founder of that website and it's just a super caregiver and teacher and sort of other professional friendly, um, website for finding information about DLD. It has definitions resources, it's just, it's a really nice place to direct. I think it's useful for speech, language pathologists, but also really super accessible for people who don't know anything about DLD. Um, it's really easy to navigate, and it has quite a few papers written sort of like, you know, code switched for people who aren't in research,  [01:00:42] Amy Wonkka: Taking a look at it right now. And this seems like a great stopping point for all sorts of different information. So thank you for that resource.  [01:00:50] Tim Deluca:  Another interesting resource is actually a visual that I think is useful when trying to communicate your ideas with a variety of stakeholders. [01:01:00] Um, and it's a visual called I guess it's called the Snow model and it's from Dr. Snow who is down in Australia and it's, uh, a model of oral language competence and why oral language matters across the lifespan. And the visual is basically like a house. So this is kind of like simple view of reading, but like really, you know, expanded upon for oral language. Um, and it's basically a house that shows a solid ground of good social and emotional support. And then on top of that there's oral language, uh, presented throughout the lifespan. The pillars are transitioning from written some from oral language to written language, and also go along with the development of interpersonal skills and showing how all of those go together to create social, emotional, behavioral wellbeing, social cognition skills. And then the roof goes up to what that looks like as an adult, right. Um, if we have good input that whole way, then we have marketable employment skills, social and economic [01:02:00] engagement, uh, academic achievement. So I really like this visual because I think it's also, it's good to communicate your ideas with families as to kind of what area that you might be intervening in or what area you might be seeing some, uh, some extra need for support. And then it also could be good for advocating for why your role matters within a team. Right? You could talk about how certain parts of this are really fall under the scope of an SLP and how we can support, uh, this skill so that this individual is going to have a, have a happy and healthy adult life.  [01:02:34] Kate Grandbois:  These are incredible resources. Thank you so much for sharing. Do you have any additional words of wisdom for any SLPs who are maybe feeling like this is an abyss of information anywhere you think people might benefit from starting or beginning their journey and learning more about this?  [01:02:53] Kate Radville:  I'll give a shout out to. Awesome resource for literacy. Um, the Florida center for reading [01:03:00] research website, which I think is FCRR.org . Is that correct? Yeah, we got we'll link to it too, but they are super hub in terms of not only helping with resources, for understanding dyslexia, but also directly linking you can go in sort of by age and grade and developmental stage. And you can click on, for example, like I'm working with kindergartners and I know they struggle with phonemic awareness, right? Like going back, like absolutely integral for developing written language. Um, and they actually have. Very user-friendly structured activities you can use. It is all completely free and evidence-based totally vetted. It's awesome.  [01:03:41] Amy Wonkka:  And just taking a look at this website for the first time, cause I'd just found out about it. Um, it does also look like they have information kind of organized for educators and then also for families. So it seems like it's another place that you can go to sort of have information that is presented in a couple of different ways, depending upon kind of your [01:04:00] level of jargon  [01:04:01] Kate Radville:  and yeah, actually that's into that point. I often share those resources with families I work with whose children are having difficulty with word reading, um, and also the international dyslexia association or IDA. Their website is great and extensive, and they also can be really great for connecting families with resources about reading and writing difficulty, and also for connecting families with sort of local advocacy groups, you know, they'll link out and help families find other people locally who are going through similar things. [01:04:35] Kate Grandbois:  This has all been so incredibly helpful. Thank you guys so much for first of all, all of these resources, all of this information and all of the things you're contributing through your doctoral work. I'm sure it is it really hard, but so worth it. So thank you for taking the time to join us here. Um, anyone who is listening, who would like to use this episode for ASHA CEUs, you can do so [01:05:00] on our website. There's also a link to do so in the show notes, all of the references and resources that we've listed are also listed in the show notes, um, and just a big fat thanks. Thanks for joining us guys.  [01:05:12] Kate Radville:  Thank you. Thanks. This was so fun. It was my pleasure.  [01:05:17] 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, www.SLPNerdcast.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@SLPnerdcast.com . Thank you so much for joining us and we hope to welcome you back here again soon. Another big thank you to our corporate sponsor language dynamics group who helped make this episode [01:06:00] possible. Our corporate sponsors keep our CEU prices low and our program ad-free language dynamics, group develops and disseminates evidence-based language and literacy assessments and interventions. They specialize in narrative language interventions for your caseload and for the whole school, check out their dynamic assessments and visit language dynamics, group.com to download a suite of language screening and progress monitoring tools for free language dynamics group did not participate in creating the contents of this episode.

This is a transcript from a podcast episode. The podcast episode is offered for .1 ASHA CEU (introductory level, related 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 may contain typos. Email us anytime  with suggestions or errors. A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. Kate Grandbois ( 00:13 ): Welcome to SLP Nerdcast. I'm Kate. Amy Wonkka ( 00:16 ): And I'm Amy, and we appreciate you tuning in. In our podcast, we will review and provide commentary on resources, literature, and we'll discuss issues related to the field of speech language pathology. You can use this podcast for ASHA professional development. For more information about us and certification maintenance hours, go to our website, www.slpnerdcast.com . SLP Nerdcast is brought to you in part by listeners like you. You can support our work by going to our website or social media pages and contributing. Kate Grandbois ( 00:46 ): You can also find permanent products, notes and other handouts. Some items are free, others are not, but everything is affordable. You can go to our website to submit a call for papers to come on the show and present with us. Contact us anytime on Facebook, Instagram or at info@slpnerdcast.com . We love hearing from our listeners and we can't wait to learn what you have to teach us. Amy Wonkka ( 01:06 ): Just a quick disclaimer, the contents of this episode are not meant to replace clinical advice. SLP Nerdcast, its hosts and guests do not represent or endorse specific products or procedures mentioned during our episodes unless otherwise stated. We are not PhDs, but we do research our material. We do our best to provide a thorough review and fair representation of each topic that we tackle. That being said, it's always likely that there is an article that we've missed or another perspective that we haven't shared. If you have something to add to the conversation, please email us, we would love to hear from you. Kate Grandbois ( 01:40 ): We just had such a great experience. We had the pleasure of welcoming Dr. David Luterman here with us to have a conversation about counseling and communication sciences and disorders. I had the pleasure of having Dr. Luterman as my professor in graduate school. He is a well known teacher, researcher, author, consultant, and lecturer and he specializes in counseling, in our field. Kate Grandbois ( 02:10 ): He was clinically trained as an audiologist, and he is a specialist in the hearing impaired and in counseling. He has written in a handful of books including Counseling the Communicatively Disordered and Their Families, Deafness and Perspective, Deafness in the Family. When your Child is Deaf, In the Shadows, Living and Coping With a Loved One's Chronic Illness, The Young Deaf Child and Early Childhood Deafness. Kate Grandbois ( 02:41 ): He presents at lectures frequently and he presents at symposia around the world. He's a fellow of the American Speech and Hearing Association, and also the recipient of the Frank Kleffner Clinical Achievement Award in 2011. He's famous, and we got to talk to him for a whole hour, and we're so excited to share it with all of you. I left feeling sort of speechless and inspired and also full of thoughts that I need to sit on for a while. Amy Wonkka ( 03:14 ): I feel like it was a really interesting conversation. I think that it was a very thought provoking conversation, and I think our listeners probably might find the same thing. His perspective on counseling is different from perhaps not what we learned in school, but perhaps what we're doing in practice. I agree, it was a really informative and pleasurable- Kate Grandbois ( 03:53 ): He's awesome. There's really just no other way to say it. Amy Wonkka ( 03:56 ): Yeah, he's pretty awesome. Kate Grandbois ( 03:57 ): He's completely awesome, and I cannot wait to share this with everyone. It's funny, I took his course when I was in graduate school, so I was probably 23 years old. Now that I'm medium old, and I have more than 10 years of experience in the field, I re-learned so much information, and I think my takeaways are completely different than what they were at a different phase of my life. Kate Grandbois ( 04:26 ): I also wanted to make sure our listeners knew that this course is available for free on our website. Well, everybody is listening for free on a podcast player, but if you would like to use this for ASHA Professional Development, this course is listed as free on our website and will be forever and today, just because everybody needs this information, everybody needs this content. Kate Grandbois ( 04:47 ): Before we get started, we do need to read our financial and non-financial disclosures and go over our learning objectives. Financial disclosures, Dr. Luterman is a Professor Emeritus at Emerson College in Boston, Massachusetts. Kate is the owner, founder of Grandbois Therapy and Consulting LLC and co-founder of SLP Nerdcast. Amy Wonkka is an employee of a public school system and co-founder of SLP Nerdcast. Kate Grandbois ( 05:11 ): Non-financial disclosures, Dr. Luterman is a certified member of ASHA and an audiologist and an ASHA fellow. He is also the author of numerous books on counseling listed on our website. Kate and Amy are both members of ASHA SIG 12, and both serve on the AAC Advisory Group for Massachusetts Advocates for Children. Kate is a member of the Berkshire Association for Behavior Analysis and Therapy, [inaudible 00:05:35] the Association for Behavior Analysis International and the corresponding Speech Pathology and Applied Behavior Analysis Special Interest Group. Amy Wonkka ( 05:43 ): What are our learning objectives for today, Kate? Kate Grandbois ( 05:45 ): Learning objectives. Okay, number one, identify and define at least two features of successful counseling. Number two, identify at least two common mistakes made by clinicians that are barriers to an effective counseling relationship, and three, identify and describe the importance of support groups. I think there is nothing else we can say to better highlight what is about to happen. So, enjoy, everyone. Amy Wonkka ( 06:13 ): Welcome, welcome, welcome, Dr. Luterman. Thank you so, so much for joining us. We are so excited to learn from you. Dr. David Luterman ( 06:24 ): Well, good, I'm glad to be here. Let me tell you a bit about myself and then we'll open it up for some discussion among the three of us. I am a clinical audiologist, or at least I was trained as a clinical audiologist and I started in 1960, that's 60 years ago. Dr. David Luterman ( 06:44 ): I was doing what I was taught to do in my training program, which is essentially the medical model. A client would come in and I would take a careful case history. I would then do my testing, and then I would counsel and counseling was seen as a separate entity at the end of the interview and the testing. The counseling was always information based. It was an explanation of the audiogram, and if appropriate, it was a discussion about hearing aids and what the next step was for them, and what might be the cause. Dr. David Luterman ( 07:28 ): It was in terms of causation, in terms of habilitation or rehabilitation, but there was no dealing with the feeling aspect of it. In fact, I remember my grad school, the injunction I had was, if there's feelings around refer to those social worker which we had associated with the clinic. Dr. David