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.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]  Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes EpisodeSponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are really excited to welcome two repeat guests today back onto our show for sort of a part two. We are really excited to welcome Heather Kaska and Kareena Khadi. [00:02:00] Welcome. Hi. Hi.  Amy Wonkka:  Heather and Karina, you're back here on the Nerdcast to discuss how to apply clinical skills in dyslexia and any of our listeners who might not have heard your previous recording with us. Can you please tell us a little bit about  Heather Caska:  yourselves?  Karina Kadhi:  Sure. I'll kind of, I'll start that. So my name is Karina. I am an SLPA. I've been practicing for about nine years now. And I've only worked, um, in pediatric, so, um, I love working with littles, I have a passion for early language, um, development, and, um, that type of intervention with littles, and Heather was my first, um, supervisor. For my first job and that's how we met and we quickly became a great team and a great pair. Yes, that's a  Heather Caska:  little bit about myself and I'm Heather. I have been a speech language pathologist for almost 10 years now. I started off my [00:03:00] career in skilled nursing working with adults for about a year and a half, but quickly learned and knew that my heart was with pediatrics and so working in pediatric clinics. I found a love for literacy and reading and started doing a lot of extra, um, education, uh, continuing education on dyslexia specifically. Um, I'm also the current president for the Arizona branch of the International Dyslexia Association. Um, I live in the Phoenix area and I own a small private practice in addition to our dyslexia education. Um, platform with Karina, um, and I have two small kids. They have a first grader and a three year old, so we're excited to be here again. Well, we're so excited to have  Kate Grandbois:  you. The first episode that you all did with us was really focused around the role of the SLP in the realm of dyslexia in general. But today you're going to be talking a little bit more about clinical application, which I am very excited to learn about because I know very little. Um, [00:04:00] so before we get into the good conversation, I do need to read our learning. objectives and disclosures. So let's get through that and then we'll get on to the good stuff. Learning objective number one, list the three principles and six key elements of structured literacy intervention. Learning objective number two, describe three evidence based intervention techniques and approaches to managing dyslexia and learning objective number three, describe three ways to incorporate structured literacy interventions into your current treatment plans. Disclosures. Heather's financial disclosures. Heather received an honorarium for participating in this course. Heather is the owner of a private practice called HBC language and literacy. Heather is also the co owner of sore with words, LLC, and co manages the sore with words educational platform on teachable Heather's non financial disclosures. Heather is the current president of the Arizona branch of the international dyslexia association. Heather also co manages the social media accounts for sore with words. Karina's financial disclosures. [00:05:00] Karina received an honorarium for participating in this course. Karina is also the co owner of soar with words, LLC, and co manages the soar with words, educational platform on teachable Karina's non financial disclosures, Karina co manages the social media accounts for sore with words. Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting, LLC, and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy,  Amy Wonkka:  that's me. My financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I'm a member of ASHA Special Interest Group 12, AAC, um, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right! Heather and Karina, I know you're here to talk to us today about intervention, but before we start, [00:06:00] can you start us off by telling us just a little bit about dyslexia, maybe just a brief  Heather Caska:  overview about dyslexia? Yeah, absolutely. So I think one of the most difficult things about dyslexia is there are a lot of common misconceptions about what it is, but one of the biggest issues with dyslexia is just identifying it. And I think a lot of that comes down to the fact that there's really no one, um, agreed upon definition. So, um, the International Dyslexia Association has a definition, um, Most people go by. However, there's still a lot of disagreement across professionals as far as what really is. include should like criteria should be included in that definition. So we really like to go by the definition. So Dr. Tiffany Hogan and Dr. Hugh Katz put out a paper in 2021 called dyslexia and ounce of prevention better than a pound of diagnosing and treatment. And so the definition that they kind of proposed is [00:07:00] dyslexia is a severe and persistent difficulty learning to read and spell words, despite adequate opportunity and instruction. And the reason we really like this definition is because it's not specifying like any distinct causal basis. But it's looking at it like multiple factors. So you're looking at a lot of different, looking at that whole child and what could be some early indicators for dyslexia. So it's really going to fit more in that preventative model, which is what Karina and I are really passionate about that early identification and our role as SLPs and SLPAs on how we can help with that early identification and earlier mediation. So it's going to allow us to really identify those risk factors early on. Um, and then also, um, It's a big part of it is that definition is it's going to be more easily operationalized in like those educational settings, because we find that most of our educational systems are still set up for that. Let's wait and see model [00:08:00] that wait to fail model for these students, which is really putting them at a disservice. Um, we talk a lot about the dyslexia paradox, which was, um, kind of a term coined by Dr. Gavin, her colleagues. And what the dyslexia paradox is, is that it's acknowledging that dyslexia is not typically diagnosed until second grade or later, which is past that prime time for intervention. So we know that research is showing us that, um, reading interventions are significantly more effective in kindergarten and first grade. So most of our. Students, though, we're waiting, you know, let's wait and see, you know, they just need to keep practicing. And so they're not being identified until second or third grade. So we've already missed that prime window to make them to have the most effective intervention in place for them. Um, so some early like factors or factors that we need to consider when we're Trying to identify these students as family history. So if you know there's an older sibling that you know may have an [00:09:00] IEP or has struggled, that's going to be a big indicator that this is a student is not going to be one that will just catch up, necessarily, we I learned really quick early on when doing. Evaluations, not to ask specifically about dyslexia, because I would say eight times out of 10, I would get, no, you know, no one, no one has dyslexia in our family, but then as you would ask more questions, you would find out, well, dad got help for reading, you know, in school or so and so didn't, you know, or I didn't like, I really struggled, you know, I didn't like school, you know, as a, as a parent. And so that right there, I mean, most people didn't get that diagnosis. And so. It's a clear indicator that that there is a family history of learning difficulties, um, and then also just that poor response to adequate instruction. So if they, you know, they've been in preschool and they've been in kindergarten and their attendance is good, you know, but they're still just don't seem to be picking it up. That's another indicator.  Karina Kadhi:  One gets tricky with what [00:10:00] has gotten tricky recently, huh? With COVID.  Heather Caska:  Absolutely. And that's, that's a, that's such a great point. And so we, we've heard that a lot too, especially, you know, with our second and third graders now, because so that. They haven't been identified, which is not necessarily atypical, but a lot of it goes back to, well, they were, they were kindergarten, they were in kindergarten during COVID. And absolutely. I mean, I think everyone is struggling now because of what happened in COVID, but we're, we really need to remember to look at all these other factors too, and not just like It's can't just be an automatic. Well, it was cause of COVID because of COVID, like everyone's behind you. Right. Everyone. Yeah. Yep. There was there, everyone is behind, but we have to make sure we're really doing our due diligence, like looking at the whole child and other early indicators. So, and that could be that family history. Um, delayed speech and language skills, uh, and maybe if, you know, they have some, they're really struggling more with that phonological processing, working memory, [00:11:00] phonological awareness skills, um, some other factors to consider, any visual processing or executive function difficulties, um, and then even trauma, you know, trauma based, um, interventions are going to Um, and I think it would be really helpful for these students to as well as just looking at, um, socioeconomic status as well. So I think when we're trying to identify these kids early on need to really look at all these other factors that are going on as well. And chances  Karina Kadhi:  are, um, especially like in these early ages, we find that where I were identifying kids that are already on our caseload, um, for speech and language services. Um, and so then in the intervention and in the time we're already spending with them. Um, we're kind of picking up and noticing some of these other, um, factors and things and that, um, kind of a point we always like to make is that, um, most of these students are already on our caseload for speech and language at that age. But not yet identified for, [00:12:00] um, those reading difficulties.  Heather Caska:  Well, that's  Amy Wonkka:  such a good point. I, I wonder if you can talk to us a little bit about, I know literacy and reading is within our scope of practice, but when you're in a school in particular, like that's probably not your chief role in that position. But can you help us understand a little bit about Just the science of reading, structured literacy. Like what are some important things there for a speech language pathologist to be aware of, even if it's not like the hat that we're wearing in our,  Heather Caska:  in our role in that job.  Karina Kadhi:  Absolutely. Like we, that's, um, one of the biggest, that is the biggest piece that we like to, um, bring to awareness is, you know, we're lifelong learners and even you said it perfectly in a school setting. That's not our main role. Um, we are not the reading interventionalist. We are not the one doing, um. really addressing that. But if we can be aware of how many of those elements of structured literacy fall in [00:13:00] our wheelhouse, we can give like heck of support, right? So when, when we're talking about structured literacy and the science of reading, science of reading refers to just that body of research. That comes from many different professions, and that kind of helps us, um, understand how our brains learn to read, right? Because if we can understand how we learn to read, then we can intervene, um, better, and we can help students learn better. Um, and so that's what we're referring to for the science of reading, where structured literacy, um, is just, uh, evidence. evidence best practice, evidence based practice approach, um, to teaching, um, those reading skills based off of the science of reading. Um, so when we're talking about structured literacy, there's, um, six elements of it. So syllables, semantics, phonology, morphology, sound symbols, and syntax, um, are those six areas. And so, um, the, there's two of those that aren't [00:14:00] necessarily Um, closely related to our field or our skill set and that's being syllables and sound symbols. Um, but we also want to talk to you about how you can support those in intervention as well. But the other four big ones, syntax, semantics, phonology, and morphology, those are language, right? We're already addressing that in the therapy that we're doing in our speech room. And so if we could be more intentional about, um, maybe things we, the supports we embed, the way we scaffold, um, then we're supporting literacy skills in the therapy we're doing. Um, and so to kind of go along with the, um, Elements of Structured Literacy also has three, um, component or how, how would I describe that, Heather, like three principles. Thank you. Um, so that it's explicit, meaning that there's like direct teaching or not assuming that a kiddo knows something before that we're teaching everything explicitly, um, diagnostic. And so it's, um, individualized, has individualized instruction. Um, That's [00:15:00] monitored by ongoing assessments and stuff. And then, um, the last principle that it's cumulative and systematic. So it follows a logical order, um, and that each new step builds on concepts that we've already, that we have already explicitly taught that child. Um, So in a nutshell, that's structured literacy, those six elements and three principles there. And can see we we have a lot of knowledge in most of those elements and not that we have to be the ones doing that direct intervention. Um, but man, we can really support those underlying skills. Amy Wonkka:  Well, and I would think that there, sorry, Kate, I would think that there are just so many opportunities, as you mentioned, many of these students are already on our caseload. We're already providing speech and language services. Many of these six areas are things that we're maybe already working on as part of our speech and language goals and objectives. And then maybe it's also just a [00:16:00] matter of being very thoughtful about the material and activities that we're selecting, because there are a lot of ways to work on different goals and objectives. Right. Exactly. I mean, I think. The longer you've been in the field, the more you're like, ah, I could, I could work on it with this activity, this activity, this activity, they're all different ways to target these skills. Um, I didn't know if you wanted to, if you guys wanted to give us some examples of how, how a speech and language session might look a little different when you, when you're being thoughtful about trying to address the literacy component within your activity compared  Karina Kadhi:  to when you're not. Sure. Um, one of, we can, one of the, I think the easiest ones to, um, support is phonology. Um, especially obviously when we're working on those speech sound, um, goals, whether it's more articulation based or whether it's, um, more of like a phonological process. Um, some of the things that we do to support phonology or that range of phonological awareness rather for [00:17:00] these kids is, um, visual supports and, um, We mentioned last time, um, so different ones like the, um, Bjorm or, um, Lips. There's, there's different like dedicated programs out there, but really blocks. We love blocks. We love wadded up pieces of Play Doh and, uh, Toilet paper, tissue, whatever we can get our hands on that can serve as a manipulative, um, and to just bring awareness to the individual sound that they're working on, because without awareness, there is no generalizing that skill. And so we can work with a kid on how to make their F sound so they're blue in the face, but if they don't know when to apply it or when to use it, then we're not going to see that generalized as quickly. So really using manipulatives and