Luterman ( 07:53 ): I had that notion about counseling, as counseling as information giving. Then I proceeded to start my clinical career, and I followed through on that. After about two or three years, I began to find that clients just weren't absorbing anything that I had said. After a while, it becomes almost routine, the information giving at the end of the testing. Dr. David Luterman ( 08:36 ): They would come back, they would be asking me questions about stuff that I knew I had covered, and I'd covered sometimes two and three times to be really clear with them. They seemed to be listening. But apparently they heard almost nothing that I had said. Then I found that there was, way back then in the '60s and '70s, a fair amount of clinical research indicating how little clients retain of the content that is given in an interview. Dr. David Luterman ( 09:17 ): This was true for me as well. I began to explore that a bit. What I discovered, looking at the literature further, is that when people are emotionally upset, they can't retain content. Your brain goes into a fight or flight mode and you're not in your left brain, you're in your right brain. I think we've all experienced this. When you're emotionally upset, you just can't read. You try to read something and you read the words and they don't connect in the brain. There's like a disconnect. It's a phenomenon that occurs normally. Dr. David Luterman ( 10:10 ): When we're emotionally upset, we go into fight or flight mode. But cognitively, we shut down. This is a survival characteristic that we have that's built into our neurological system. It doesn't matter how prepared a client is, but when you make a diagnosis, and this would be true if you tell them that their kid is on the spectrum, or he has an articulation disorder, certainly, if he's developmentally delayed, you're going to have that shock response, that fight or flight response, and cognitively, they shut off. Dr. David Luterman ( 10:51 ): I used to think, well, okay, I was wasting my time maybe giving content, but it's not benign, because what happens is when you give content early on, and the client is not ready for it, not emotionally ready for it, or physiologically ready for it, it contributes to their feeling overwhelmed, and scared, and inadequate, and all that are very negative things for a positive outcome with a client. Dr. David Luterman ( 11:27 ): I found that in order for me to be effective as a clinician, I needed to deal with the emotional realm. ASHA, way back when defined counseling as both cognitively and personal adjustment counseling as aspects of it, that we as clinicians in the speech and hearing field should be comfortable with. There was that personal adjustment piece. But what I realized is you really can't do one without the other, or you shouldn't do one without the other. Dr. David Luterman ( 12:12 ): In other words, the content has to be intertwined with working with the emotional state of the client. We can't ignore it. If we do, we're not going to be effective. I think that's what happens, I think right now, in looking at the research that's out there, the predominant way of counseling, at least for audiologists has been this medical model. We've inherited it, it's comfortable, it's self-protective, and a lot of people in our field are very uncomfortable when we're dealing with the emotional aspects of it. But the emotional component is there. We are dealing with people who have lost the life they thought they were going to have, and we're really doing grief work. Dr. David Luterman ( 13:04 ): What we must do is we must become comfortable with that feeling component in order to be effective clinicians. We can't do one without the other. I have built my career on trying to help people in our field, clinicians in our field become more comfortable with that emotional aspect of it. Dr. David Luterman ( 13:38 ): I recently wrote a paper on teaching counseling, and the reviewers asked me to write a definition of counseling. Now, I've been teaching counseling for 40 years, and I've written a number of books about it. But nobody had ever really asked me to write a definition of counseling. So, I sat down and wrote it. It's a bit of a mouthful, but let me give it to you in pieces, and then I'm going to just open it up for discussion. Counseling are the components of the clinician-client relationship, that promotes self-enhancing behavior in the client. That's one piece of it. Dr. David Luterman ( 14:28 ): What happens is when clients have a lot of feelings, they behave in ways that are not self-enhancing. A lot of anger gets displaced around, they're feeling overwhelmed and scared, so they go to seek somebody to solve their problems for them, and so on. We need to deal with that behavior which is not self-enhancing. We can promote self-enhancing behavior in the client through the judicious provision of information, while also allowing for the expression of painful feelings in an emotionally safe context. Dr. David Luterman ( 15:13 ): That's what we need to do, we need to be able to build in to the relationship, where they feel emotionally safe, to begin to talk about how they're feeling, to experience their feelings, to cry. Because, what happens to our clients is they're not given permission to feel bad. Everybody conspires, including people in our field, to try to make them feel better, and that's probably the worst thing you can do for somebody who's in pain. Dr. David Luterman ( 15:53 ): It seems counterintuitive, but what you do when you try to make them feel better is you invalidate their pain. I remember one parent, as she was sitting down in a support group, she looked me square in the face. She looked at me and she said, "You're going to make me cry." I looked back at her, and I said, "No, I'm just going to give you permission to cry." And she started to cry. Dr. David Luterman ( 16:25 ): See, when we try to make them feel better, we invalidate the feelings. We tell them they have no right to feel pain. Yet, they're in a very painful situation. It's that safe context that we need to provide, where parents or clients can feel and experience their painful feelings. If you're successful, successful counseling results in an empowered client, who has the information he needs, and who is emotionally grounded. By emotionally grounded, I remember one parent said to me once, she said to me, "I have the same feelings I used to have, but they don't control me anymore." Dr. David Luterman ( 17:14 ): We're not going to try to do away with the feelings, we're going to just let them not control their behavior. Then successful counseling is also transformative. People should come out of that growing, they should be better off. There's one thing I've learned over the years, I never feel sorry for our clients. They're in a painful situation, none of their own making very often. I know that if I hang in there with them, that they are going to grow and learn from this. These disorders are powerful teachers. So, they can be transformed into a more grounded human being. Dr. David Luterman ( 18:11 ): Kate and Amy, what would you like to know? Amy Wonkka ( 18:14 ): I feel that you've touched on so many wells of information. I think what I'd like to start with is the concepts of... It's really twofold. The first is deep listening, which is something that you reference a lot in your writing, and the second is self-care, which is something that you touched on briefly about being grounded, and I know that there's a relationship there, but can you tell us a little bit more about the importance of deep listening and self-care? Dr. David Luterman ( 18:47 ): Okay. Well, yes. Let's do listening first. Listening is I think one of the most important tools. It's not always seen as a tool. Because students are trained and clinicians are trained to perform, to be doing, to be showing you how smart they are, to be helping and, and yet sometimes, or most of the time, actually, the most helpful thing you can do is listen to the client, because nobody's bothering to listen, they're all busy telling them what they should do and how to feel better. Instead of listening carefully. Dr. David Luterman ( 19:29 ): What I mean by that is listening and listening selflessly without having any agenda. Then being able to listen to what Carl Rogers calls the faint knocking. See, the language we use is really a map of a territory, and underneath the territory, is very often how we're feeling or what the feelings are. Dr. David Luterman ( 19:59 ): We need to listen to the map very carefully, to see what the territory is described. Let me give you an example of this. A question you're going to get almost invariably is an etiology, what caused my child to be autistic, or what caused my child to be deaf or my husband to have a stroke or any of those questions about causation. On the surface, you can just look at that question, and you can see it as content based question, and you can give them the content from your courses. Dr. David Luterman ( 20:53 ): But I can tell you right now, that that's going to be unsatisfactory. Because most of the time, people already have an idea of what autism is, or deafness is. Before they come in, they've been on the internet, people have told them all kinds of things. When they answer that question, they're really not asking that question. The underlying feeling there is probably guilt. They're really asking is, did I do something to cause my child to be deaf, or autistic, or my husband to have that stroke? They're really dealing with guilt. Dr. David Luterman ( 21:38 ): It can be much more helpful when you're listening carefully to the client, to be able to indicate, in some kind of way in which you respond. You can say, sometimes it's very easy to feel guilty, that you may have done something to cause your child to be deaf. Is that true for you? It might be a way to respond to that, rather than to the content level. That's what I mean about deep listening, being able to hear that faint knocking that Carl Rogers talked about, which is related to the emotional state of the client. What is the emotional state of the client there? Dr. David Luterman ( 22:32 ): That's the listening piece of it. I think there is no single more important aspect of counseling skill than that ability to listen, to allow the client to come to you, and then to be able to respond to the territory. Then the second question you had was about care, or self-care. This is something I find, especially with women in general. I don't like to generalize this way, but women are acculturated to be taking care of everybody else, and to take care of themselves, usually involves a certain amount of guilt. Dr. David Luterman ( 23:23 ): But yet, we are the most important tool in the clinical interaction. By self care, what I mean is that we have to be sure that we're comfortable with ourselves, and then we're able to listen. If we're running on empty because we've had so many clients that day, we're not going to be able to listen, and we're not going to be effective. Dr. David Luterman ( 23:55 ): I always tell my students, one of the most important things you can do for your clients is to have lunch, and they always laugh at that. But no, you need time out, you need time to just get yourself together, to get yourself what I call centered. I teach the students very often to meditate for a few minutes, just go back and sit and be comfortable with their feelings. Then when you're centered, you can be much more effective. Dr. David Luterman ( 24:32 ): Is that enough, Amy? Amy Wonkka ( 24:38 ): I feel like when I listen to you speak and when I read the writing since you also wrote my counseling textbook for grad school. But I think that it's such a big topic, and I guess I appreciate the examples that you give in your writing about how to learn to be a listener, and what types of questions to ask. Because I think, you're making the point that it's a skill just like, for a speech pathologist transcribing an IPA is a skill. It's a skill that has features that can be learned. Amy Wonkka ( 25:21 ): But I think it's hard to know how to do that, and we don't get a lot of training in it, necessarily. Which is another thing we wanted to ask you about in terms of, for our listeners out there, who maybe didn't have the pleasure of having you as a professor, or one of your books, do you have recommendations for how clinicians can acquire these skills, no matter where they are in their career? Dr. David Luterman ( 25:54 ): Well, I have a confession to make. I have never had a counseling course. They weren't in existence then, and I've never taken a counseling course, formal ones in school either, in the psych department. My learning has been all self-taught by looking and reading books. But it was also by doing a lot of personal growth experiences. As I get more comfortable with myself, then the counseling skills get added on. A textbook helps, like the counseling textbook, when I wrote, but there's several others. There's one by Holland and one by [inaudible 00:26:45] that are pretty good, too. Dr. David Luterman ( 26:48 ): Reading about counseling in our field, and then counseling beyond our field into the psych literature is helpful. But I think the most helpful thing for me has been keeping myself grounded, that self-care that I talked about. Because when I do that, then you can listen better, and you somehow hear better. But what I can do is, I can talk about two ways, there's two ways of going at this. One is we can talk about what you should be doing. But I think there's another way to go, which is let me talk a few minutes here about some of the mistakes we make, what I call counselor caveats, things you shouldn't do. Dr. David Luterman ( 27:44 ): If we strip away a lot of the things that get in the way, what's left is the good stuff of relationship. We're really talking about relationship here, and what makes a relationship work. What gets in the way of our relationship, if we can strip that away. One of the things that's a real problem in our field is what I call over helping. It's when we do more than we should be doing, and we tend to create a dependent client so that they're not empowered, and gets in the way of empowering. Dr. David Luterman ( 28:21 ): Clients want us to solve their problem. They want us to be a fixer, and to fix the problem. If we take that on, which is very tempting for people who have a strong need to be needed, and there are a lot of people in our field who have that need to be needed, then we create dependent clients who are just looking to us for the next answer. Dr. David Luterman ( 28:46 ): I had a poster in my office and it said, give me a fish, and I eat for a day, and teach me to fish and I eat for the rest of my life. That's what counseling is about. We're there to teach fishing. Not to over help, to the point where we would create a dependent client. Because that would be giving them fish. We have to trust that the client themselves is going to be able to solve that problem, eventually. If we give them enough support and enough information, they'll make good decisions for themselves. Dr. David Luterman ( 29:26 ): We need to understand denial. Denial is a coping mechanism. It's something that the client goes into, right away. It's the way in which we self-protect ourselves. We may admit that our child is deaf, where it becomes very hard for us to put hearing aids on the child, because looking at the hearing aids means that he's deaf. Very often, you have parents who are just remiss about putting hearing aids on. Dr. David Luterman ( 29:58 ): It's very easy to start blaming the parents, or trying to rescue the kid from the parents, both of which are bad mistakes. We need to understand, and we need to put the parents in as our client, understand that denial is a crisis of confidence. That's the only way I can cope right now, by emotionally pretending that this is not there. Dr. David Luterman ( 30:28 ): Denial gets in the way so often, because it's just not understood well. There's implicit expectations that get in the way of relationships. This is when we assume something. The other person, and we haven't really checked it out. It's what's called contracting, being very explicit about what you want, and what you expect from the client. I always ask clients, what do you want from us? What are you hoping will happen here today? I do this with students in my class, always start off a class with, what do you need? Dr. David Luterman ( 31:14 ): We then see where there's a match. Very often, clients want you to be the Anne Sullivan, and solve their problem and take the good and be the fixer. If you've been listening carefully in here, you don't want that wrong, it's a bad roll, because you're not going to get a good result long term with that kid. Because you only have the kids for such a limited amount of time. We need to spend that empowering the parent and not diminishing the parent. But over helping diminishes the parent's self-esteem. Dr. David Luterman ( 31:51 ): The thing that we also have to avoid is stereotyping people. It's very easy to do it. To try to put them in a box. I had a prof who was really good about counseling, he had it intuitively. What he used to say is, "Remember, you have to see each client as a wonderful experiment of one." Once we can do that, set aside expectations, then we can hear clients and seek clients and just be present for the client. Dr. David Luterman ( 32:35 ): Then the last thing that gets in is what I've talked to before, and that's all about that cheerleading, thinking our job is to make the client feel better. That's going to invalidate their feelings of pain. They won't have that kind of honesty, the kind of openness in the relationship that I think it needs in order to be successful in promoting growth in the client. That's some of the things that get in the way of the relationship. Dr. David Luterman ( 33:14 ): We can get those out of the way, then technique flows from this. The best technique is, as I said, listening, and not always responding with content. Content is the easy thing to do. We do have a content mandate, as I've said at the outset. We do have get information, but it's the timing of that content. Very often when clients ask you a question, there's an underlying, as I talked about before about the feelings, but very often they want a confirmation. When people seem to be asking for advice, 95% of the time, even closer to 100% of the time, what they're really seeking is for you to confirm what they've really secretly known. Dr. David Luterman ( 34:22 ): If somebody asks you, "What do you think of my boyfriend?" Don't answer that with content, trust me. That isn't what they want or need. What they want is confirmation of some position they have. The way to respond to that is what I call a counter question, which is, "Well, it sounds to me, when you're asking me that question that you have some doubts. Could you tell me how you feel about your boyfriend?" Dr. David Luterman ( 35:06 ): That's a much safer way to do that. Now, to get back into our fields, if they ask you, "What do you think about cochlear implants, or is that School for the Deaf a good school for the deaf?" Or anything else where they seem to be asking for advice, they seldom are, they're asking for confirmation. What you want to do is throw them back on their own heels, on their own self so that they really answer the question for themselves. If they sometimes get angry at you for that, but it's the best teaching technique you have. Amy Wonkka ( 35:51 ): That brings me to one of the other questions I had going through your readings. You've framed it so well about these obstacles to relationships, in terms of denial. Then earlier, you mentioned misplaced anger. I'm wondering if you have, I don't know, wisdom. You have lots of wisdom about counseling parents are working with families where there is misplaced anger or denial, that is such a roadblock that the clinician might feel a little powerless in terms of either the family's asking for a treatment that is against our code of ethics or they're being butt up against our evidence based practice or there is misplaced anger, where there's name calling or inappropriate behavior on the side of the family. What tools would you recommend, given the realistic restrictions of our work environments, to navigate those spaces? Dr. David Luterman ( 36:57 ): What you need to understand, that's the non-productive behavior that I talked about, which really comes about because people haven't heard and listened to the client. Almost all of that is fear based, or that's what you need to understand. We're dealing with people who are grieving, and they're feeling overwhelmed. These are the two principal feelings that they have; they're in pain, and they're feeling overwhelmed, and they're scared to death. Dr. David Luterman ( 37:28 ): What we need to do is respond to the fear. Let me give you an example, which I saw from that prof, Jean McDonald, who was my mentor in graduate school, and what he taught me so well. I watched as he was counseling this family with a Down Syndrome kid. The father was this big, burly steel worker. He comes in to the meeting with his wife. He says, "If anybody tells me my kid's retarded, I'm going to punch him in the nose." Dr. David Luterman ( 38:09 ): McDonald, without missing a beat, looks him square in the face, and he says, "You must love this child very much." The guy started crying. He just blubbered. It's the feeling underneath there. A response that helps me a lot with parents, well, not just parents, I've worked a lot with parents of deaf kids. That's where I went on after I left clinical audiology. I always tend to refer to them in that way. Dr. David Luterman ( 38:51 ): The response that I find very helpful is, this must be so hard for you. I don't respond to the anger, I respond to the pain that's there, Or I respond to the fear. "It's pretty scary right now for you, isn't it?" and mean it. if you say it that way, and mean it, it sets the parent back, I don't get defensive. The worst thing you can do is get defensive, and then it's hard not to. But to hear the pain, hear the fear and respond to it. Amy Wonkka ( 39:32 ): I think in part that, for me, when I listen to you speak and in reading the content you had sent to us, I think part of it is also about just shifting though and shifting from that role of being the fixer and if you as the clinician give yourself permission, that that's not your job, I think it's a little easier to step outside and have a more human relationship with the person, because you're no longer having all the weight of all of these responsibilities, that actually aren't that productive in the first place. Kate Grandbois ( 40:09 ): I was actually thinking something somewhat related. But having been in situations like this before, it really makes me think about how grounded you need to be. Because when someone is yelling at you, or threatening to punch you in the nose, or calling you names, as a clinician, as a human, I have a fight or flight response. Then, being really able to ground yourself and separate yourself from and not take it personally, I think that those two things combined are just of utmost importance. That's something that we talk about a lot as a field. Amy Wonkka ( 40:48 ): I have one more question, also, which I think Kate and I talk about this a lot on our show, and the fact that- Kate Grandbois ( 40:55 ): I know what you're going to say. Amy Wonkka ( 40:56 ): The fact that we're a reimbursement driven model, and all of the negative repercussions that that can have on our continuum of service, overall. But I think a real challenge with forming genuine relationships with people is this pressure of time. Whether you're in an outpatient setting, or you're in a school, we have such limited time with the families, and I didn't know if you had any tips about how to operate in the treatment model that many of are operating under? Dr. David Luterman ( 41:34 ): It's what I've talked about really, is embedding that information with the emotional responses. That's how you're going to be effective. If you're going to just try to deal with the content and information aspects, again, it's a waste of time. In fact, you're damaging your client when you do that. You need to realize that and hopefully reimbursement can. Dr. David Luterman ( 42:05 ): Somebody asked Carl Rogers that, because what I'm talking about is the non-directive counseling that he [inaudible 00:42:12] He said, "What do you do if you have 20 minutes only with a client?" Rogers looked him square in the face and said you do 20 minutes worth." It's a question of how to be effective with your client, and we have to recognize this as a profession, that the most productive way we can spend our time sometimes is just selflessly listening to the client. Dr. David Luterman ( 42:44 ): It pays huge dividends later on. The pay off may not be right away, but what happens is you get an empowered client, so then you can start really dealing with content a little bit later. But you embed the content there too. It's a matter of being effective. I hope we just don't get pushed around by insurance people. I know the pressures are there. Amy Wonkka ( 43:23 ): I remember working in a hospital setting where, I had to see X number of patients a week. To your point earlier, the best thing you could do is eat lunch, I barely had time to eat lunch, and it wasn't necessarily... I think that burnout is high. I know, you've mentioned that a lot in your writing about burnout. I can't help but feel that the funding model and lack of funding for indirect service, frankly, is really a contributing factor there. Dr. David Luterman ( 43:56 ): I think we have to change it. We have to work at that. We have to create environments that make it possible for us to be effective in our job. Kate Grandbois ( 44:12 ): Such a good point. Dr. David Luterman ( 44:12 ): If you have lunch, you can be more effective. If you go outside and take a little walk and get some air and give yourself a break, you'll be more efficient to use your time better. Amy Wonkka ( 44:30 ): I was wondering about the role of support groups. You mentioned a lot in your writing about the power and importance of support groups. Can you tell us a little bit more about that? Dr. David Luterman ( 44:46 ): I am such a fan of support groups. I got disaffected. I just didn't like clinical audiology. I decided that I'm going to transition myself out of clinical audiology, and I'd start nursery school for parents of young deaf kids. I did this in 1965, it became one of the first early intervention programs around. I didn't have any of this vocabulary at the time. Dr. David Luterman ( 45:25 ): But what I knew what needed to happen was, you needed to focus on parents. It's very frustrating