visuals to, um. To support their phonological awareness so that they can then apply these, what we're working so hard on with them. Um, we like to, um, I'm just looking at my pictures here for that. [00:18:00] Some other things that we do in the speech room for that kind of piggyback off of phonology are also, um, support the sound symbol aspect of, um, Structured literacy and those, those same visuals, those sound cue cards, um, can easily be adapted by just writing the grapheme or that orthographic representation on the letter for them by tying that sound to the visual letter, um, is going to support them huge and just writing it out on that is another. Um, way to support to incorporate that sound symbol aspect of structured literacy without having to teach them the alphabet, right? Like, it's just exposure, just modeling that, um, what are some other ways? I was going to ask  Kate Grandbois:  you, you've mentioned the, the name of this episode that you've proposed is outside of the box. Is that sort of what you're getting at here? Can you tell us a little bit about how this might [00:19:00] differ from what we would typically think of as literacy  Heather Caska:  instruction? Yeah, I, that's a, um, it's a great question. So I think a lot, a lot of times as SLPs, we, when we get, when someone brings up, you know, dyslexia intervention or reading intervention, our automatic go to is, well, I, I'm not trained. I'm not trained in like a specific program. I'm not trained in Orton Gillingham. I'm not trained in, um, Linda Mood Bell or the Barton program. You know, there's a lot of really great Commercial programs available that are or in Gillingham based or structured literacy based, um, that are really can you can that are helpful to support these students. Um, but our whole thing is. Especially in the schools when that's not our primary role, we don't necessarily have to be trained or certified in these specific programs. Like, so thinking outside the box, um, is more of like using our clinical skills. You know, we already know, like Karina mentioned, four out of those six elements [00:20:00] fall, those are in our wheelhouse and these other two, you know, they're fairly closely related, but easy to support once you have some general knowledge about it. And so you don't necessarily have to be. trained in this program or, you know, certified in a certain type of intervention to support the students on your caseload. Um, as I think, especially in the schools as a school based SLP, it's important to be aware of what curriculum or intervention programs are being used, you know, in the classroom or even in like an ESS classroom. Um, to just to have a better idea of, you know, what the student is being exposed to, but to necessarily be trained in it, I don't think is necessary to support your students.  Kate Grandbois:  I really appreciate that perspective. What I've learned from you all and from a few other individuals over the years is that literacy can feel very siloed because of the different roles we play, particularly in an education setting where you have a [00:21:00] quote, reading teacher, and that's the person who does the reading intervention. Right, only them. Right, right. And so I think because we have this I don't know if you, if the word culture is the right word, but because you might have this professional workplace culture or set of standards or norms where reading might be a little siloed, I really, I really appreciate the perspective of sorting of trying to branch out outside of that and generalize some of these or create normalcy around, um, um, um, Intervening, addressing, addressing them. Exactly. Exactly.  Karina Kadhi:  Yeah. And we, we, we do get a lot of like pushback in, I wouldn't say pushback, but feedback in that. Um, well, that's not my role in a school. I can't look for all these other students. How do I, I can't go add on these additional students and screen more students. And that's why we always like to emphasize like, Yeah. Chances are they're already in your classroom, right? Like, if we can just focus on that [00:22:00] population, we're making a difference, right? Because, because we might have a little kindergarten or first grader working on these things who's not going to be screened or identified for any, um, literacy related difficulties at that age, you know? So if we can Um, kind of embrace like be open minded about that and, um, embrace that lifelong learner kind of mentality and bring more, um, awareness to, Hey, what are some other factors that I could, these kids already sitting in my room to help, um, identify that  Heather Caska:  I think. To they so a lot of states now do have legislation in place where you know, you're you have to be screened as universal screeners that are administered to all kindergartners first, it's usually like kinder through third grade. And so finding out like if you have students on your caseload or if you are, if your school is it has that RTI. where you're doing, you know, RTI with some of these younger students, find out about those [00:23:00] universal screeners, how are they performing? Are they below benchmark? Um, because those are kids too, you know, that might just need extra support. Here in Arizona, if they are, you know, kind of flagged on these universal screeners, then they are automatically put into a tier two intervention. Um, at one of the charter schools I worked at, you know, I did part of the tier two intervention. We did that. And so we started an RTI group for some of those kids that were, you know, that had more difficulty with the phonological awareness. And so that's what we were doing, um, as part of that tier two. And I know that's not, you know, realistic For all SLPs, like we have a lot on our plate already, especially in those school settings, but I think just being aware and asking those questions, you know, I have so and so on my caseload, how'd they do, how'd they do on their screener, you know, and then just finding what additional supports you can give them, you know, during your speech and language therapy. I wonder if  Amy Wonkka:  it makes sense to talk a little bit more in depth about [00:24:00] each of those different structured literacy elements. Um, I don't know which one you guys would like to start with, but I think just giving people an overview of the element and then just talking kind of specifically about it. So, like, I thought, Karina, you gave a great example of just if you're, if you're working on sounds, you could integrate that sound simple correspondence component, you know, so maybe just talking about some of those tips would be really helpful. Karina Kadhi:  Okay, I want to give some more examples for when, how we can incorporate some things we can do in our speech therapy to support that sound symbol element that not. Uh, element that we're maybe that falls under that language domain, um, like a few of the other ones. And so, um, we already mentioned the sound cue cards and, and then just, um, using the visual incorporating that visual grapheme when you're working on your sound. So just make that associate help them build that association. Um, another thing I like to do is, um, I [00:25:00] like to make sound. cards, I guess you can call them. And so say we have a kiddo working on S. So we might have on, on our little index cards, all the ways that he might come across the sound when he's reading. So S will be on there. SS is also on there. Cause at the end of words, It comes across that way, C E C I C Y is on that card also, that way he knows visually. These are, when I'm reading, these are all the ones where I'm going to have to use my snake sound or whatever sound I'm working on. But also, I'm just exposing them, um, and, um, and Modeling and just giving, bringing awareness that, hey, this can be represented different ways. These are all the, it's, I'm not his English teacher. I'm not going to quiz him on it. I'm not going to, it's just one thing that I'm embedding into my therapy to support that sound symbol component of not going to test them or quiz them. Right. But just something I can embed there. And I really like that. And the kiddos really like it too, because then we can go and do reading tasks and they can search for those and highlight them and then [00:26:00] practice reading at a sentence level, maybe, um, just to con. Oh,  Amy Wonkka:  Nope. I was just gonna say, just to contrast with that, like I can think of an example from when I was working outpatient and I would be working on articulation and I would go through my like super duper articulation cards with the pictures on them. And I would never draw that connection. I would just never make that explicit connection between the orthography, like the  Karina Kadhi:  written symbols. Yeah. The written representation. And again, that's not,  Amy Wonkka:  we're essentially both doing the same thing and working on that target sound production. But what you've done in your approach is you're just making that that much more visible, giving that student exactly visible. And I just, I love it. And I think it's, it feels like such a small thing. It seems  Karina Kadhi:  like it's easy, easy. Yes. Yeah. It's an easy thing. And again, we're not fancy when I say no card, usually it's like a ripped piece of printer paper that I'm like, Oh, here's a little square for you. Here's your card. Or, or have them make it right. They can pick whatever medium they wanna write it on, [00:27:00] and then it's more exciting for them. And so it doesn't, it, you're right, it, it can be very easy, um, and very low prep, uh, to be able to do that. Um, sound wall are another, I personally have never had, um, a sound wall in my speech room. I wish I would have, but, um, I wanna make one and I, and then it's a great, it would be a great resource to even have, um. Just like in the, maybe collab with teachers and have in the classroom setting, you know, um, those sound walls are, are a great way to help, um, tie in that sound, um, symbol when you're working on your speech sounds. Um, we also, let's see, we won't go into syllables yet, because that one can get, well, nevermind. Yeah, we will, because this one can be easy. So syllables is probably the one of the, um, the elements that we know the least about as speech therapists. Um, there are different syllable types and also different syllable division [00:28:00] rules. But the most important thing to know about syllables is why it's important, why it's part of structured literacy. Um, it's because when, uh, when students can predict what sound a vowel is going to make by knowing the type of syllable, it's going to make reading and spelling easier. So knowing how to break that word into syllables essentially makes them easier to read and spell. So if we could explicitly teach them that, we're giving them a tool, um, to support their decoding and spelling. Um, and so the different syllable, um, division rules, um, they can get kind of It's tricky. But again, that's not our role isn't to learn this and teach them this, but just, we take that approach of that. We're lifelong learners. And if we can have this in our toolbox and we can support kids just one different way. So we have some pretty good resources that explain this in a little more depth on our Instagram site. Um, and so we have some, um, I think they're called reels pinned,  Heather Caska:  saved on [00:29:00] there, highlighting.  Karina Kadhi:  They're on our highlights. Um, and so you guys can check those out and they'll go into a little bit more depth in, in this syllable component, but, um, We, ways that we have used this in our therapy is like, um, reading comprehension. Sometimes our kiddos get stuck on decoding bigger words. And so we whip out our syllable division, um, tools and kind of teach them how to segment and break apart those words to make it more manageable for them to read. And then they've decoded an unfamiliar word and now they know context. And so really just functionally using it, right. Um, And so if we can make our bring this syllable type and syllable division knowledge, just our attention. It's just another way to support them.  Heather Caska:  One thing that I've noticed, um, or that I've a pattern I've kind of seen in the schools too, is oftentimes we are asked like SLPs and SLPs are asked to like, can you give so and so their spelling test this week? Or like we help [00:30:00] support, you know, administering spelling tests. And so if you do that, this is also another way. Just having this knowledge, that's going to be helpful. So kind of backing up a little too, like the sound symbol. Um, one thing that we found, especially with our older students that, you know, like gaps that we find is just even that basic awareness or knowledge of what a consonant versus a vowel is. And then even. like long versus short vowel sound. So that's going to also be really important for that syllable division piece because it like certain syllable types, um, like if it's a closed syllable, it's a short vowel. But if your second grader has no knowledge of what a short vowel is, that's not going to be helpful for them either. So I think that's a big piece that we often miss and overlook that we can be really supporting too, is just that basic knowledge of like a consonant versus a vowel, like, you know, visually looking and can you show me which ones are your bowels, but then even, um, Like orally giving [00:31:00] them a sound like ah, is that a long vowel or a short vowel and really supporting that because one thing I've seen before too is they would give these visual supports for this student who was doing for like spelling tests. That's that was part of in his IEP where they would just underline for however many sounds there were in the word. There was that many lines. So it was helping him as far as that phonological phonemic awareness, but then they would also put little dots underneath the line that were supposed to be vowel sounds. And he was still writing, you know, consonants where those dots were, and it was like, well, that's a vowel come to find out the student had no idea what a vowel was like, he could not understand so that those supports weren't even supporting him because he didn't have that. And so I think just even that, you know, that knowledge, um, is, is something that we often overlook, especially in our older kids, um, where I found that that's one of the biggest [00:32:00] pieces that. You know, hindering, I don't, I don't know if that's the right word, like, um, the barrier. You're right. Yeah. Thank you. That's all right. A barrier to, to them with more of these, like the syllable type this, um, so  Kate Grandbois:  everything that you're both saying is making me think so much about the opportunities for collaboration. So if that student is already on your caseload. Making time for that five minute conversation with the classroom teacher. Where does this student where, where do you suspect they struggle? What are some of the literacy related goals? Or maybe it's not the special education teacher. Maybe it's the gen ed teacher. Maybe it's the quote reading specialist or the resource room person. I mean, every district has different labels for this, which is one of the reasons why I find this to be such a murky area, depending on where you are. But. Any collaboration with a literacy oriented [00:33:00] specialist can create so many additional opportunities for generalization. I have to  Karina Kadhi:  assume.  Heather Caska:  You're absolutely right. And that was a big piece we talked about in, um, like the, the last episode is one of our roles, like under one of our domains is collaboration. And so, especially with these students and you'll get, I mean. I've been fortunate in the schools I've worked in. Um, you know, I come in obviously with a lot of background and knowledge and literacy in this area and was little nervous at first coming into the schools thinking, you know, that they're going to be like, Whoa, like this speech therapist needs to stay in their lane. Like they're not a reading specialist, but I've been really fortunate in that everyone's been open to, you know, collaborating and discussing and. And suggestions and ideas, but then also me learning from them too. I'm not a teacher, you know, I don't, that's, that's different, you know, that's a whole different wheelhouse. And so just that collaboration and not only with the teachers, and [00:34:00] I think it's all of the above a reading interventionist, special education teacher, general education teacher, you know, um, but also with the school psychologist. Um, and even the occupational therapist, I mean, really, it's, it's truly a team support and the parents. I mean, it's, but you know, in the schools, I find it harder when I'm versus my prep, my private clients versus the students I work with in the school, I'm obviously in communication a lot more with my private clients. I see the parents where at school, you don't, you're not, you know, but I think keeping that, um, in mind too, that collaboration with the families as well. It's so important  Karina Kadhi:  because we do wear so many hats right in a, um, in a, in a school setting or even in a private setting. So um, sometimes that, or a lot of times that even just opens up the door for like divvying up goals. We've seen a lot to where our speech and language goals look really similar to like the, goals that they might have under their [00:35:00] ELA section of their IEP. And so divvying up things that way we're getting, um, max repetition, max exposure, um, yeah, it's always a great, it's always a great plan for these students and it kind of helps us too. Right. Where we're not trying to have to do all of these things we've made a plan with. The rest of the team and they're going to cover this and they'll help this and, um, so good things come from that  Heather Caska:  for sure. I think, um, to sometimes, you know, looking at those goals and like Karina said, a lot of times they're very similar or they at least support each other. But then I often see, especially in our older students where they're reading and writing goals like they have a goal for reading comprehension and reading fluency. But they're still completely missing those basic reading skills as far as just decoding and phonological awareness, but there's no goals for that. And so that's where we can really come in, especially when it comes to like the phonological awareness and support that too, or at least advocate for some of those goals. Because I can't tell [00:36:00] you how many times I've had a student come, you know, where I've looked at their IEP. Or even in the schools, you know, when they go to write the goals for a second or third grader, the goals are just reading comprehension. We'll answer, you know, WH questions after reading a grade level passage or read so many minutes or so many words per minute. And I was like, okay, yeah, but that's our end goal. But how are we addressing their decoding skills? Because they're not going to be able to answer those questions if they're focusing so much on what they're decoding, you know, but there's no goals to address that. And so I think that's. That's another piece where we can at least advocate for that or somehow try, try to support those, those goals as well. So the we've talked about three elements of structured literacy so far. Um, phonology, which is well within our wheelhouse. I think we're most familiar and even known for that. So teachers are going to come to us and ask for help with phonological awareness and phonology. And then we talked. About, um, sound symbol relationships [00:37:00] and syllables. So the next area that we are pretty familiar with as SLPs and SLPAs is morphology. And so I think one of the biggest takeaways for morphology is we need to remember that we have to think about their phonological skills too. We had one client specifically that stands out in my mind every time we talk about morphology, that this really, um, was an eye opener for us where we had goals for him. He had, he came into our clinic. He had goals already. He had had an evaluation. So we were working with him and one of his goals was like regular past tense verbs. Um, you know, wasn't marking those. And so we were, you know, addressing the past tense. And all of a sudden he just was not getting it. And I don't remember exactly what happened, but I was, we had another SLPA who was working with him. And I remember I was super supervising her session. And all of a [00:38:00] sudden I was like, Oh my gosh, this student has no phonological awareness. And so I was like, okay, hold on, let's take a step back. And so we gave, um, the student a phonological awareness screener and he performed very poorly on it. And I said, here's the thing, like we're trying to teach him what we're teaching him is to like these grammatical markers, you're adding a sound to the end of a word. But if he has zero awareness, that words are made up of all these different sounds anyway, of course, he's not understanding. Of course, he's not getting it. So we had to back up and take more of a phonological awareness approach with. And versus just like that syntax or morphological approach with him. And so that was just kind of like a big eye opener, um, For us as therapists and then just kind of keeping that in mind. So, um, I think for us, you know, that's, we're very aware of that, you know, it's part of our, our education, the different types of morph, um, Morpheme, so we have our inflectional or derivational [00:39:00] morphemes, um, and how we can go about building vocabulary and then even just building that syntax with that as well. But when it comes to more of the structured literacy, the piece we don't have as much knowledge about is when it comes to like those spelling patterns. And so, um, you know, there are rules for when you're adding a suffix. And typically, like if you're adding a suffix like ed or ing that starts with a vowel, there are certain spelling rules and spelling patterns, like if your base word ends with a Y, you know, do you change the Y to an I or do you just keep it and add the suffix to it? Um, and there's also rules like if, um, if you have, if your word ends in a CVC, do you double that? So think of the word stopped. S T O P P E D. Why are you doubling that P? Versus a word like jumped. You're not doubling the P in jumped, you're just adding E D. So there's, I know, these are things I have [00:40:00] never  Kate Grandbois:  considered. Exactly. I was 10 years old when I realized how completely ridiculous some of this  Heather Caska:  is. I know. And it is. It really is. And some students really benefit from being explicitly taught those rules. But then other students, it's just even, it's just too complex, overwhelming. It's more, it's very overwhelming. So we do have some resources again, like on our Instagram, like in our bio that just kind of like a cheat sheet of the most common, like spelling rules and spelling patterns as far as, um, like morphology and then just other spelling, spelling patterns too, that are commonly taught in these structured literacy programs, um, just for, just for you to have. Um, but I mean, again, when I got my training, I did my training through the Academy of Orrin Gillingham, practitioners and educators. It was a 90. Program. Like it was a nine day training. And so, I mean, obviously it's way beyond what we would have time for here. Um, but we do have like a cheat sheet as far as that. And then we have like a phonics practice sheet. And I, I don't [00:41:00] know if it's linked in our bio, but we can, you can always reach out to us too, and we can send that where you have the opportunity to go through and practice a lot of these skills as far as like identifying syllable types, syllable division that we've kind of talked about, and then even using and practicing some of these spelling patterns. So we have some opportunities. Opportunities for you to practice again, like Karina keeps reiterating. This is not for you necessarily to now turn around and teach, you know, especially if you're in the school school setting, but more so just that knowledge so you can better support the students and then just have more knowledge as far as like the interventions that they're getting, um, in the class too. But then you do. I mean, for us, private. practice. Like that's what we focus on. We are the reading intervention, reading intervention, you know, when they come to see us. So maybe you want to take that route and you just want to learn more too. But as far as just getting a little bit of knowledge. So, um, I mean, and again, a lot of times we're already addressing a lot of these issues. Morphology goals, you know, we have those syntax goals. We're [00:42:00] working on verb tense. We're working on plurals, um, and adding those, but I think again, adding that orthographic piece and really highlighting that is going to be helpful. Just that awareness. Um, and then also just again being aware of their phonological skills and making sure that's not something we've skipped over.  Karina Kadhi:   Some things that we've done, um, to work on morphology in our speech and language sessions, um, is, uh, it's always a big hit. We call it past tense basketball. Um, and we usually have three baskets set up. And this is when we're working on like, uh, our past tense. So it has three, it can sound three different ways, right? To the id, our past tense marker, as in, um, I can never think of examples, y'all. I'm gonna need some help. Um, like painted, walked. And jump. No, that was the same. Hugged. Okay, hugged. There you go. Um, and so, whether, and then depending on what we want to focus on, do we want [00:43:00] to work on that auditory awareness piece? So then maybe we'll verbally give our kiddos a sound and they have to isolate. So working on phonologic, um, phonemic awareness, again, they have to isolate that marker and think about what they heard. Um, And they have to shoot their basketball into the right basket and they get points if they get it right. Um, or we might, we might be working on decoding, right? So they might have strips of paper with the different, they're all spelled E D E, right? But they just make different sounds depending on other parts of the word. And so then they have to practice reading it correctly. Um, and then shoot it in the basket that it goes in. So it's, it's great repetition, great drill. You can target different aspects of that. Um, and we're supporting and addressing that morphology in there and speaking in some great, uh, phonemic and morphological awareness as well. That's always a big hit. Um, and then the other one I'm looking at here, I think you made this one, like that, that book. The, the suffix book, like fully [00:44:00]  Heather Caska:  lastly. Yeah. So when we're working on some of those morphemes to working on those suffixes and prefixes, some things that we've done with. Our students is we've created like little vocabulary notebooks where we add in like we have the suffix or the prefix, the definition of what it is, but then we always draw a picture to kind of help with. So like one I have is Lee L Y. Um, and our word that we use was slowly. That was our keyword. And so we drew a picture of a turtle and so kind of just, but again, making it very specific, the child, like letting the student come up with it because individualizing it and making sure it's meaningful to them is. Um, and that goes back to, to those speech sound cues that we talk about, um, you know, with some of our students that we've, we've worked with, um, we love the beyond speech sound cues. We use those a lot. And we also, um, do use like the lips pictures, but some, sometimes those don't click for our student. And so we let them come up with our own. And I don't remember if we mentioned this in our last, [00:45:00] um, episode we did, but Karina had a little girl and we were working on her. F and the, um, the mad cat wasn't working. We tried fish just coming up with the keyword instead of the environmental sound, nothing was working. And so her mom helped us, um, come up with, uh, part. And that was her keyword for, and it stuck, I mean, but we just, she could not. And so it was, it's hilarious, whatever it gets from there, right, exactly, you think you should see the picture, it's, it's so great, but it's just a great example of how individualizing and letting the student, you know, like a lot of times we, um, We draw, let them draw the picture and we've, some of them have come out really, um, hilarious, you know, like they draw the picture and you're like, what is that supposed to be? And, um, they're, Oh, it's a monkey itching its butt. And you're like, Oh, okay. Okay. [00:46:00] Um, for that, I itchy. And so, yeah, so I think it's important. And then just going, you know, going back to morphology, same for that, you know, when you're working any vocabulary, really, what is like, what do they picture in their mind for that? And that's, what's going to, that's, what's going to help because I mean, we can tell them things, but if it's not clicking for them, and that's another piece with those programs too, is they're very scripted, you know, and, and tutors and people that are trained in it are trained, you know, you do not go off the script. And I understand that as far as like. for it. But what if it's not, what if it's not working? Like, what if those keywords that are in that program are not clicking with that student because they don't have the background knowledge for that, or, you know, whatever, it's not meaningful to them. Um, they need to be able to use what is going to be meaningful. And I think us coming in as clinicians, we have that knowledge and Understand how important that is. So same goes back for that when you're just working on morphology too, and helping build that vocabulary. I just want to say that all  Kate Grandbois:  of the examples you're giving [00:47:00] make it feel so easy to address. Literacy in what we're already doing. I'm just imagining a situation where you might have a student on your caseload that you maybe you're working on speech sounds and that's what your goals are related to. But then if you take that extra step to collaborate and find out if you know if they do have some sort of. Services for literacy or need additional support for literacy, just tacking in those letters or putting in that extra step into your therapy program to tie it back to literacy. I, I. The way you're describing it makes it feel so accessible. Like it's not this whole extra thing you're doing. You're already doing it. You just need to  Heather Caska:  tweak it a little bit. Yeah. I'm  Karina Kadhi:  glad you say that because that's our goal.  