to me, because everybody agrees in early childhood deafness, and notice how important parents are, and nobody's ever going to argue with you about the importance of parents. They seldom do it though. What you need to do and it causes a paradigmatic shift of saying, the parent is the most important piece here, and I'll get to this [inaudible 00:46:09] in a minute, but I just went a long way around here for a minute. Dr. David Luterman ( 46:14 ): Its causes a paradigmatic shift when you put the parent in the center. I remember talking to a group of itinerant teachers of the deaf, and this was in England. I said, "How many of you think the parent is the most important person?" Everybody raises their hand. Then I said, "How many of you go into the house with a toy?" Everybody raise their hand?" I said, "So, why are you bringing a toy to the parent? They don't need it." Dr. David Luterman ( 46:55 ): It's just the reflective of how we go about things, that people say their parent centered, but they're not really, because our training is all geared towards the identified patient, the kid or the adult with the stroke and so on. Dr. David Luterman ( 47:17 ): I started a parent centered program, and we had a nursery school and we had the parents observing, and then we had two parents doing therapy. But I knew something else, too, at that time, although I couldn't have articulated it. I took the parents upstairs, left the kids down in the nursery, and had a support group. I can still remember, this is in October 1965, I can still remember it vividly, because it made such an impression on me. I didn't quite know what I was doing, and I didn't have the vocabulary. But intuitively, I knew that they needed to be together. Dr. David Luterman ( 48:01 ): That group was so powerful. We just went around the room, and I had everybody introduce themselves. I had these short speeches, as an audiologist, content. But here I was committing myself to a whole semester worth. I was scared to death. I said, "Well, I just think we need to just use this space as you need to use this space." And I shut up. Then the torrents started, the parents just started to talk. Dr. David Luterman ( 48:39 ): What I realized right then, that what happens when you have a catastrophic event in your life, it's emotionally isolating. It sets you apart from all your ordinary places of being. You're now different than anybody else, and people don't understand. They all, again, what I was talking about, conspired to make you feel better, which just tends to isolate you and invalidate your feelings. Dr. David Luterman ( 49:20 ): When you can get into a room with a bunch of people that are experiencing the same thing you're experiencing, you get validation for your feelings, and for your experiences. No other place can you do that. Every time I do a support group, particularly an initial one, it's the same thing. There's a palpable whoosh in the room when people recognize that/ Here's a place I can be safe, here's a place that I can talk and people will understand. Dr. David Luterman ( 50:02 ): Now, I have taken this model, this support group model, and I have used it in all kinds of contexts, including people giving up smoking, and smoking cessation groups and caregiver groups of one kind or another, experiences is always the same, is always is that validation of my experience. The only place I can really get that is this support group. I can't imagine any program without it. It's the most valuable tool that we have, and it's a great gift that we can give our clients. Dr. David Luterman ( 50:48 ): First of all, you got to see the parent or the caregiver as your client, and two, you got to give them that kind of safe environment where they can talk to each other. It's a wonderful experience for yourself. I've learned so much, these parents have taught me so much. I'm a big fan of support groups. I couldn't imagine a program without it. Kate Grandbois ( 51:13 ): When you said that before, as you're describing it, it sounds incredible. Yet, I don't know of a single program that has one, which is, obviously, we're unearthing a lot of deficits in the normal day-to-day of our field. I'm sure or hoping that a lot of our listeners will leave this conversation and try and advocate for a support group. Kate Grandbois ( 51:37 ): I think a lot of speech pathologists and possibly audiologists, but I'm not an audiologist, may not feel that running a support group or starting a support group is within their scope of competence or something. For example, in one of my settings, we're consistently advocating for a social worker, because the social worker is the role that will initiate these kinds of endeavors. Do you feel that a speech pathologist and/or an audiologist has it within their scope to spearhead these kinds of projects and start support groups? Dr. David Luterman ( 52:14 ): You bet I do. In fact, I don't want the social worker in there- Kate Grandbois ( 52:19 ): That's the answer I wanted. Dr. David Luterman ( 52:22 ): Well, the social worker comes from a pathology point of view, we're not dealing with pathology here at all. We're dealing with us, we're dealing with people who were in a catastrophic situation, not of their own choosing. Their life is turned upside down, all of a sudden, once they find their kid is deaf or autistic, or whatever. Dr. David Luterman ( 52:50 ): It's grief work. Grief is endemic to our humanity, and it needs to be within our scope of practice, and makes it so much easier. This is not pathology. These are people who are emotionally upset, not emotionally disturbed. It's much more relaxing for them, to be with a speech pathologist or an audiologist than with a social worker. Amy Wonkka ( 53:17 ): Such a good point. Dr. David Luterman ( 53:17 ): But that gets sent to the pathology piece of it. In fact, I get some blow back from psychologists and social workers sometimes, because they also say, "No, I never refer any of our clients to social workers or psychologists." They always look at me, I say, it's not their problem, it's my problem. I just identify it as such. Dr. David Luterman ( 53:52 ): There are clients who really do need professional help. But I don't make that referral, I just tell clients, this is as far as I can go, and I want to go. These are parents who are having a lot of problems with their marriage, for example. I don't go there, I just say, "I want to go, this is beyond my scope of practices," is what I always say. But I leave it there. I don't say you should go and see a marriage counselor. Because it may not be within their value system at all. That's the same way I just don't bring a social worker in to work with them, because then that may not be their value system either. Dr. David Luterman ( 54:43 ): The discussion will go on, then where do I go and then we can talk about that. I'm always looking for them to make a self-referral. When it's a self-referral it has a much greater chance of being successful, than if they're going to the social worker, because I sent them there. It's not necessarily their problem, it's my problem, certainly, because I didn't want to go there. Kate Grandbois ( 55:14 ): That makes a lot of sense. I am hoping that all of the people who are listening to this course, take a nugget from that and advocate with their administrations. Gosh, after hearing this whole conversation, I hope we all do a lot of things. I hope we all do a lot of things differently. Dr. David Luterman ( 55:37 ): That's my goal. My goal is to make you upset. My goal is to make you upset, and upset people will make changes. Happy people bliss out, they have no investment in making some changes. I love the book, way back when. I love the title of the book, it's also good content called Teaching As a Subversive Activity. They talked about that, that the teacher's job is to undercut the learner to a certain extent, and make the learner uncomfortable. Kate Grandbois ( 56:18 ): Good job. You did a really good job. Dr. David Luterman ( 56:22 ): Good, so I succeeded? Kate Grandbois ( 56:24 ): You did. Oh, my gosh. We're uncomfortable, but I'm not that uncomfortable. I think it's really refreshing, and I say this to my mentees a lot, you're never going to learn until you're operating in some moment of discomfort. Even just thinking in reflecting back on ourselves, as new graduates, that first time you're sitting with a client, you're being looked at through the mirror, you're sweating, you're nervous. These moments of feeling nervous are so important. Kate Grandbois ( 56:57 ): I think all of the things that you've just touched on, highlights so many deficits that... I can only speak for myself, I have not embraced as deeply as I could have or should have, but will and I feel pretty comfortable saying that as a field, we don't have an emphasis on these areas. I'm so grateful for you pushing us to a place of discomfort so that we can share all of these things with our listeners. Dr. David Luterman ( 57:30 ): Yeah, you should always be operating on the fringes of your competency. If you're comfortable about what you're doing, you're not learning anything. I have a whole list of aphorisms, clinical aphorisms. Did I send those on to you? Kate Grandbois ( 57:42 ): You did. Amy Wonkka ( 57:44 ): Yes, they were so good. Dr. David Luterman ( 57:44 ): Good. All right. I think those, you might find them helpful too. If somehow you could share it with your listeners, it would be anything helpful. Kate Grandbois ( 57:54 ): We will. We can list them on our website that will correspond to this episode. We will put them up there for everyone. Dr. David Luterman ( 58:04 ): Oh, good. Kate Grandbois ( 58:05 ): Thank you so much for joining us. This was an unbelievable pleasure. Before we close the episode out, do you have any advice or closing remarks or more words of wisdom than you've already given us? Dr. David Luterman ( 58:19 ): I think you got enough. It sounds like you got enough. You got to go digest it for a bit, and come back, we'll talk some more. Kate Grandbois ( 58:29 ): I think digesting is a good idea. We're so grateful for your time. Thank you so, so much for joining us. Dr. David Luterman ( 58:37 ): You're very welcome. Do take care. Amy Wonkka ( 58:39 ): Thank you. You too. Dr. David Luterman ( 58:40 ): Good luck to you. Kate Grandbois ( 58:42 ): Thank you so much. Dr. David Luterman ( 58:43 ): Bye-bye. Amy Wonkka ( 58:43 ): Bye-bye. Kate Grandbois ( 58:44 ): Thank you so much for joining. As I'm sure I hope all of you are walking away from this conversation feeling like you have things to digest and feeling empowered to effectively make change in our fields. If you have any questions, please email us anytime, info@slpnerdcast.com . We really, really enjoyed this episode and we are so excited to have been able to share it with all of you.

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. We are so excited to welcome two guests who have been here before. We've had a great time catching up with the two of them for, I'd say, almost 40 minutes since our, since our recording time started. And we're really excited to share all of their brilliance, wisdom, and laughter, likely, uh, with the rest of our audience. Welcome Natalie Douglas and Kathy  Cathy Binger:  Binger. Thank you. We are very excited to be here again. For sure.  Amy Wonkka:  Well, we're super excited to have you, and you are here to continue our discussion on bridging the research to practice gap in the field of speech language pathology. The laughter has already started, folks. If you are not accessing this through YouTube, I'll just let you know, Kate is silently cracking up up there.  Kate Grandbois:  I'm going to be [00:03:00] fine. We're going to be fine. It's going to be great. We're going  Amy Wonkka:  to be fine. Uh, so before we get started. Um, Natalie and Kathy, can you please tell us a little bit about yourselves for our audience members who may not have listened to your prior episodes? Cathy Binger:  Go ahead, Natalie. Okay, great.  Natalie Douglas:  So right now, I am a professor at Central Michigan University in a speech language pathology department. My background, I was a clinician for about 10 years and hospital skilled nursing home health settings before transitioning back into academia and I've actually been here at Central Michigan for 10 years, which. I don't know how time flies, but it does. Um, but primarily, my research aims to improve quality of life and communication for people with dementia living in nursing homes. And what goes along with that, and why I'm here with Kathy today, is how we can merge the research to practice [00:04:00] gap with implementation science. So, people living with dementia, their communication needs in nursing homes, that's just, you know, one small area of. People that we serve, but, you know, I've been really lucky to get to work with lots of people kind of across our scope because the principles and the tools of implementation science can really help to merge that gap kind of in whatever setting that you're in. Um, so that's a little bit about me.  Cathy Binger:  And I'm Kathy Binger. I'm a professor at the University of New Mexico. Um, I'm an SLP as well, and I practiced as an SLP for about eight years before I got my PhD. So, worked in, uh, lots of different settings, particularly with young children, um, Head Starts, preschool, that kind of thing. And, um, I've had my PhD for a long time now, so I've been here at the University of New Mexico for about 18 years, something like that. And I've always been, I was [00:05:00] interested in implementation science before I knew that implementation science existed. I think like Natalie, I've always been interested in doing work that was going to have a real life clinical impact and was frustrated for a lot of years, seeing that a lot of the Quote unquote research evidence based work that had been completed was not necessarily being used commonly in clinics and in clinical settings and educational settings and certainly coming to realize a lot of that had to do with how that research was created to begin with and that it wasn't necessarily devised to be constructed to be culturally Well, culturally sensitive for one thing, but also, um, clinically feasible to do these things. So that's my interest in implementation science. And it's, it's such a pleasure to be here with Natalie. We, we work with 2 very different populations, but our motivations for implementation science [00:06:00] come from exactly the same place. I really love  Kate Grandbois:  the idea of two scientists, two researchers from such vastly different areas of interest really working together for with a shared common goal and understanding. So I'm very excited to get into the content for today. I know we're really going to be unpacking the research to practice gap, which is something that we did in a previous episode that Amy already mentioned. So today's episode is a part two to that original episode that aired, I think in 2021, and we're recording this in October of 2023. So this is a long time coming. If you have not listened to the part one, please feel free to go back in time. Give it a listen. Um, today we're going to do a little bit of a deeper dive into how we can, what action steps we can take to mend the research to practice gap and how we can make it better. Uh, before we get into the content, I do need to read our learning objectives and disclosures. I will try to get that, get [00:07:00] through that as quickly as I can. Learning objective number one, describe levels of involvement for researchers and non researcher invested parties, depending on the project. Learning Objective Number Two lists the five key dimensions of research to practice partnerships, and Learning Objective Number Three lists at least two real world examples of research to practice partnerships in action. Disclosures. Natalie Douglas's financial disclosures. Natalie receives a salary from Central Michigan University and the Informed SLP. She also receives book royalties from Plural Publishing and has research funding from the American Speech Language Hearing Foundation. Natalie is a member of ASHA SIG 2 and SIG 15, the Gerontological Society for America and the Aphasia Access Group. Kathy Binger's financial disclosures. Kathy is employed by the University of New Mexico. Her non financial disclosures, Kathy is a member of ASHA and Special Interest Group 12. Kate, that's me. I am the owner and founder of Grand Bois Therapy [00:08:00] 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 Therapy. Amy, that's  Amy Wonkka:  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, which is AAC, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. Alright, disclosures are done. On to the good stuff. Um, Kathy and Natalie, why don't you start? So I'm going to start us off by giving us and our listeners just a little recap about implementation science. I think you both talked a bit in your introductions, um, about sort of what's drawn you to implementation science. So maybe you can talk a little bit about why it's important for the field of speech language pathology. Like super Cliff Notes version because we do have the other podcasts for our listeners. Go [00:09:00] for it,  Natalie.  Natalie Douglas:  Okay. Yeah, so I think a sum up would be implementation science is technically the study of how we get interventions or assessments or really any practice of interest, something that might work really well in a lab or controlled setting and. Implementation science is the study of how we get that. Into the real world. So, in our field, that's going to look like schools, hospitals, rehabs, places where we, our, you know, we're, we're serving the people that we serve. One thing that's happening, so the field of implementation science has been around for almost 20 years now, so they had their inaugural journal kind of started in 2006 and it we've been a little behind in kind of catching that train in our field, [00:10:00] but. Even for the people that have been at this for a long time, they're asking questions like, perhaps there's still something fundamentally wrong with something being created in a research setting and then pushed into a real world setting. So, perhaps when we think about this kind of the next iteration, or what the future of implementation science. Might hold and what I think is super valuable for our field is to stop and critically reflect on how evidence is even constructed to begin with, because if we're not able to, um, get that evidence from, you know, where the, in the context of where it's actually happening, then maybe it's not remotely relevant to where we're trying to push it in. Maybe it's not even meeting a community need. So that's kind of my cliff notes version and Kathy, I [00:11:00] don't know if you have anything to add to that  Cathy Binger:  Yeah, I just what you said reminded me of our, um, funny discussion about the ivory tower when we talked about this the last time. Um, and I believe the never ending story came up for some reason. Oh, my gosh, it did. It just came up on my Netflix page the other day. So it made me laugh and think about that. That's why that was top of mind. Um, So anyway, you know, the, the old quote unquote old approach to doing research is for people to be in their ivory towers, thinking up these great ideas, all these PhDs who are supposed to know stuff and coming up with assessments, coming up with interventions, coming up with approaches to try to help people, um, in our, you know, in our world with communication disorders, and then, you know, Living a life of frustration and blaming clinicians for not doing the things that we've been spent we meaning academics have been [00:12:00] spending our lives and all of our wisdom, trying to impart to the clinical world out there and the reality. Being, um, that really the flip side is what we need to be looking at, which is, as Natalie said, the work that academics are doing, um, is through an implementation science lens inherently needs to be tied to real life clinical practice and educational practice and medical practice, um, and that from that we should not actually be doing our work without involving these Very, um, key invested parties to informing us and working with us and working hand in hand with us to devise. Programs and assessments and whatever it is that we're working on from the get go to make sure that they are responsive. So it's really a fundamental mind shift that's required as well as a fundamental [00:13:00] research practice shift. That's required. Um, I think there's a lot of needing to let go of ego and let go of, you know, it works in every direction. You guys have done sessions and even written a paper with Natalie and others on power privilege and how people are looked at up and down, you know, different levels of the ivory tower, if you will. Um, and, um, you know, that those things need to be considered and And, Reconstructed, um, with different frameworks so that we are really all working together in functional ways from the beginning. Amy Wonkka:  Yeah, I mean, it's, it's super exciting as a clinician, you know, that this sort of shift from researcher as Keeper and disseminator of information to forming these collaborative partnerships. I know we were all at the implementation science conference, um, through MGH and awesome conference, by the way, if you're listening and you're interested in implementation science, it's [00:14:00] a wonderful opportunity to learn some more. Um, and you know, one, one piece that's. Interesting is just thinking about within those different types of partnerships that might happen. And this gets a little bit into our first learning objective, but you know, there really can be flexibility. It sounds like there really can be some flexibility in terms of the different roles of the different participants, the researchers, the non researchers who are involved in implementation science. Um, and I was wondering if you could speak a little bit just about what those. different levels of participation might look like.  Natalie Douglas:  Yeah, sure. I'm happy to do that. And this, um, I've taken from, it's the international association for public participation in research, but I, I think that we can learn a lot when we think about how clinicians for ideally, even clients themselves and families and patients might participate in the. Research process, but what you have is [00:15:00] essentially a continuum where the least level of involvement is that of informing right? So, this is, it's kind of very similar to what's happening now, right? You go to a conference and a researcher is informing the clinicians about. This is the results of the research, right? So I'm letting you know, um, and I'm going to keep you informed, right? Like how this, you're, you're sort of doing that with this podcast in a way, right? So we were talking off mic earlier that Kathy has some new studies coming out and like, you know, getting something scheduled to like, let your audience know about some developments in her work, right? That's kind of informing, right? And then the next level is consulting, right? So this is where you are. Bye. Really getting some type of feedback. Um, I think about maybe some focus groups here, [00:16:00] right? Like, this is kind of what we're doing. And what do you think about this? What are some of what your ideas are? What are your concerns about this? And we're going to incorporate that feedback either into. the intervention development itself or into some type of the structure of implementing the intervention. And then you have involvement. So this is where you really are working closer together. So I think you're having more than just a pre and post kind of focus group meeting, but you're really working throughout the construction of that research to ensure that people are. understood and that their, um, concerns are being fully addressed throughout the process. And then you have collaborating. So this is really when, if you're thinking about it from a clinician standpoint, the clinician and the researcher would really partner in each aspect of the decision making. And [00:17:00] you're really, as a researcher, would be looking to that. clinician for advice and innovation on how to kind of form solutions and the researcher is incorporating those advice and recommendations. And then really the most involvement you could possibly have according to this continuum is the word empower. So really at this point, the researcher implements what the clinicians decide, right? So I would envision something like the clinician saying, This is the area of need. This is where we need data. Um, and they're really calling the shots. And, of course, the researcher is there with, you know, perhaps the study design and the methods and the how to go about it. But in terms of, like, really, what is the research question that's coming from the clinician standpoint and really, you know, in terms of from the inform piece, all the way to the empower piece, I think it's important to realize [00:18:00] that none of those levels of involvement. Um, Are wrong in and of themselves and I don't think Kathy nor I are coming on here to say every project for researcher does has to be empowering. Right? But I think it's important as researchers that we consider. How do we want to involve clinicians and at what level and to let clinicians decide based on their different capacity levels and what they're able not because we know they can do the job intellectually. So it's not a matter of that. It's a matter of productivity. And can they get it done during their workday? Or do they have to like, what many clinicians do? Do this research participation is like a hobby. Um, outside of their normal work hours, because there's no, um, compensation for that during the day. Um, so those, you know, I think it's important to think about where [00:19:00] clinicians might want to be involved, where researchers might want to be involving clinicians, and again, patients and families, ideally, and be explicit about what the roles are and how you might want to proceed. I so appreciate  Kate Grandbois:  that you brought up the infrastructure related barriers here because I think there are a lot of clinicians who would love to participate in some research practice partnership, but like exactly like you said, there's no funding for it. They don't have time built into their day. They don't have the support from their administration. They don't have time that they can take out of their personal lives. Um, and there are some, there are only some There are only some action steps that we can take to mitigate those infrastructure related barriers. One thing that you said, one of you said earlier that I want to just bring up again is this concept of ego and power differential. I think another barrier. [00:20:00] At