Heather Caska:  That is, um, and even if the, even if your student doesn't have goals for literacy, like it's gonna benefit everyone, you know, you're benefiting. Everyone's going to benefit from that. And that's the [00:48:00] thing is not only students, not only students with dyslexia are going to benefit from structured literacy. All students benefit from structured literacy. So  Karina Kadhi:  I feel like that's going to funnel that can funnel us into executive function. Can we like jump to that? Yeah. He's really quick because what, what that no students going to We had a disadvantage from being exposed to this in their intervention, right? Because what we're doing is making it multimodal. What we're doing is making it accessible to everyone and just incorporating another neural pathway that's going to make an association, you know? So no one's going to be at a disadvantage from us embedding phonological or phonemic awareness into our speech therapy. No student is going to be harmed in this therapy. Right, but yeah, yeah, it's it can be something simple that we embed and hit on that. And so I talked a little [00:49:00] bit about, um, executive function. I know it's not a one of the formal six elements of structured literacy, but it's involved in everything. It's involved in, um, learn our students learning. So in a nutshell, uh, executive function skills are like, um, perception, awareness, attention, working memory, inhibition, initiation, self monitoring, retrieval, right? What Heather was talking about when, when that sound cue isn't working, it's not sticking. What's not sticking for me is I'm not able to like retrieve that information that I've learned and then apply it. And that, that's an executive function skill, um, or several together. Um, and so we love to embed, um. supports for executive functioning into our speech and language therapy as well. And so, um, a few different ways we could do that is. Making things multimodal, giving them visuals of things, um, making things tactile, just making, individualizing it, and finding what works for them. Um, and then probably the most valuable [00:50:00] tool that we can, oh, I say valuable in that we can do the easiest and reach the most students, um, without really having to, because EEF is a whole, can be a whole, Presentation on its own. Right. And so without having to dive too much into that, something that we really think that we could do to support this is called reflexive questioning. And Tara Sumter is a SLP who specializes in executive functioning and she has a book and she's extremely knowledgeable in this and so we got this, this strategy, if you will, from her and so it's the idea that it. Thank you. Our words matter and the way that we word things can support our students so a reflexive questioning really remote promote self reflection and self awareness, which ultimately leads to that generalization right which is what we want, and it doesn't give or tell our student what to do, but rather guides and models [00:51:00] self talk and teaches problem solving for them so in our speech room, what that might look like when we're working on our coughing camel sound or. And so maybe we are producing it and they make the instead of just nope try again that wasn't it. Some way we could use our words differently to put them into a reflexive question is where, where did you feel that working? Where should you feel it working? Because now we're forcing them to think and to kind of get some of those self talk patterns and self checking, self monitoring patterns in there. Another way that that one other thing that could look like in our speech room is we have that kiddo that really can't sit still and it's doing all this and instead of sit still sit down, sit down, that we're just telling them what to do right there's no thinking involved for them. Where should your body be right now, what's your job right now, what should you be doing right now, because then what's that's going to force them to come back and be like, Oh, wait, what should I be. And maybe they don't know, but then [00:52:00] that's an opportunity to, oh, so here's where we can, here you can ask. And, and so it's just great modeling, problem solving, making, um, our, our kiddos more independent and less reliant on those external cues. And more aware of their internal.  Heather Caska:  Yeah, I think and on top of that too. And I remember Tara talking a lot about this as well as it's also just like they're confident. So if you say like, um, you know, where did you feel that your tongue working? Um, I felt it in the front. You're right. Yeah. So you're not. Like you're not, it's not like a, nope, you do it wrong. Do it again. Wrong. Do it again. You know, where did you feel your tongue working in the front? You're right. Or should you feel it working in the back? You're right again. Can you show me that? Show me it working in the back so they can get the, and so I really like the independence and also just. That confidence to have like affirming. Yes, they're doing, you know, they're doing the right thing instead of constantly. Nope. Do it again. Wrong. Do it again. Um, because then that can just be super discouraging as well. Amy Wonkka:  I think that those are such nice. And I think that's one of the big points to raise to [00:53:00] not only about shifting the student into a more reflective state, but also providing a more positive environment for them to be in when they're practicing like those strategies seem, I can't remember exactly what you said, Karina, but the best bang for your buck in terms of, you know, it's not a big change to your, to, to what you're actually doing, but I think it benefits the student and your relationship in multiple ways. Totally. And similar to some of that. integrating the literacy concepts. I don't, I don't know that that would  Karina Kadhi:  be a bad approach for anybody. Yeah. Yeah. Yeah. Um, we can go, you want to go into semantics? Yeah.  Heather Caska:  So, um, the fifth element that we'll talk about as far as structured literacy, again, is very much in our wheelhouse. So we won't spend too much time talking about it, but semantics or vocabulary. Um, again, I think the biggest takeaway for this, it goes back again to that orthographic piece and writing it out. Um, there's, uh, a podcast episode with Dr. Mary [00:54:00] Eltz, um, and Dr. Shelley Gray and Dr. Tiffany Hogan, um, on the See, Hear, Speak podcast. And it just talks about working memory, um, and word learning, um, and it's. I've listened to the episode probably like five or six times because it's just, it's so good. But, um, Dr. Alt has this really great quote in there. Um, it says we don't always do a good job of identifying when students have both like oral and written language difficulties because what their research is showing is that kids that struggle both with oral and written language that there's, they, um, They do have a lot more difficulty learning words. And so when it, and so they just say by writing, even kids with dyslexia, by giving that orthographic representation of a word. So even think about that with sounds. We keep talking about that when you're working on articulation. Match it with those orthographic cues too, that they're, they're, they're significantly better at learning those words when you have the [00:55:00] orthographic piece too. So don't, don't forget about that. You know, when you're working on vocabulary development, write it out for all students, cause it's just going to really benefit them. Um, we have a really great resource, um, that we like front it's called from talking to writing. Um, it's a, it's a book that we really love. And it, um, addresses a lot of vocabulary and syntax, um, and even written expression. So, um, it starts just, you know, vocabulary goes into basic sentences and then even into, like, um, multi paragraph essays, um, scaffolds it to wonderful curriculum. We use it and adapt it a ton with the students that we work with in our, in the school and privately. Um, so just a, a really, um, useful resource. And then again, that just goes into syntax, something that we're probably already doing in our, in our speech and language rooms as well. Um, again, we love the book from talking to writing to support this, but just writing it out. So we do a lot of, um, [00:56:00] we start a lot kind of like bigger working on phrase. There's like who phrase, what phrase, where phrase, when, and kind of building that way. And we literally cut out colored pieces of paper, who, what, where, when, um, we have a lot of examples of these on our Instagram. I know of videos of how we've used it and really just helping showing how we can build sentences. And then we kind of break it down even smaller than into nouns and adjectives, like those parts of speech, but we start bigger, you know, with the, who phrase, who did it? The cat, what did the cat do? Ran? Where did the cat run? In the yard? The cat ran in the yard and just, and then, you know, then you can kind of go back and break it down into, okay, so what's your noun, what's your adjective, what's your verb. Another way we've kind of helped support even spelling like that is we will have like, um, on the whiteboard and we make three columns, maybe like noun, adjective, verb, and then we give them a word, maybe like a, a specific target spelling, like phonogram that they're using. Um, and then we use it in a sentence and then they just, they spell the word like in that column, as far as like, what's that a [00:57:00] noun, what's that a verb, what's an adjective. So just another way to just really support those syntax skills, but then also supporting. Um, their spelling as well, and just that sound symbol piece. So those are the six elements. So again, phonology, sound symbol, syllable, syntax, semantics, and morphology. Um, and four of those six well within our wheelhouse. And then the other two, um, you know, sound symbols, I think we have a little bit more knowledge syllables and syllable division. Syllable types might be be a little bit more new. But again, we have a lot of resources to kind of help you understand that. And then the last piece we always are, um, encouraging or that we, what we do address or encourage you to support is reading comprehension and written expression. So we've talked a lot about the reading comprehension already. Um, this really ties heavily into your executive function as well, as far as self monitoring really using, um, active reading strategies. building background knowledge, um, is going to be really [00:58:00] important for these students. Sometimes, you know, with some of our students, we've created these like active reading checklists, um, you know, for that visual support to kind of help them, you know, check in, um, you know, Review questions first. So we talk about background knowledge. We kind of do a scan of what we're about to read, looking at pictures, headings, read pre read and in comprehension questions that we have. And then as we go through and we read whatever we're reading, we have check in points where we kind of stop and do some self reflection. Okay. What did I picture for that? What am I reading? You know, and just using, and then kind of going. And then again for written expression, we use lots of visuals to kind of help as far as like the writing process and organizing your thoughts, a big thing we really encourage our students don't stop writing, you know, they'll start writing and they get stuck on spelling a word, and then the rest of their sentence is gone, you know, they completely lose their train of thought. We have one little girl, one girl that we worked with for a while. And she was, I think it's seventh, eighth grade at [00:59:00] this time. And Karina was doing like a writing, um, task with her in, in their session. And she was, I don't remember what it was, but she wrote the cooks going to write instead of kitchen. And Karina was like the cook's room and she's all, well, the kitchen, but I didn't know how, how to spell it. And so completely avoiding, you know, and changing their sentences. And it didn't sound as good,  Karina Kadhi:  right? That didn't, that wasn't as nice of a, of a sentence, um, for her.  Heather Caska:  Yeah. So really we're working on. Just add like teaching them, you know, it's okay, like just get it down and then we will come back and we'll edit later, you know, but it's hard because a lot of times kids with dyslexia, they're, they also tend to be perfectionist too. So it's hard for them, you know, if they don't, if they're not getting it, you know, right. Or it's not exactly the way it should be. And, um, we had another, um, boy tell us one day, he's like, I have my thoughts here, like they're here, but then it's like, as it goes down and gets to my hand, it gets lost. And then he just like, can't get his [01:00:00] thoughts on paper. And so like, just to have him be able to verbally express that was like really helpful for us, you know, like, what could we do to, to better support him then? Cause it's not like he doesn't have the ideas he has them, you know, but it's when he'd go to get it on paper, he loses it. And you hear that all the time with your students with dyslexia. So, um, really supporting that written expression. Scribing for them so you can get it, you know, you can get it down. That's often a big support or an accommodation on their IEP as well. Um, but just really encouraging them not to not to worry about spelling. So, um, and I think that's it. We talked about executive function. So, um, again, you're you're We're not saying that you now have to start adding all of these new students onto your caseload because I, we get that a lot to like new goals. Yeah, but just being aware of the students you have on your caseload, and how you can really support them with these structured literacy elements with the therapy that you're already [01:01:00] doing by just adding in some different elements or kind of tweaking your, your activities that you're doing with them. Kate Grandbois:  You all have shared so much with us today. I can't tell you how much more accessible this all feels now. And we're really, really grateful for you sharing it all. Do you have any additional last rec last set of recommendations or words of wisdom that you want to leave our listeners with?  Karina Kadhi:  Um, I, you know, I, I think it's just that I've really, and for myself personally too, is just that we're lifelong learners and sometimes it can feel like, oh, you're asking me to do what? Because I remember learning these spelling words, rules at one point and I felt the same way. But, um, but, but to know that we have a bigger, look at the bigger picture and that we can, we can play a bigger role in the, um, with, with these students, um, in the, in our existing role. Um, and hopefully we spark some interest for some, um, speech therapists that really have a passion for [01:02:00] literacy. Heather Caska:  Yeah, and I think especially in your kindergartners, because again, they're the ones we are most often the first professional that comes into contact with these students that are going to have, you know, learning difficulties, specifically in reading and writing. And so really just being more aware in our younger students because we're the ones that can really make that impact. Early on, um, because most likely they're not going to get tested or formally evaluated until later on. So especially in those younger students, just kind of come up with a good action plan of how you can better support them and be aware of them on your caseload. Thank you so much for  Kate Grandbois:  all of this. We're so grateful for your time. For anyone listening, all of the references mentioned will be listed in the show notes. Thank you again so much for being here and we hope to welcome you back here again  Karina Kadhi:  sometime soon. Thank you.  Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA [01:03:00] CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]  Intro Kate Grandbois: Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka: Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois: episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka: Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois: specified. We hope you enjoy  Announcer: the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois: Welcome to SLP nerd cast. We are so excited to welcome today's guest. Welcome Megan Holmes.  Meghan Holmes: Hi, guys. Thanks so much for having me. I'm so excited.  Amy Wonkka: We're excited, too. Uh, you're here to discuss the SLPs role in palliative care. But before we get started, could you please tell us a little [00:02:00] bit about yourself  Meghan Holmes: or I graduated from Northeastern University in 2016. I did the accelerated bachelor's masters there. Um, and since then, I've worked exclusively with adults and geriatrics kind of across the continuum of care. I've done skilled nursing facilities, home health, uh, a long term acute care hospital. And I'm now working in an acute care hospital in central Massachusetts. Kate Grandbois: We're really excited about this. We had a lot of really, um, interesting conversations before we hit the record button about how. This topic of palliative care might not be obviously related to what we do as speech language pathologists, but as you're going to tell us soon, this is much more related to the role of the speech pathologist than you might think. So there's a cliffhanger there, and I'm looking forward for you. I'm looking forward to you filling in more information. But before we get there, I do need to read our learning objectives and our disclosures. I will get through those quickly, and then we'll get on to the good stuff. Learning objective number one, [00:03:00] define palliative care. Learning objective number two, describe knowledge and skills specific to the SLP role that can benefit patients, caregivers, and clinicians navigating serious illness. And learning objective number three, identify at least one communication tool that uses patient tested, person centered language as a framework for discussion around serious illness. Disclosures. Meg's financial disclosures. Meg received an honorarium for participating in this course. Meg receives a salary from UMass Memorial Health and Worcester State University. Meg's non financial disclosures. Meg has personal experience with palliative and hospice care. Meg is also a member of ASHA SIG 13 and a member of the Dysphagia Research Society. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I'm a member of ASHA SIG 12 and I serve on the AAC advisory group for Massachusetts Advocates for [00:04:00] Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka: Amy, that's me. Financial disclosures. I am an employee of a public school and co founder of SLP Nerdcast, and my non financial disclosures are that I am a member of ASHA. I'm in Special Interest Group 12, which is AAC, and I participate in the AAC Advisory Group for Massachusetts. Advocates for children. All right, Megan, as Kate mentioned, before we hit record, we talked a little bit about the audience for this specific episode. And like, in my mind, when I think about palliative care, I'm thinking about geriatric clients, but it turns out I'm not super correct in that thought. Um, so could you start us off just by telling us a little bit about how, if you're an SLP and you're listening and you think this topic doesn't apply to you, In fact, it probably does. Meghan Holmes: Yeah, I think, you know, palliative care is just an extra layer of [00:05:00] support that can be, you know, given to a patient at any stage of a serious illness. But realistically, it's just those are your big picture doctors. And so they provide what the healthcare system and what, uh, the overall school system, I think, claims to provide, which is person centered or client centered or student centered care. And so if you are an SLP and you work with people and patients and clients, like those tools that we're going to talk about, I think are going to be helpful for you.  Kate Grandbois: And to sort of start us off with defining palliative care, you've just given us a generally a loose description of what it is. It is different than hospice care, or it is not different than hospice care. I feel like I've experienced some confusion around that delineation just in my personal life. Can you explain a little bit about the difference between those two  Meghan Holmes: things? Yeah, so palliative care is not necessarily end of life care in the way that hospice is [00:06:00] hospice in order to qualify for hospice. You know, you need to have a terminal illness with less than six months of life expectancy. Whereas palliative care is focusing on symptom management and quality of life. And so that can be initiated at diagnosis. Um, and so I think that the current model And, you know, the United States healthcare system is exactly the way that you currently understand it where palliative is like this bridge to hospice, but that's not necessarily true. Amy Wonkka: So, does the role of SLP. The role of SLP who are working to support palliative care is that does that look different depending on the setting that you're in like we I know we've talked about nursing homes we've talked about schools. Um, I know your experience is primarily with geriatric clients, but, uh, do you, can you give us sort of a view of how that might look depending upon the setting that you're in? Yeah,  Meghan Holmes: I think that, um, [00:07:00] specifically with adults, you are going to be working with patients who are at very different stages of their illness. Um, like my job is working in the acute care hospital. And so oftentimes that I see them when they've had an exacerbation of their serious illness, they've had some sort of setback. And so that's kind of. a prime opportunity for them to step back and be like, Oh man, like this is going to keep happening. What do I want next time to look like? Um, if you're working in a skilled nursing facility or home health, I think that you are seeing more of the day to day, like more stable and controlled symptoms of like, Hey, are you happy with how this is going? Um, I know. You know, 60 percent of adults have some sort of chronic illness and what blew my mind when I learned that fact was, you know, when I am reading a history of a patient, I'm like blowing past all of these [00:08:00] illnesses that are listed on my go. congestive heart failure, diabetes, hypertension, hyperlipidemia, not super related to dysphagia all the time. And so I'm like skimming it. I'm like, Oh my gosh, this person has four chronic illnesses that they have to manage every single day. And, you know, I think that remembering that we are treating an entire person and not just, Hey, I actually only care about the part of you that is relevant to me is really important. And just  Kate Grandbois: going back to what we said at the beginning, having now a better understanding of what palliative care is, this could absolutely be part of what an SLP in a school needs to be aware of, or in a pediatric setting outside of what you've listed, you know, still nursing facilities, acute care, all of those kinds of things. Because if you're really trying to support a family or a child or a person with a chronic illness, People live with chronic illnesses and in many places in many, [00:09:00] they experience treatment in many settings. Is that a fair assumption? Oh,  Meghan Holmes: absolutely. Yeah, I think, you know, remembering that everybody that you're interacting with is dealing with more than you can wrap your head around makes you a better clinician. And so, you know, having the ability and the tools to remind them that they do have more control than they think and kind of empower them to say hey what's been given to you so far is a recommendation based on this goal. Is this your goal also? And making sure that you're You know, advocating that their care gets adjusted appropriately in that way. So you've  Kate Grandbois: mentioned, you've already started mentioning, or you've touched on some of the things that an SLP might need to do in terms of skillset to support someone with a chronic illness. I'm assuming that counseling is also a piece of this. Can you tell us a little bit more about the knowledge and skills needed for an SLP [00:10:00] or even an SLP who might be listening and thinking, I work in an elementary school, but I'm already thinking of my My little client who's in kindergarten and kindergarten, who's living with a chronic illness. What kinds of knowledge and skills do we need when we're, when we can identify that we're working with someone with a chronic  Meghan Holmes: illness? Um, I think the quickest and easiest answers are of course, you know, compassion and patience and knowing that. Anger is never anger, right? Anger is often like fear or sadness or a lot of things and being able to take a step back and remember that, like, in this conversation, I am the face of a problem. I am not the problem, but I am like the person that this family or client or child is interacting with who, like, if they're mad at this situation, like. I'm here for that. And trying not to take that [00:11:00] personally, remembering to breathe, and I think using some sort of structured interview strategies has really helped me pull myself out of it, because I think You know, while empathy is important, leading a difficult professional conversation with empathy is too emotionally draining to be sustainable. And so the kind of framework that I fall back on a lot is the, from the Ariadne labs, the serious illness conversation guide. Um, and I can email that to you guys so that your listeners are able to have, um, a copy of it, but it's available online. Um, And it basically is intended to be not a script, but just a framework like training wheels of, Oh my gosh, we have this super tough thing to talk about. Where do I even begin, and how can I possibly as an SLP as you know, not the doctor as not the [00:12:00] whoever, what am I supposed to do about this, but you know, we still have a lot of value as clinicians. Because. We especially in the adult setting are working with communication and thinking and eating. And those are really, really important in terms of quality of life. Um, and so I do think that it's important that we insert ourselves into those conversations because Probably nobody else is going to  Kate Grandbois: You mentioned an interview or using a structured interview. Is there a format for a structured interview? That's specific to supporting someone. In palliative care, or are you referencing just using structured interviews in general to make sure you're providing person centered care? What does that interview process look like?  Meghan Holmes: Um, I think. What I'm referencing is using, um, that particular framework that breaks a [00:13:00] conversation kind of into steps. Um, and, you know, the first step is just to kind of announce like, Hey, I want to talk about this today. Is that okay? Like, um, And, you know, for somebody who, let's say they have Parkinson's disease and their Parkinson's has really started to advance to the point that they're having trouble swallowing. I'm like, Hey, you know, I want to talk about how your disease has impacted your swallowing. Are you up for it? Is that okay? You know, you can pick language that feels natural to you. Again, this format is not intended to be a script, but you know, and then you check in with the family or the patient or the client and you're saying like, tell me what you understand about where we're at with your swallowing and why we're talking about your swallowing and what we're worried about so that you can kind of hear what they have retained, what over the course of what you have hopefully already educated them about at least a few times, [00:14:00] so that, you know, if you are just monologuing at them and telling them something that they already know, they don't have any buy in into that conversation and they think that you're not going to listen to them. And so opening the conversation by saying, tell me what you know, tell me what you think, that can be really important and really helpful and really valuable and people are going to really appreciate it. Um, and so I think I'm just trying to open the guide right now so that I can make sure I'm not skipping any steps or anything. Um, but I think that, you know, people freeze in these tough people being SLPs and clinicians freeze in these really tough conversations because they feel like they don't know what to say. Um, and they don't want to say the wrong thing. You know, it's coming from a. Kind place and so, you know, if you have tools to be able to navigate it, then that helps a great deal.[00:15:00]  Kate Grandbois: In thinking about working with someone and supporting someone who has chronic illness and understanding that there might be caregivers involved, or as you mentioned, grief or anger, um, moving through those conversations with sensitivity is so important. And. I love the idea of a framework. We love a good framework here on the nerdcast. We talk about them all the time. Um, but knowing that there are frameworks or structured components out there to help with that is incredibly helpful. So we will make sure to link that reference in the show notes for anyone who is listening.  Meghan Holmes: Perfect. Yeah, I totally agree. And I think it, I have gotten better at it, but I still stumble, right? Like these are really, really hard topics. Um, and you know, you mentioned grief and one of the topics that comes up a lot in the acute care setting is anticipatory grief, which is either, you know, the [00:16:00] loved ones grieving before somebody is gone, or even just like, if you have a progressive illness, you're kind of. Preemptively grieving the loss of functions that you know is coming. Um, and, you know, trying to navigate grief in an SLP role and not like a social worker role or, you know, we have some amount of counseling training like that's heavy and I do think it's important that we, you know, have. Tools to help us. We have frameworks to guide us and we know when to back off and when it's not our place anymore. You know when it's going to potentially cause more harm, either to us or to the family because we're out of our depth. So, I do definitely want to make sure people are. careful and checking in with themselves, make sure that they're not going to overstep and cause themselves any harm. [00:17:00] Um, cause burnout is very real and compassion fatigue is very real. And, um, if it can be avoided, it should be.  Amy Wonkka: I, I a thousand percent agree. And I think, you know, we've had some other folks on the podcast in the past talking just about. How really, really important that is that self care and that self awareness and those strategies for ourselves to be able to check in with ourselves and monitor ourselves, and make sure we're taking care of ourselves so that we can effectively do our job for our clients. So that's, that's a very important point that I think we can't emphasize enough. I guess I also had a question. Connected to what you were saying in terms of like, we're not social workers, and we're not, you know, these other types of providers, how do you collaborate in your role, at least with other health care professionals, like physicians or nurses or social workers or counselors? Do you collaborate? Is there room for that kind of in providing wraparound [00:18:00] service? And what What might that look  Meghan Holmes: like? So I am definitely very spoiled to be in the acute care setting because palliative there's a palliative team, right? Like there are dedicated providers and social workers who like this is their whole jam. And so, um, they are a consult service that the primary medical team can engage. And so, like in some of these, yeah. You know, big family meeting type situations, they are guiding it and so I get to sit there and like, wait to be called on to say my piece instead of leading, you know, hospice is covered by most insurances and palliative care is not. And so I do think that, you know. SLPs who are not in the acute care setting or not working in an outpatient clinic that has access to a palliative team are a lot more on their own with this kind of thing. And so they need to be [00:19:00] collaborating with the primary medical team and the social workers to be like, hey, this patient told me this. And this is how our conversation went. Do you want to come with me next time this comes up? Or, um, do you feel comfortable calling this patient's family about this thing? Like, should I do it? And kind of figuring out who's taking lead on this, um, because I think what I realized, you know, the acute care setting that I work in is also a teaching hospital. So I'm working with a lot of interns and residents who are like, yeah, yeah, you do it. Like, I don't know. And, and I appreciate that because I, you know, they want to learn and they want to be able to offer this service and. They feel out of their depth. And so they're turning to me. And so I would encourage your listeners to also when they feel out of their depth, think about who on that interdisciplinary team they can turn to, to take lead and what they could offer. Kate Grandbois: And that also sort of makes me think about the role of the [00:20:00] SLP, because I have to presume if you're Lucky enough to be able to work as part of a team and have other disciplines at your disposal, you're bringing a wealth of knowledge related to, as you mentioned, communication, swallowing that the other professionals may not have. How do you tailor some of these skills to? Individuals with different skill level. I'm just sort of bringing this back to this concept of person centered care and interviews. So for example, if you're working with someone who's in cognitive decline, but has palliative, but is in palliative care, how do you approach and adapt your person centered care interviews or your communication style? How does that change how you approach a case?  