least from a clinician's perspective is feeling like we don't belong feeling like we don't, we shouldn't have a place at this table feeling like well I'm a clinician not a researcher I can't do research, or the researcher doesn't need me there or doesn't want me there, or, you know, there is this invisible  Cathy Binger:  cultural construct  Kate Grandbois:  that we're. We don't belong. We don't have a place in the ivory tower. We don't have a place at this table. And I think that is something that we can actively work to change in ourselves and through conversations with other people. Um, and it's a very complicated mess. You know, these are not things that we're going to solve overnight, but I wanted to highlight those two particular barriers that you brought up because I think they're both really important. Cathy Binger:  Yeah, I, I totally agree, Kate. Um, they are, they are really challenging and they are really important. It's still, Natalie and I talk about this sometimes, you know, we go to conferences and people come up to us and, you know, talk to us like, we're all that. And we're like, no, we're not. [00:21:00] We're like, we're just getting paid to do a different job from your job. We're getting paid to do a complimentary job to your job. And we can't actually do our jobs without you. Like we, you know, we, this is a. I mean, I like to think of it the same way I like to think about how I like to work with families, which is we're all in this together. We all have our areas of expertise. You know, when I work with a family, one of the first things I always say to them is, I may have some expert expertise in speech and language or in augmentative communication or whatever it is. But you're the expert on your child, and we, I absolutely, you know, we need that expertise just as much as. We need my expertise. So I'm really looking forward to working together with you. And I think of implementation science in this partnership work as being very much coming from that same frame of reference of we all really, you know, not just in a roses and sunshine and butterflies kind of world. Oh, we all need to work together. We [00:22:00] really all need to work together. If we're going to change outcomes, improve outcomes for individuals who have communication disorders or swallowing disorders or whatever. Um, or impairments or differences or whatever we're talking about. We we genuinely all do need to work together. I  Amy Wonkka:  wanted to. So now, Natalie and Kathy, you've both mentioned family components and I wanted to circle back to that for just a second because we've talked a lot and we talked a lot in our last podcast about the power differential and the dynamic between people who are in the researcher role and then speech pathologists who are in the clinician role. And I was curious if you felt like now that you've done more with implementation science and learn more about it, have you felt any difference in it shifting your dynamic with your clients and their families? And if so, can you talk a little bit about. How that might be different when you're using an implementation science approach versus like a previous more traditional [00:23:00] research,  Cathy Binger:  Natalie, why don't you take this one? Natalie Douglas:  Yeah, I think I can. I think that what your question is making me think of Amy, and it kind of goes along with what Kate and Kathy have said is we have to think about knowledge and what we consider to be Knowledge that is of value, because in the scientific community, the knowledge that is most valuable is data from a randomized controlled trial, traditionally, and that's so good for so many reasons. Right? Like, I am so glad that I can take ibuprofen when I get a headache and that all of that data is supporting me. That right, like, we need that, but when you start to get [00:24:00] into behavioral treatments, which is most of what we do, right? We're trying to change behavior of somebody. Um, things get real complicated real quick and I think. We have to wrestle with as a scientific community, and perhaps as a clinical community to how do we value the lived experience? Right of our clients and our families and what they are telling us. About what is happening to them, right? Like what their symptoms are, what they're experiencing. Um, and I think what implementation science does, and definitely implementation practice, or, like, really getting these things into the flow is kind of equalizing those different forms of knowledge. Right? And to be able to take a wider view to say, Yes, it's not just, you know, whole, um, what almost every research methods class [00:25:00] is based on the hierarchy of research where a meta analysis is at the top and then a systematic review and then expert opinion is like the lowest. Right? And I just sort of wonder when we think about families, clients in particular. Um, what are we doing with that? Right? And so that's what implementation science has helped me to do is to really reflect on my own perceptions as to what does knowledge mean, right? Whose knowledge do I value and why and starting to try to really say that this person who is in front of me. If it's a nursing assistant or a speech pathologist or a person living with dementia, this is their knowledge and it's equal to, right, some data that I might get from somewhere else because we're in this murky world of human behavior change and to make, to [00:26:00] try to make it any more linear, it just doesn't work. Thank you.  Amy Wonkka:  That was, that was helpful because it does seem like it's just, it's such a different, it's such a different way of thinking about research, at least as somebody who's just been on the consuming end of research for a long time. Um, so it does seem like it would have such profound effects, like shifting to implementation science on, on all sorts of parts of that. Um, I, I know that we're, I'm trying to keep an eye on the time too, but we do, we should look at our next learning objective. We should not get on too many tangents. Um, And I wondered if we could talk a little bit just about some key dimensions of research to practice partnerships. Natalie. I know this is an article another article. Natalie Douglas:  Yes. And maybe Kathy, you want to chime in here with some examples from some of your projects. And we talked about this a little at the implementation science conference that any mentioned, but this is a. [00:27:00] Model that was kind of, um, really brought the light to our field by Crystal Alonzo and colleagues. It's a in the American Journal of speech language pathology where it talks about if you're going to have like a successful research practice partnership. Right? So thinking back to that continuum that we talked about earlier. So this is more in like the collaboration phase. What makes that successful? And so there are five dimensions that she talks about. And if you're interested in this, I really encourage you to check the article out. She's got a really cool infographic in there. But the first kind of dimension is building trust. And that's huge, especially when we have all of these barriers and power differentials and all of these. Aspects that we're up against. The second is conducting research not just the positive but to inform action So it's really talking about something that's iterative and really probably never [00:28:00] ending Right, cuz you like you do a study and then you learn from it and then you do it again and then, um The third piece is supporting the partner organization in achieving its goals. So I work with some health systems. I work with some nursing homes. You know, one of the goals of the health system that I'm working with is to reduce falls, right? And you might not think that that has anything to do with speech language pathology. We think it does, right? But that's their goal. So it's like letting them drive the bus in terms of. What the practice organization, what their goals are, and then the 4th is producing knowledge. That's going to inform improvement efforts more broadly. And then the last and final dimension is to. Think about capacity building of whoever is participating. To allow them to engage in partnership work. So we talked a lot already about some of the infrastructural [00:29:00] barriers to doing this work. So thinking about having those, like, frank discussions about bandwidth and priorities and what you're able to do and when all of those factors really contribute to a successful research practice. And I know  Amy Wonkka:  we talked a little bit, Natalie, at the implementation science conference just about how some of those infrastructure things, just thinking back to the different levels of involvement that you might see in a project. And to your point, that empower level might not be the best fit for everything. So I might be somebody who has infrastructure barriers in my environment, but I really would love to. to be involved in some of this research. And so some of that flexibility and having those ongoing conversations about what is a realistic ask, like what's a barrier versus what's a roadblock. Um, I think where the terms we were using, you know, and I think that that's probably a helpful conversation to have on the clinician side as well as the researcher side. I don't know. Um, [00:30:00] if either of you want to talk about some projects where you've maybe experienced barriers or roadblocks and like work through that with your, with your teams. Cathy Binger:  Yeah, I'll, uh, I'll talk about that. But, you know, maybe not even just the roadblocks and barriers, but some of the other pieces as well. So, you know, going back to that step 1 of building trust and cultivating partnership. Um, I'm working with a group here. And we presented at the Implementation Science Conference, the MGH conference together with Jessica Matney and Kitty Estrand at the New Mexico School for the Blind and Visually Impaired, and they both work at the school. And they work with primarily preschoolers who have multiple impairments, including visual impairment. And, um, We, you know, I've known one of them for a long time, the other one, not so long, but we've spent a lot of time together, like, having really, I mean, really, we've been having weekly meetings for for quite some time now to work on [00:31:00] building that trust and cultivating that partnership together. And, um, they, they, they're very ambitious. They have what's helpful in working with them as part of their school mission is to disseminate good information and for them to be creating information. So, um, you know, that fortunately, that's part of what they do. But even then, you know, even though they have some time that's supposed to be dedicated to that, it's very difficult. Um, and so they've tried to do some research projects on their own. Um, Um, and they spent a lot of time, um, and have some expertise in that, but had some challenges with it. And so, you know, I kind of, as we've, as I've been shifting some of my focus and really wanting to take this relationship in a direction where. We were bringing implementation science to bear. They were very excited about that, and we've been working together on that for a while now. So, um, one of the things that we've been working on is taking the data that they collected themselves, [00:32:00] and they really needed my expertise to kind of help them get it ready for publication, because there is a value of getting something out in the world that way, and they can go to conferences and do presentations and that sort of thing. And so, like, I've been able to help them out with it. Um, offering some student assistance with analyzing their data and helping them develop things like fidelity checklist to see if they really were implementing, you know, what were they doing when they were doing their intervention and us working through that, like me looking at it from a researcher perspective and them looking at it more from a clinical perspective and us finding a place in the middle to be able to define what they're doing and just Just this week, just earlier this week, it was so, it was so sweet. We, um, we've been working on, uh, doing a, uh, treatment fidelity checklist. One of my students has been looking at the sessions, which kind of freaked them out a little bit, like, okay, like somebody else is going to be looking at this to see what we've been doing. And my student, um, looked at them and came and shared the results. And we, [00:33:00] you know, they had good fidelity with what they were doing. They were so excited that the operational definitions that we had worked on together and that the things that they thought they were doing they were actually doing in the intervention and it was just really just fun and exciting to to see their level of excitement and their level of investment in all of this and and I think because we've spent this time um building this trust and building this relationship it's really it's really contributed hugely to helping us move along and and and for me. You know the um, we're really looking at I mean all not just for me for all of us We're looking at hoping to work together long term on larger projects And so we're looking at this smaller project right now that didn't everything didn't go right for them We're going back and doing some subsequent analyses to try to really figure out. Okay, like this didn't actually change with this person Let's go back and