Meghan Holmes: I think you're bringing in. More stakeholders, I think, to somebody who has experienced [00:21:00] cognitive decline, um, you know, one line that I think it's very important for SLPs to draw is, you know, I have often been asked, Hey, can you do a cognitive evaluation on this person to figure out if they have capacity to make medical decisions? No, I absolutely can tell you information about this person's attention, memory, all of these types of SLP related things. But capacity, the ability to, you know, Make a decision like that has to be determined by a physician. And so I think that if everybody on this interdisciplinary team is like, Hey, you know, Mr Smith here might not be able to make his own decision. You know, you're having these conversations, maybe still including Mr Smith. but probably focusing more on the health care proxy and the health care agent, the person who is going to ultimately make that call. Um, I'm thinking of specifically [00:22:00] patients with dementia. Um, you know, the overall goal of palliative care is to improve the quality of life and I think that there are definitely stages of dementia where being a part of those conversations is more distressing than it is helpful because they are confused and so they're hearing for the first time it feels like I'm dying. What? And so that is not going to be, first of all, productive or kind like you are causing undue stress. to your patient, your client, the person that you are allegedly caring for by involving them in something that they don't have the capacity to do. So you're shifting this kind of framework to be targeted more at family members and or you hope family members, but healthcare proxies in general. Um, And I think that, you know, that adds almost a new [00:23:00] layer because every family has very different dynamics, and it's, you have to come into those conversations without judgment. Especially me in the acute care setting, I'm often meeting somebody for the first time and interacting primarily with like their spouse or their child or somebody who has known them for longer than I could ever imagine. And so I say, listen, like my expertise is in swallowing, but your expertise is in your mom. And so we have to kind of work together so that we can make a plan. Um, and you know, Reminding them that we're on the same side here and we absolutely have the same goal, making sure that they feel heard.  Kate Grandbois: That brings me to a question about how you communicate and support the family. So if you are dealing primarily with, uh, a spouse, a partner, a caregiver, a care partner, I recently [00:24:00] learned that that's a preferred term care partner or their, or their children, their adult children, how are you? Counseling them in terms of how to support them in palliative care, because I have to assume in your setting or in any setting, you know, we're allotted one visit a day. I don't know what your service delivery models look like in acute care because I've never worked in acute care, but thinking of any speech pathologist, we're not with these families all day. How are you providing education to the care partners in these, in these instances?  Meghan Holmes: It's certainly easiest when they are visiting the patient and they are in house and I can just be like, hey, I'm the SLP. However, that's certainly not always the case. And so I spend a good amount of time on the phone in these types of conversations specifically, especially when The medical team has asked me to because in the acute care setting, you [00:25:00] know, the point family or the primary care partner is usually updated at least once a day. And so, you know, whether that be a nurse or a doctor like. That person is expecting a phone call from the hospital. And so if I'm like, Hey, when you talk to this care partner, do you want to bring this up? Or do you want me to make a separate call? And then, um, that's kind of what the plan ends up being. I think that the bigger meetings where like a palliative provider is present or, and a social worker and a case manager and the primary team and me and anybody else, those are usually. Scheduled separately. And so, you know, that is all right. I know that on Friday at 10. I'm going to be in this meeting. Um, and Having that conversation Amy Wonkka: about assessment, can you help us at least within the like acute care environment? [00:26:00] Like how, how does your assessment change with the incorporation of a palliative care component or how might it change over time with the same client? Um, what might that look like?  Meghan Holmes: Sure. So my, you know, primary focus in the acute setting is swallowing. It's dysphagia. And so, you know, I think that because I'm so passionate about palliative care, I've started to incorporate this in pretty much every assessment. So they don't look super different, but they do look different than past Megan's assessments. So I can talk to that. So I think that There is a lot heavier focus on education where you're saying, Hey, like, you know, we're worried about swallowing because we're worried about potentially pneumonia when you're in the hospital already. Or if your immune system is battling other things, you might not be very good at fighting off a pneumonia. Um, and I have found that it's [00:27:00] important to say the word fatal and like. You have to make clear, like, hey, when you are making decisions for yourself and your own body and your own life, like, I do need you to understand that potentially you are making a life limiting decision. Um, so I do think that saying like, hey, I have concerns about the safety of your swallowing. I have concerns about your ability to meet your nutritional needs. Um, and so. I had heard I'm not going to be able to remember who I heard this from, but I heard a quote that was basically if you don't provide choices, then you can't get consent. It's just coercion. And so I loved that, especially in the dysphagia world. And so I'm like, Hey, I Based on this goal of making you live as long as possible, recommend that you don't eat or drink anything and get a feeding tube. However, your other option would be [00:28:00] to eat and drink, even though we're acknowledging that you're probably going to aspirate sometimes, even though we're acknowledging that that aspiration could lead to pneumonia, which could ultimately lead to your death. And like, being delicate, but clear about the way you're presenting that. I love that  Amy Wonkka: quote, by the way. I'm sorry. I just jumped in front of Kate. I see you unmuting, but that, that is such a great point, right? We're not, we're not providing options if we're not providing all the options. And I think also. I, I'm going to ask you to circle back on the, on the, on the difficult conversation matrix and tell it or framework and tell us a little bit more about that. But I think something like that must be very helpful in having those types of conversations where you do use words like fatal and we don't kind of dance around the topic. And I'm thinking, you know, I'm, I'm not in a position where I'm having those conversations. I don't work in dysphagia. Um, [00:29:00] However, I think a lot of these ideas are broadly applicable to all of this. We talk in euphemisms all the time, you know, I mean, even in special education, you know, we being able to come out and be transparent and provide actual options, like actual choices and be clear about what we're really talking about. Has got to be only beneficial, but also stressful to begin having those conversations in that transparent manner. Kate Grandbois: I want to piggyback on that. I want to piggyback on that quickly because I, you've just made me think of something else in, in terms of that transparency. I think one thing I have experienced a lot in my career and that I have seen a lot is. Our hesitancy to provide clear prognosis. And I think, you know, because it's because it's bad news, you know, no one what, in your example, we don't want to hear that, [00:30:00] you know, you can aspirate and die in pediatrics, outside of something medically. You know, medically threatening or life threatening, we might say, you know, you're the likelihood of you developing oral speech is low based on X, Y, and Z. I feel that as clinicians. And maybe this is my professional culture. You guys could correct, you could, you could disagree with me completely, but just the, the willingness to be clear and provide information about a less than favorable prognosis, something that I am realizing right now that I have avoided my entire career. I mean, it's, and I have watched other people avoid it  Meghan Holmes: too. Yeah, I think that the best again I will come back to the framework I promise, but the best tool, or the best little clip it that I got from there is the phrase, I wish I worry, or I hope I worry. And so it's like, I hope. that you [00:31:00] do develop oral language someday. However, I'm worried that you won't because of XYZ. And so you are joining them in some of the grief of like, this is a bummer. Like, I know that this is what you wanted and I wish that I could tell you that it was possible, but I think we need to manage expectations so that we can set goals together. And so, you know, from a serious illness perspective, you're like, I hope that when this infection clears, then your swallowing improves. But I'm worried that because the swallowing difficulty is because of a progressive disease, that this might be as good as your swallowing ever is. And so, you know, using that, I hope, I wish it's like, yes, I, I hear you. That you want that, and I want that for you too. And I'm so sorry. But making sure that they understand kind of what the situation is so that they also know where you're coming from when you're potentially bringing up, like do you wanna consider. Non curative types of [00:32:00] treatment now. Um, like that's really hard to hear if you're not in a spot where you are ready to be like, Yeah, this progression that I have been afraid of is here. And now I have to like make some choices. I think that the SLP is who are focusing on dysphagia with a lot of these. you know, chronic, progressive, especially neurodegenerative diseases, swallowing is kind of like the crossroads where if that starts to become a problem, oftentimes that is the stage of disease that patients are ready to be thinking about hospice, where they're like, Oh, hold on, this is close to the end. But I think it's extra hard when, if that's one of the first functions to be impacted. And it's like, hold on, like, if you didn't, um, like I think they, they're less prepared for that type of conversation when diagnosis is really new or something like [00:33:00] that. I think that the clients and families that have An easier time with these types of conversations and are more ready to hear it. Or it's like, yep, like they were diagnosed with dementia 20 years ago and we've been told to expect this day and I hate that it's here. And it doesn't make it better or less hurtful that they were ready, but does start the conversation more easily. All right, so I can talk a little bit, uh, have it up now, the Ariadne framework now, if you want me to go right into that. Yeah, I would love you to. Okay.  Amy Wonkka: Just because I feel like it's, it's going to be very broadly applicable. This is my, like, projected,  Meghan Holmes: projected view, but we'll see. Okay, perfect. So again, this is from the Ariadne labs. They focused on, you know, they tested all of this language with patients to make sure that it was clear and like agreeable to patients. They were coming at this specifically from serious [00:34:00] illnesses, but Amy, spoiler, you're right. It's applicable to a lot of people. So the first step is set up the conversation. That was kind of what I had started talking about, where you're introducing the purpose and asking permission. It's like, hey, I'd like to talk about what is ahead with your illness, do some thinking in advance about what's important to you so that I can make sure we provide you with the care you want. Is this okay? And they have the is this okay, bolded because everything leading up to that point is not supernatural. Like I am consider myself to be fairly well versed in these types of conversations, and I would never talk like that. And so, you know, you do want to take the step and take the principle and put it in your own words. Because you're a human having a conversation with another human and you want to make sure that other human knows that that is happening. And so once you have set up the conversation, you know, everybody who's present is aware of what is about to be discussed. That's when you're [00:35:00] assessing understanding and preferences. You know, what is your understanding of where you are with your illness? Tell me what you know about why we're here today. Tell me what you know about, you know, the concerns that we have so far. Um. And then the other factor that they recommend is how much information do you want to be given today? Like, you're kind of checking in and saying, what, what kind of headspace are you in? Are we having like big talks or do you want to just kind of gloss over this? And both are okay. I think when I've. I learned a lot about this particular topic, palliative care in general through, uh, actually a nursing education program through my hospital that's interdisciplinary. And so the palliative doctor who was giving this presentation, she was like, just because the conversation didn't go the way that you wanted doesn't mean it wasn't productive. This is supposed to happen over the course of many, many [00:36:00] conversations, you will have this exact framework, many times, you know. Especially in the hospital. Maybe this is the first exacerbation of their illness and you're like, wait, hold on. Like, I'm not ready at all to be talking about the end when we just got here. And like, that's okay. But maybe next time they're hospitalized hopefully years from now they're like, Oh, I remember like we did start to talk about this and over time, you know, they have it kind of. That seed planted in their brain of like you get to pick like you don't have any control really over your illness in the course that this takes but you do have control over where your life goes in this point and so reminding them continuously like this is about you we're here for you you get to choose um is very very important very powerful um and the third step is sharing prognosis and so when you're in The hospital.