see what did change Let's look at these things and and for them, you know as they've shared with me just [00:34:00] meeting with me weekly and having My eyeballs on the data to and having a little help from my students has made a huge difference for them and they feel like they've gotten further in this relatively short period of time than they were getting for a couple years. Well, I was back here very much in the background, you know, not really directly helping them. So it's it's really shifted things for us. And it's been such a Such a positive experience. So I think the, you know, the bear the big barrier so far was more when I wasn't involved and we started overcoming barriers. The more I got involved. One of the other really practical things is something I think Natalie brought up a little bit earlier that that is a bit of a barrier that we're going to have to figure out as we move forward. Um, is has to do with funding. So some schools will not allow Okay. Us as researchers to buy out the time of a teacher. Um, so, like, I may be able to get grant funding to support our work, but the school, like, in this [00:35:00] case, the school saying, like, that was one of the first things that they were like, hey, we all have to meet. Like, and we would need to meet soon. If you're going to be applying for grant applications, because. You, you can't basically, you're not allowed to buy out their time. This is, this has to be done as part of their regular work or in there. We were like, okay, well, what if it's on Saturday? Can we pay for their time? If we, you know, have some Saturday activities that we do, or, you know, trying to figure those things out. Those can be some of the. Um, roadblocks that are that they're not necessarily. I don't even remember which one's worse, but some things that we can at least climb over, you know, we can figure these things out. But, oh, like, I haven't done this work in this way before. So I really need to think about this. They need to think about it. We need to find a way to to work through this so that we can not allow that kind of thing to really prevent us from doing good work. But that's still going to be a way that's going to honor the time and not just be an. over, you know, create this hyper burden on my colleagues, my clinical colleagues, but find a way to make sure that [00:36:00] they're, you know, that they're okay as they're doing this work and that their level of involvement is appropriate and that it's not too much for them. I think  Kate Grandbois:  that's a great example of an infrastructure related barrier. I mean, and I'm, I'm thinking about this story, this example that you've, that you've shared. I'm thinking about any clinician who's listening, who's, you know, Excited about research, doesn't want to get their PhD, but is listening to this and going, yes, I want to be maybe not empowered, but I want to be consulted. I want to be asked. I want to, I want to play. Let me in. Right. And where do we go? You know, well, how do we go about. Making or initiating those relationships. I'm, I'm asking this question. I'm not even sure that there is an answer. I'm asking this question to the universe. This is one of the problems that we haven't necessarily solved as a field, um, and Kathy and Natalie and, and, and Amy too, having participated, um, in the implementation science conference. If there are resources [00:37:00] out there, I would love to hear about them. I'm sure our audience would love to hear about them. Just, you know, I think that there is this con, there is this feeling of being in a dead end. So back to what I said earlier about ego and power differential, not feeling like we are, we belong at the table, but even if we do feel like we belong at the table, what door do we walk through to get to the room where the table is? How do we, how do we go about doing this? Natalie Douglas:  Yeah, I think that's such a legitimate question and it also points to there are really very, very few if any situations where researchers and clinicians are like, mixing it up in a informal way. Right? I mean, it's just doesn't happen. I can tell you that the large majority of my clinician collaborations is somehow connected to conferences, be it at the state level or at ASHA. Yeah. Um, where people have come up to me [00:38:00] again, um, has Kathy said inappropriately or, you know, being like, Oh, wow. And I'm like, Are you  Kate Grandbois:  trying to tell us that people fangirl over you, Natalie? Is that what you're saying?  Natalie Douglas:  Not really. Yes.  Kate Grandbois:  It's okay. It's a it's okay. Cathy Binger:  Natalie's so comfortable with that. She just like, she privately just can't wait for all the crawling out of her skin.  Kate Grandbois:  For anyone who doesn't know Natalie, she's the most humble, approachable, like, brilliant human on the earth. And I can't I didn't, I didn't mean to put you on the spot, but I had to, I had to make a funny. I apologize. Let's move  Cathy Binger:  on. Uncomfortable. She's closing. She's like covering. We're going to  Natalie Douglas:  leave.  Kate Grandbois:  He's going to hang up on us. Don't go.  Natalie Douglas:  Oh my God.  Kate Grandbois:  Anyway, as you were. So people approach you at conferences.  Natalie Douglas:  Yeah. And they're like, I really [00:39:00] love your work. Like, let me tell you how we might do this in this nursing home. And literally I will be like. Well, do you want to try this in your nursing home? I'm not kidding, you know, and then, you know, we, and it doesn't happen to everyone, you know, it doesn't happen to like every person that we talk to, but, um, it's, you know, so I would say to clinicians, like the talks that you go to that you really like the articles that you read that you really like the logs or whatever you're, you're, you're getting your CEUs. And you're like, I really resonate with this to reach out to that person. Would be, um, 100 percent appropriate and welcomed by the large majority of clinical researchers and again, you know, of course, humans are human. So you can't guarantee how people are going to respond, but at least in our field with implementation people who are doing. This type of clinical research, they're doing it to, like, have [00:40:00] an impact. And so when clinicians who are working with a certain population want to collaborate or have ideas, it's just so welcome and I think that, you know, once you start to really get in the groove and develop that trust and partnerships, you realize, Oh my gosh, like we're both people, you know? And Kate, when we first started working together, you called the Google folder fancy pants. It's still  Kate Grandbois:  called the fancy pants. Who has the fanciest pants? It's the fancy pants party. Because you have fancier pants than me.  Cathy Binger:  I told you from our very first interaction with you guys, that was my first email to you guys, that you can't call me fancy. I  Kate Grandbois:  know, but do you see how these, these concepts are so culturally ingrained that even as I've, I've had the privilege of having some academic work in the last two years and I am constantly butting up against my own [00:41:00] internal critic because I am not worthy. You know, I air quotes, and I think that these, these concepts of, you know, I don't belong at the table. I am, I don't belong here. Nobody wants me here are, are very quick at work. I think without us realizing it, I think Natalie, it was you who brought up. Or even pointed out to us that originally on this podcast, we had a disclaimer that played at the beginning and you can, if you go back in time and listen to the earlier episodes, it's still there because I don't have the bandwidth to go back and edit all those files. I'm not doing that, but it's still there and it says we are not PhDs, but we do research our material because we felt we had to disclaim  Cathy Binger:  that we were not that  Amy Wonkka:  fancy. Our pants are not that fancy.  Cathy Binger:  Our pants are not fancy. If you want, I can stand up and show you how not. Let's see my pants are, I'm not sure that you want that. So, but I  Kate Grandbois:  think, I think it's worth just repeating for anyone who is listening, who is at a conference [00:42:00] and is, you know, in sitting in the chair and really resonating with the lecture and feeling intimidated to go speak to that person. Or it's just, you know, it's sort of like in those magazines where it's like, celebrities are people too. Well, researchers are people too. There's it's, it's  Cathy Binger:  not a thing. It's not a thing and well I think it used to be a thing, right? That's fair. I mean, it comes from a real place. When I think back, you know, I'm the oldest one of the group here, so I can think back longer. So, I told, I was talking about the 1970s to somebody the other day, and they were like, well, you weren't alive then. I was like, yes, I was. I remember. But anyway, you know, academia that you think back, back, back, right? It's the. Older white guy with the white beard and the spectacles and the tweed jacket with the leather patches on his elbows kind of thing. Like that was [00:43:00] incredibly accurate and detailed. I've got my tweed jacket hanging up behind me, but I don't think you can see it. So, but right, like this, this image is still out there, even though, especially in our discipline, it's changed. It hasn't changed enough from a, um, a racial ethnic perspective in terms of cultural diversity, but it's changed dramatically in terms of male female ratio, right? Like, when I was starting at, there were at least 50 percent of my professors were always male. And that's just not the case anymore. Our department is, you know, has more, you know, we're like, Five to two ratio of female to male in my department for tenure track PhD faculty members. So, you know, that that has shifted dramatically. I think in most CSD departments over time, but that doesn't we still have this cultural residue. I just made that term up, but I like that a lot. [00:44:00] That we still live with that. And yeah, so we have to, I think it's going to keep shifting as time goes on. Um, but we still have a long way to go. Another piece of it to encourage folks to reach out to us is that in the post COVID as much as we are post COVID world. We've as academics, just like clinicians and everybody else, we really learn how to do things at a distance. So, you know, more and more projects are coming along where, um, researchers who are doing implementation science work as well as other kind of clinical research, um, can do their work. With people from all over the country. So whereas, for example, the communication partner instruction work that I used to do, we would always do it in person, you know, if and when we get back to doing more of that work, we'll never do it the same way again. I'm sure that we'll do it using telepractice and that opens us up. That makes our lives easier as researchers [00:45:00] because our participant pool is wide open and it also opens up the opportunities for collaboration. Clinicians who are in rural areas who aren't near universities, you know, all of those things. So that maybe, you know, maybe that's a little bit of a push to encourage clinicians who are interested in working with researchers to go ahead and work out or reach out to not just one person, but to many people because. Who are doing some, you know, work that you're interested in, because you can, like, as a researcher, you can only take somebody on to a research project. If you have a research project, if with clients that meet those particular criteria, like, that's just a reality of it, but, you know, having some persistence and some grit with, with contacting people, um, I think is, is. Uh, a good clinical practice if that's something that you're interested in, in doing.  Kate Grandbois:  I know we have one more example that we need to get to for our third learning objective of examples of [00:46:00] research practice partnerships. But before we get into that, I wonder if. You could talk to us a little bit more about the role of cultural competency in this whole arena. Um, you mentioned it a few minutes ago, and I know it touches everything we do. And we've already spoken about power differentials and, you know, different hierarchies and all of these cultural components that impact this problem. I just, I wanted to just give it a moment. If you wouldn't mind just telling us a little bit about how cultural competency touches all of these components and  Cathy Binger:  variables. Natalie, you want to take that 1 or you want me to take a stab?  Natalie Douglas:  Well, I actually happen to have a paper that I was just reading for a talk. I'm preparing for that addresses this exact thing. But the article is by, um. Ana Bauman and colleagues, and it's called advancing health care equity through dissemination and implementation science [00:47:00] and essentially, um. What they have in this article, um, they have a figure of. Guiding principles if you want to you achieve health care equity, um, in dissemination and implementation science. Um, and there's 4 of those. And the 1st is racism must be recognized as a fundamental driver of health care and equities. I think you could probably say the same thing about educational ones, um, equitable health care requires active engagement of community members and other relevant partners. Equitable health care requires multi sector partnerships, and context is central to health care equity. So I think you could put. Substitute schools or educational environments for health care and all of those places, um, but they have those principles and then they have, like, 8 recommendations again. The onus of this is on the researcher, my opinion to consider, [00:48:00] you know, anchoring their. Their work in this, but they actually have in their table, table one in the article, they have 60 opportunities for action for researchers in terms of how you might  Cathy Binger:  structure 6 0, 66 0.  