[00:37:00]  Again, I'm a spoiled brat because I get to sit back and say, I'm going to defer to the medical team to let you know about the overall medical picture, because I do also firmly believe that that is not my role. I am not a neurologist, I am not, you know, a pulmonologist, I don't know enough about the disease to be able to give a life expectancy. And so like, you know, I don't think that SLPs should feel pressured to make that kind of claim because that's not within our scope at all. And so what we can do is share prognosis about something that we can diagnose. And so we can diagnose dysphagia. And so I'm like, you know, I can say, I wish I worry. I hope that I'm worried. And You know, one family meeting that I had somewhat recently was, um, I had a patient who had Parkinson's that was [00:38:00] fairly advanced, and he fell and he hit his head and so the like acute issue was that he had. A subdural hematoma because he fell and hit his head. And so the ICU team was very much like, well, like once this gets better, then he'll be back to his baseline, but that's not really how chronic illnesses work. And I suspect that they know that also, but it's like, you don't go back to your, the baseline you were at where I have a new baseline. And so in talking to this patient's family, I learned, oh yeah, he's been, you know, He's been hacking his brains out for meals for like weeks and weeks and I was like, it's interesting. Okay. And then they're like, yeah, he, I think he's had pneumonia. What is it? Is it six times in the past couple of years? And I'm like, okay. Okay. So like maybe this isn't a subdural hematoma issue. Maybe this is a Parkinson's issue. And so the, I hope I worry that I got to use was like, I hope that as he gets some strength back after this injury, you know, [00:39:00] He does feel strong enough to eat again, but I'm worried that these exact examples that you told me, you know, the coughing during intake, he's already had pneumonia a bunch. We know that Parkinson's impacts is swallowing. I'm worried that all of the things. That preempted this fall are working against him. Um, and it did kind of shift the conversation a little bit to be like, Oh, okay. So like, yes, this is one isolated incident. Anybody can fall and hit their head. But the person who fell and hit their head is somebody with an advanced chronic disease. And so that's kind of what we need to be talking about. Um, so I do think that a sharing prognosis ends up being Yeah. The scariest part. Um, and my advice for the students that I take in the hospital is silence is your friend. Like you need to let the people that you're talking to process what you've just said. Um, I [00:40:00] still actually from this palliative care course. The nursing education course at the hospital, I stole an activity and used it when I was teaching this Asia, where it's like partner up, and one partner has to say, talk about something that's important to them for five minutes, and the other partner can't say anything. And it's a really cool exercise because you realize how often you want to jump in and be like, I. Oh, I agree with that, or, oh, I have a thought, or, oh, I, because you're like seeking connection, and especially as SLPs, I feel like we're a chatty bunch, and so to realize how much more information comes out if you're silent was really powerful. You're like, oh, the people who are sharing were like, I probably said more than I would have to this classmate if I, you know, had the opportunity to stop talking or re evaluate, and, you know, it, As I'm saying this out loud, I'm like, sounds a little manipulative, but I promise it's for the greater good. And so, [00:41:00] um, I think the fear of not knowing what to say can be squashed. If you are okay with silence or you're like, give yourself a minute too. Right. You know, you don't have to have the perfect thing to say, because oftentimes it's better not to say anything at all. And I  Amy Wonkka: think it's a way that so many of us kind of deal with our. anxiety and uncomfortable feelings around having difficult conversations with clients. Um, I think back to particularly when I was earlier on in my career. Um, I sort of just tried to fill the space because I was feeling uncomfortable and I could see that my client or their primary care person partner was feeling uncomfortable. And so rather than. be present with that uncomfortableness together. I was like, ah,  Meghan Holmes: I'm just going to get through this.  Amy Wonkka: Um, I wonder if, if you, I mean, you just gave us a really great [00:42:00] example, but I wonder if you had any additional reflections just on how your practice has changed and how your interactions with your clients have changed in terms of your dysphagia service provision from when you first started out to now that you're sort of incorporating this palliative care approach for all of your clients? Meghan Holmes: Yeah, I think, um, it definitely has reframed how I think about alternative nutrition. Um, you know, I wholeheartedly stand by the no advanced dementia, the ethic statement that came out can put it better than I ever did. And I think that that is so important, but to kind of look at each patient case individually and be like, will their life be improved by this feeding [00:43:00] tube? In a lot of cases, yes, like, yeah, we do anticipate that your swallowing is going to take a long time or the improvement of your swallowing is going to take a long time. And so we want you to be out of the hospital and getting the calories that you need so that you can rehab so that you can eat safely, or, you know, you need to have this kind of backup plan because eating is so difficult for you and you might not be able to sustain yourself. Um, but. I think having this I approach every single recommendation I make as choices makes me think, Okay, what, where do I see this patient in six months, and, you know, I think every person has a different reaction to the overall medical world, and you know there are some [00:44:00] people who are going to take your opinion as fact. So I think you need to know what your opinion is when you're walking in and making that recommendation so that you can make sure that you do not share it. I think that the The question that I get all the time in these family meetings is like, if this was your mom, what would you do? Like, if this was your spouse, what would you do? And my response without fail is the only reason I know that answer is because I know what my mom would want. You know, we're asking you because you know what your mom would want. And so just kind of like, I hear you, flip it back. And so, I don't know, it's people are tough and I think, you know, you want. to be somebody who can support them. And I think that being the person who delivers tough news doesn't feel very supportive. Um, but you SLPs do have [00:45:00] knowledge that medical professionals that they have interacted with so far don't have. Um, and I think that we, in some cases, Also have more time than some other medical professionals to that we can spend with these patients and their families to have, you know, lengthy conversations. Um, the area me labs who've made this framework. Um, they also really specify that This type of conversation is its own billing code for physicians, and so it's like, nope, this is still worth your time physicians, because, you know, you can bill for these hours, having this specific type of conversation, because I think it's a tougher sell for somebody who feels very. you know, stressed and like they're in a time crunch to really sit down and have this conversation. So they have a big reminder, like physicians, you can, you [00:46:00] should. And, um, I thought that was very cool and very helpful. Um,  Kate Grandbois: Ashley, if you're listening, if you could please do some advocacy work to get us some reimbursable indirect service codes, that would be great. Thanks so much. Anyway, as you were  Meghan Holmes: saying, Meg. Oh, I wholeheartedly agree. Uh, I know. I. I'm very conscious as I'm speaking that I am spoiled in the acute care world. Like I am not as bound by insurance limitations as some other settings absolutely are. Um, and I think, you know, a quick tangent that's important about that is if you're in home health and if you're in skilled nursing facilities, if you're, you know, you are so conscious of my goals have to be achievable, they can't be for maintenance. And so you. have to kind of get creative with your goal setting when your patient has goals that are not necessarily curative or rehabilitative [00:47:00] or life prolonging because We are still providing skilled services that are defensible, but you have to make sure that you are protecting yourself. Um, one of the best ways that I would recommend doing that is to use patient reported outcome measures. You know, there are some for dysphagia, there's some for aphasia. Um, the ones that I turn to. Most often in the hospital setting is going to be the eat 10 and the MD Anderson dysphagia inventory. And so if you have a goal documented that you want the patient reported outcome scores to improve, then That helps you provide the quantifiable data that the insurance would need in order to justify the education and the strategy training and, you know, the time spent checking in with your patient, um, and using those to bill. [00:48:00] Um, I know that it shouldn't be like that, but it is. And so, you know, you have to get creative sometimes to provide the person centered care that we are. Billing for  so the fourth section of the framework is explore key topics. Um, and so that's kind of their overall goals, their fears and worries, their sources of strength. Um, and I think that I have seen this done more often by the palliative team, but I think that, you know, some ways that we can incorporate this into a more natural conversation is you're like, what are your biggest worries about what the future holds? And, you know, if your situation were to worsen, what is, what do we need to focus on the most? Um, I think incorporating how much does your family know how much do you want your family to know, um, who can we talk to about this if you're not up for it kind of making sure [00:49:00] that you are checking in and getting permission and remembering who you're focused on. The heartstrings to hear is like if you become sicker, how much are you willing to go through for the possibility of gaining more time. And so you're asking the person to examine, these are the treatments that are being offered to you. These are the benefits, but it's going to come with a burden as well. And like, where are you kind of in that benefit versus burden spectrum? And I think that that particular question is also where I, as the SLP, maybe just Megan as the human, tend to insert my own opinion the most often and so that's where I have to be the most careful about judgment. Because, you know, I can think of patients who are so confused, they are not their own [00:50:00] decision maker. And you know they're in the hospital and you can hear them down the hallway screaming, screaming, let me die, let me die, let me die, and then the You know, healthcare proxy is doing and full court press on whatever illness they're battling. And that feels gross as a human, but I think that what's important to remember is that this healthcare proxy was tasked with making the decisions that. This person who's yelling would have made in their right mind. So maybe she would have gone through absolutely anything for more time with this family member. And like, maybe, um, what I see is just the surface level of the worst day of both of their lives. And I need to pull my own judgment back and just be like, I have to present options. I have to provide support. I do not have to make decisions. And that is so freeing. And so if you can take the step [00:51:00] back to just be like, that's what's happening. And because this decision maker has told me what the goal is, that's what my goal is to, um, you know, It is, it can feel gross. And I think that the moral distress that can come from that where you feel like you're being asked to provide a service that you don't agree with can be very difficult, but reframing it in your mind to be this is still person centered care. This is what the voice of the person that I'm caring for has said that they want. Um, of course there are ethical dilemmas at play that we do not necessarily have to get involved with. Um, and those, thankfully, are rare. So I think that remove yourself from a position of decision making as often as you can and just [00:52:00] The, you know, right alongside them. Um, the very last of section is just to close the conversation. So summarizing it, making a recommendation, um, you know, affirming that you're there for them. So saying like, oh, I've heard you say that X, Y, Z is very important to you. So keeping that in mind, the plan that I think we've agreed on is this. Is that correct? Um, you know, how does this plan seem to you? And then, you know, promising what you can promise, which is I will do everything I can to help you through this. Um, I think the behind the scenes self care is like everything you can stops earlier than you think it does. And so it is very tempting to overextend because of shortcomings In institutions and you know systems that we are chosen to work in, [00:53:00] but you can't continue to be a provider if you overextend all the time. If you burn out you're good for nobody. Right. So, you know, I will do everything I can to help you through this is I will do everything within my power. That I can safely do to help you through this.  Kate Grandbois: That brings me to a question. I wanted to ask you about our third learning objective and, uh, the different tools that you use in your setting. But since you've brought up our own, the intersection of our own compassion and empathy and, you know, acknowledging that we're not a limitless amount of emotion, that burnout is real. How do you take care of your own emotional wellbeing in this role?  Meghan Holmes: I like therapy for everybody. I don't know if I can say that, but everybody should go to course. Yes, it's definitely important. Um, and I do think that. Having these kind [00:54:00] of training wheels of like a framework like this of a conversation like this, um, has made a world of a difference for me in a prior job, I was working, and I didn't have a lot of physician or administrative support. And the compassion fatigue became very overwhelming to the point that I. Had to leave that job with no backup plan and was like briefly unemployed because I was just like, I am X number of years into my career and it hasn't been that long I told you all I graduated in 2016. So I'm like, I can't believe that I already feel like this, how can I, you know, continue to work. And so finding a new setting, you know, asking in interviews. You know what types of supports are available to employees and like, what kind of experience do you guys have with these types of tough conversations and who takes lead on this type of thing. I think, can give you a lot [00:55:00] of information about whether or not that spot is going to be a good place for you. And I. I hope that there are SLPs out there who are ready and prepared to be the ones to take lead on this right out the gate, but I certainly wasn't. And so this is something that has come over time. So I think, unfortunately, being kind to yourself and giving yourself the grace to bumble through a lot of these really tough conversations is also what can help. Um, and. Yeah, I think it's mostly been a lot of boundary setting and like one other piece of advice that I got from the palliative team at our hospital. They actually they published an article about this and I think the Journal of Social Work for palliative care. They had a buddy system [00:56:00] throughout the pandemic, where they would, you know, have kind of check ins with. Hey, how are you doing? How are you, how are you taking care of yourself? And so just that kind of accountability buddy of, uh, I'm going to have to have something to say in this stupid weekly meeting, like of how I'm taking care of myself. Um, and they also, they opened every one of those meetings, um, with a moment of silence for the people who have lost that they lost. And so I think that that really helped me too. And that's something that I have done myself where you're like, Death is inevitable, but it's awful still. And so, you know, to understand that, you know, like, I hate that we're here, and I hate that I was, um, you know, that I do have to feel this, but