Natalie Douglas:  Yeah. Six zero recommendations with 60 opportunities for action for researchers. Wow. Well that's some homework work. . Yeah, it's everything I think. I think it's everything. I don't think you can really talk about. This work without it. I don't know what you think, Kathy.  Cathy Binger:  Oh, yeah, of course. Absolutely. I mean, you know, we're just constantly learning about learning about this and, um. Yeah, I was thinking about the class that I, uh, one of my classes I was just teaching earlier today and we were, we were talking about cultural responsivity and, um, it was actually in the context of [00:49:00] doing early intervention work and the wonderful, um, some of you may be familiar with FGRBI that Molly Romano is directing that now the, um. Oh, what's it stand for? Um, family guided FG family guided. Oh my gosh. I'm so embarrassed. Molly. I'm sorry if you're listening to this that I don't have it right. Um, routines based intervention. That's what it is. Family guided routines based intervention. And we were, you know, I was talking with my students about how. Um, what a great program it is and how at its very core, it's the foundation of the program, um, part of the foundation is being culturally responsive and that you walk into every situation with every family from a very open perspective. stance. So I think this goes back to ethnographic interviewing too, which you guys have talked about on this podcast before, um, where you're going in and asking very open ended questions, not making assumptions. So tell me what mealtime looks like within your [00:50:00] family and not even making an assumption. I think I was just listening to a podcast. Um, episode where you guys were just talking about this, you know, maybe they don't even eat breakfast or maybe there's a meal in there that isn't. So just asking really open ended kinds of questions so that they can tell you their own experience without me putting my judgment on them. Right. It's important to be discerning. It's important to not be judgmental. Right, we can be discerning without being judgmental, and I think implementation science. It's one of the things that really draws me to implementation science as well is that, you know, are we perfect at it? Absolutely not. But if we're going to do this work with our partners, going back to that second learning objective of building trust and cultivating partnership relationships as step one of that, we have to do this from and we need to do this. And we want to do this from this very open stance of wanting to understand, um, what's going on with our partners, whether those partners are [00:51:00] educators or medical professionals or families, whoever those partners are, um, we need to be open and understanding what, what the reality is of their environment. So, in the FGRBI case, we're talking about families. If I'm working in a school, I'm talking about, you know, what's going on with the SLPs and the educational assistants and the special ed teachers and whoever it is, I'm gonna need need to be working with what are their caseloads like and what are their who's on their caseload and what's going on with these family members and, you know, blah, blah, blah, blah, blah, like all the things that have an impact. And I need to be realistic about that in implementation science work, not try to Go in and change the system so that they can do my intervention, but for me to look at the current state of the system and, um, create interventions and assessments that can work within these existing systems. So the, the mindset is a very different one entering into [00:52:00] all of that. So hopefully that got it, some of what you're asking.  Natalie Douglas:  That's huge, Kathy. I mean, it's just so, it's just, it's just so fundamentally different, right? It's just so fundamentally different to go in. But, but at the same time, it's like, why in the world have we been waiting so long to do this? It just doesn't even make sense. It's like, we're trying to, to go into, um, you know, and this is a lot of things. So, 1 of the things that we, um, I don't know if this fits with the learning objective, but in 1 of my partnerships with nursing homes, they weren't able to do the study and they felt terrible. Um, but I was like. No, like we need to know. And so the structure where my intervention was being implemented would not allow it to be implemented. And it was no fault of any individual person, but the, you know, the nursing home. Are [00:53:00] having a huge crisis right now more than before cobit with staffing. And so what I'm trying to do with that is kind of walk that line of, like, yes, I need to get data for my grant accountability, but also. I need to let these higher ups know what it's like in a nursing home. I need to let them know that there's no way that they can think about offering somebody a whiteboard to communicate key words when they've got eight people who haven't been toileted. Um, you know, this is the reality  Cathy Binger:  of it. You know, Natalie, that to me goes directly back to what you talked about earlier with from a researcher perspective. What is good data? Right? Good data is I have 8 people who need to be toileted and they can't be messing around with a whiteboard right now. You know, that that is important data too. And so 1 of the things I love about this is a little more research, but 1 of the [00:54:00] things I love about implementation science is this. Um, ability to there's a value that's placed on different kinds of data. So not just the really clean cut. Um, Kind of numbers driven data, but using other kinds of methodologies, like qualitative methodologies, where we can talk about the real life lived experiences and interviews and focus groups and, you know, whatever it is to gather information about these kinds of things. And so the things that we used to try to clean out. of our data set of, oh, that's noise. We now embrace the noise with implementation science, and we embrace the mess. And I've, I've always liked the mess. So that, that's really, um, I think that's, that's such an important fundamental piece of, of, um, implementation science world and work. In our last  Kate Grandbois:  couple of minutes, I wonder if You all [00:55:00] could give us one last example. I know we've already gone over two, but are there any other examples out there that might, you know, just give us another perspective of how a clinician might get involved in a research practice partnership. So you've talked about clinicians working in a nursing home. You've talked about clinicians working in a school setting. Um, What else is out there just to give clinicians who might be interested in this work a little bit of a glimpse into into what this is what this work is like?  Natalie Douglas:  Yeah, I kind of wonder about state conferences. I kind of wonder about the implementation science conference. I know a huge Focus of that is, um, partnerships. And so there are a lot of ways to connect. I know it's hard to get the doc, Amy, you were a speaker and you could only like get off for the talk, which was just very [00:56:00] realistic.  Amy Wonkka:  Clinician versus researcher landscape right there. That's a good.  Natalie Douglas:  So, I mean, networking that way, um, I know social media is like a blessing and a curse, but a lot of there are a few researchers that are on social media and we'll have discussions and you can reach out. You can slide into their if you will. You know, there are lots of ways to do that, but I think, you know, conferences networking. Um, social media, I'm trying to think what I'm missing. Amy Wonkka:  I mean, I, just for another plug about the implementation science conference as somebody who attended as a clinician, um, I, it was a super cool experience. It's a virtual conference, which is also for me, always a barrier remover because I don't have to travel. I don't have to get time off from work to like travel to go there. And I do feel like at the end, there was. An actual form that people could fill out to show that you like your contact information. [00:57:00] I'm interested in this is where I currently work. I'm interested in research in this area. Um, so that's definitely something to keep to keep your eyes open for. I don't know if there's a list to get on. We can email us to find out about that. Um, email also, if I've learned anything through this project, it is that you can email professors and they are generally very friendly people and will respond to you with kindness and generosity. So old fashioned  Cathy Binger:  email. Yeah. And a way, one way that I think a lot of people don't know about to find researchers, right? Like whatever your thing is, whatever your area of interest is, you can go on research gate. Um, is one place to go. Um, it's, just like it sounds, researchgate. com I think it's dot com, um, and you can look up your topic of interest, whether it's childhood apraxia of speech or AAC or what have you and put in some key words and find, [00:58:00] um, you know, A, you can find research articles if that's something that you actually want to do, um, on there that people have That are up and publicly available. And once you find papers that you think are of interest, even just by reading the abstracts of, oh, like, this person's work is really interesting to me. You can follow that person and then you get notifications when they publish something new. And you also can, um. Oh, it's. net. It's researchgate. net. Thank you, Amy. Um, thanks for checking that. Um, yeah. And so you can follow those people to, to learn, you know, about what they're doing, but you could also can like figure out who you want to follow and who's of interest to you and then contact them directly. And I think essentially every academic has an email address online that you can find on their university homepage or on their university page. Natalie Douglas:  As we wrap up, are  Amy Wonkka:  there any parting final words of wisdom that you would like to leave us [00:59:00] and our  Natalie Douglas:  audience with? I mean, I, I don't know if this is what I would like to say to clinicians. Not only do you belong at the table, but in my mind, I think Kathy would agree. You are like the MVP at the table. Period. Like, you are the implementer. Like, it's, it doesn't happen without you. Both, not just from you implementing a research intervention that was developed without your input, but also in your, I mean, maybe that would work if it meets a need, um, that you have, but also in your ideas, right? Because people in academia are very out of touch with what is happening. On the ground in day to day clinical practice and without your input. These cycles will continue, and I in no way want to imply that I think the burden is on you as a clinician to do that. [01:00:00] But if you have the desire and the capacity and you want to, um, you are so more than welcome and, and, and truly like the MVP for sure. Mic drop.   Kate Grandbois:  That was  Cathy Binger:  really funny. I had to say that. Natalie Douglas:  We keep talking about the. Implementation science conference from the or the Massachusetts general hospital. Thank you. Yes, Institute of health professions. Um, and I don't know if we have show notes or anything that we can put this in, but it looks like even if you weren't there from this year's conference, you can purchase, um. All of the talks, they call them the lightning talks, and this is where people give, um, it looks like it's 30 and you can get immediate access to all conference talks recorded on April [01:01:00] 2023, and it looks like they're going to, um, the conference talks are eligible for CEUs and you get a certificate of completion. And I wonder, too, if that might help you get connected with that group. Um, so, yeah. Kate Grandbois:  Well, thank you both so much for being here and sharing all of this with us. Um, anything that you all mentioned throughout the course of this episode will be listed in the show notes, um, of, of, along with links, any links that are available. Um, And if you're, if you've made it this far in the podcast, presumably you've also listened to part one, um, and learned a lot about implementation science and the action steps that we can take as clinicians to bring ourselves to the table, participate in these research practice partnerships. So thank you both so much for being here. This was incredibly helpful and, um, we'll have to have you back again soon.  Cathy Binger:  Thanks so much, Kate and Amy. We [01:02:00] really appreciate it.  Natalie Douglas:  Oh my gosh. Yes, you guys are fab. Thanks so much. This was a lot of  Amy Wonkka:  fun. Thank you. Sponsor Post-Roll 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. 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 [01:03:00] episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.