like what a treat it was to like feel like I was able to. make the end of this person's life as comfortable [00:57:00] and pleasant as possible. Um, I think this job stops being fun if you to become jaded or, you know, disillusioned by how serious this is. And so, you know, you need to make sure that you're able to show up as your best self every day. So, I don't know if that was anything concrete, but that's what I do. I think  Amy Wonkka: it's very helpful. I mean, I think all of those. All of those tips and like strategies are important, um, therapy for everyone. Totally. But yeah, I mean, I, I think it's, it even just hearing you talk about it, it's, it's such a heavy. It's so heavy. It can be so heavy that I think having an active plan and being thoughtful about taking care of yourself sounds like it's almost required. Um, and I also think you [00:58:00] made a great point about work environment. I, I get on my soapbox of like part of the only way we're going to make our work environments better is by pushing for them to be better. And that includes choosing. To work in places that are more supportive, right? Work in the more supportive place. Be kind to yourself and like vote with your job, right? Um, in, I know we don't have a ton of time left, but I know we talked a lot about the framework tool in terms of, you know, a tool that you're using a lot in your work. I just wondered, are there any other formal or informal tools that you're using that you want to kind of give a shout out  Meghan Holmes: to? Or, yeah, I think, um, I used some of the, um, honeycomb therapy, motivational interview cheat sheet, I thought was really helpful, um, just to, again, help you realize that this conversation [00:59:00] that is probably going to take a long time, right? And this is at least, we'll say 10 to 30 minutes. And you're like, Okay. I have no idea what I'm even going to say. Okay, let me break this into how can I establish what this conversation is about. Um, how can I, um, make sure that this patient feels heard? I think one of the, one of the most helpful pieces of advice that I got from that Those principles was to reassure whoever you're talking to that, you know, they're doing their best. And it's like, it's clear that you've been working really hard to follow our recommendations. Um, I've said it to family members and like, it is clear that you have been taking excellent care of him. Because I think that a lot of the hesitation for, you know, palliative treatments, treatments focused on quality of life requires people to feel like [01:00:00] They are giving up on their loved one, or we, you know, we still have more to try. And you're like, yes, you absolutely have more to try and we still can. And also add this thing that focuses on their quality of life. This is not an either or this is an addition. Um, and so yeah, the honeycomb speech therapy, motivational interviewing. Um, I listened to, I don't. I have some counseling, um, CEUs, um, that are on another platform. I don't know if I can say that name or not, but yeah, okay. The of course you can, I'm like MedBridge has a bunch of, um, counseling courses that are very helpful. I think, um, it's funny, not with those specifically, but I think that in a lot of counseling CEUs, you start to. Or at least I kind of started to tune out too quickly because you're like, yeah, yeah, yeah, I know. And then you get into this [01:01:00] conversation. You're like, I did not know. And so you're like, listen to the whole thing. Make sure that you are practicing kind of in your head sometimes, um, that Ariadne labs framework. I also use with. You know, interdisciplinary team members and providers because I think that there is a lot of hesitancy to incorporate palliative care when the goal is life sustaining and curative treatments because, you know, the medical teams don't want to feel like, um, or the medical teams don't want to anything to interfere with the ultimate goal of that patient getting healthier. You know, kind of regardless of the cost and the lack of acknowledgement of the limitations of medicine or that there are some horrifying side effects to some of these medications that might not be worthwhile. So saying the I wish I were a [01:02:00] statement, even to Doctors has been really helpful for me where I'm like, Oh, yeah, you know, I hope they leave this hospital and we never see them again, but I'm worried that they're not going to follow this recommendation when they leave because it's so unpleasant and kind of helping to have the doctors join you in that conversation. The I wish I worry is my ultimate tool. I think that that's the most important thing that I hope your listeners take away from this is you have the power to be clear and direct and kind also, and that is the best way to do it.  Kate Grandbois: Didn't know how to do that. I am personally very much looking forward to incorporating that into my practice. Thank you so much for that list of references. We will make sure that there is a link to all of these in the show notes for all of our listeners. You've spent already a whole hour with us today. Thank you so much for being here. Are there any words of wisdom that you would like to leave our audience with before we say  Meghan Holmes: goodbye?[01:03:00]  Um, I think just be kind to yourself and whatever stage you're at with these types of tough conversations, you know, they will feel easier. They won't get easier, but they'll feel easier. I promise. Thank you  Kate Grandbois: so much for all of your time. This was really  Meghan Holmes: wonderful. Thank you. I had so much fun. Outro Sponsor 2 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.[01:04:00]

This is a transcript from our podcast episode published December 11th, 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 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 ncast.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 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. We're so glad to have everybody here. We're um, really excited to welcome a guest Jill Woods onto the show. Usually I am here with my counterpart. Amy. Amy is out today, so I am here by myself, but I am not alone and I am [00:02:00] not lonely. Welcome, Jill. Thank you so much for being here. [00:02:03] Jill Woods:  Oh, thanks Kate. It's great to be here. I'm super excited.  [00:02:07] Kate Grandbois:  I'm really excited. Um, this is a topic that I am really interested in learning more about not only for my own practice, uh, but I know before we hit the record button, we had a really nice conversation about how important it is for private practice owners to feel comfortable and confident in marketing services and how that can create a lot of feelings of discomfort. And as clinicians, we don't get any business training. So being able to discuss all of this openly with you is gonna be really, really exciting. And I'm wondering if, um, before we dive into the content, if you wanna tell us a little bit about you and how you came to be doing what  you're doing. [00:02:44] Jill Woods:  Sure. So I am a podiatrist qualified in the UK as a podiatrist in 1995, which feels like a very, very long time ago now. Um, but before that I worked in marketing and PR, so I learned old school [00:03:00] marketing and old school PR. So the real kind of in the trenches, theoretical principles and practices. Um, so when I graduated as a podiatrist and started my own private practice, I was looking around at my competitors going, oh, why aren't they doing that? And why are they doing that like that? And suddenly the light bulb came on and I realized, ah, that's because I've worked in marketing before and they haven't, and we don't get any of this training when we're trained to be, you know, whatever clinical profession we're training in. We get no training. So I ran my own private practice. I also taught, um, on a podiatry program for a few years. Uh, and then I ended up my life, literally flipped on its head and I married, uh, a soldier in the British army. And we suddenly started moving around all the time. And so clinically I couldn't practice anymore. And so I had to find something else that I could do. And eventually through lots of trial and error, I won't tell you the long boring story, but through trial and error, we, uh, [00:04:00] I ended up in a position where I had a light bulb moment and thought, hang on, I could teach the marketing stuff I know and understand and have since honed through a couple of digital businesses and a and hospitality business that I ran, I can now teach all of those skills to my fellow health practitioners. And so 10 in 2010, I started practice momentum and started sharing what I know about marketing with fellow healthcare practitioners.  [00:04:24] Kate Grandbois:  This is gonna be so great. So your practice is called. Practice momentum. And this is really your primary focus. You're no longer a practicing podiatrist.  [00:04:32] Jill Woods:  No, I haven't practiced in, I haven't, I haven't. I always say I haven't lifted a scalpel in anger in a very long time.  [00:04:39] Kate Grandbois:  my goodness. That's a very different from our clinical, our clinical perspective is speech pathologist. That's a very interesting phrase.  [00:04:47] Jill Woods:  so I, the last patient I treated I think was in 2005, so it was a very long time ago. [00:04:51] Kate Grandbois:  Okay. Okay. Well, I'm really excited to talk about this. Um, I, even, as I mentioned before, we hit the record button, we had [00:05:00] such a great conversation, and I'm even thinking now of all of the little, all of little comments and questions that I wanna ask you. But before we get started, I do need to read our learning objectives and financial disclosures.  Learning objective number one, describe the seven point marketing cycle and how to apply it in your practice to help create effective long term marketing strategies. Learning objective number two, identify the three primary marketing principles that underpin an effective practice marketing strategy to help identify gaps in your current marketing, and learning objective number three, identify three exercises to use in your practice to ensure you are attracting, connecting with, and delivering a service to the right patients.  Disclosures. Jill woods' financial relationships. Jill is the owner of practice momentum, which provides marketing services for healthcare professionals. Jill Woods's non-financial disclosures. Jill is a licensed podiatrist. Kate, that's me. My financial disclosure is I am the owner and founder of Grandbois therapy and consulting, LLC. And co-founder of SLP nerd cast. [00:06:00] 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 analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. Okay. Long, long blurb over. I can't wait to hear everything that you have to teach us. Why don't you start by telling us a little bit about this seven point marketing cycle or, or what's the precursor? What is the background information we need to have about this marketing cycle?  [00:06:35] Jill Woods:  Awesome. Okay. So the thing that I see all the time when I start working with healthcare practices is that they are doing what I call marketing spaghetti. They're literally like throwing random marketing things out there just to see if something might work. It's. [00:06:51] Kate Grandbois:  For everyone who can't see my face, I'm laughing because if anybody follows us on Instagram, it's basically spaghetti. That's exactly what it is. I [00:07:00] just, and then marketing is not my strength at all. So carry on. I just had a little light bulb moment of like, oh, that's exactly what I'm doing anyway. I'm already learning new things.  [00:07:10] Jill Woods:  So I mean, the thing that I want to say right at the beginning is you have trained as a clinician, right? You are an expert in your field. You have not trained as a marketer. Like you can do master's degrees in marketing. It's an enormous subject. So don't beat yourself up that you're not good at this thing. Okay. That's point number one. But you also now have to take ownership of it and go, right. So now what I, if I am doing marketing spaghetti, what else can I do? How can I do this differently? Um, and so what I want to do just initially is paint the picture of, um, your, of marketing and what it is so that we understand, cuz a lot of people think that marketing is just promotional. So your social media feeds your website, all that kind of stuff. And it's not, it's a huge subject. So marketing is made up of what we call seven PS. All right. We've got promotion, [00:08:00] product people, pricing, processes, place, and proof. Those are the seven PS that sit within marketing's lot time in it's a lot. It's a huge subject. So anytime you're in your practice and you're working on your pricing structure, or you're working at developing your, the product that you actually deliver, the services that you deliver, that's marketing, it's not just advertising, it's not just the promotional stuff. Okay. So as we go through what we're gonna be talking about now, I want you to understand that we are not just talking about promotional marketing. We're talking about all those different seven elements that make up the whole of marketing. Does that make sense?  [00:08:35] Kate Grandbois:  It does. It also really paints the picture. I mean, I've already let the cat outta the bag that I think marketing is my Instagram feed or that's what I did think it was. Okay. So that really does give the scope of how, how wide, how big of a topic this really is. And I'm surprised to hear that product is in there too.  [00:08:56] Jill Woods: Yeah Your product. So product development. So developing that [00:09:00] service, that patient experience that you are selling, that's part of your marketing activity.  [00:09:06] Kate Grandbois:  Okay. Interesting. Okay. Okay. Okay. Okay. Yep. I'm I'm with you. I'm here. Yes. Okay. Let's do this.  [00:09:12] Jill Woods: So for all of your marketing, you've got one single objective and that one single objective is to be famous locally for the thing you do. That's it. Okay. To be famous locally for the thing you do and everything that follows that we're gonna talk about now, hopefully will all lead back to that single thing. All right. Okay. Good. So you're with me so far.  [00:09:35] Kate Grandbois:  I'm here. I'm here. Yes. I'm I'm hook, line and sinker [00:09:38] Jill Woods:  Awesome. Okay. So we've got our seven PS of marketing, so we get how big it is. And the next thing I want to really talk to you about is this seven point marketing cycle, another seven. It's not a coincidence. I don't think it's a coincidence anyway. Um, but basically all of our potential patients who are out there in some kind of pain, whether that's physical pain, emotional pain, [00:10:00] it doesn't matter. People are out there in pain and you have the solution. So you owe it to all of those people in your local area who are struggling to get better at marketing so that they can understand that you are the person they should see for the solution to their problem. Right?  [00:10:18] Kate Grandbois:  Yes. And I am, you can see that there are words in my mouth because it's making me think of what we just talked about before we hit the record button, which is how important. How important market viability is with a science. So in speech pathology, we are providing rehabilitation or rehabilitative services to people with communication disorders. They may or may not be experiencing pain, but they do have a communication disorder of some variety. And, um, we could have the best services in the world. We could have the best, we could have a life saving intervention, but if we can't sell it to them, if we can't. Tell people how to [00:11:00] access those services. We're not helping to close that gap. Um, and I know before we started talking, I, in my nerdy ways referenced an article, there is starting to be research about this through the field of implementation science. And I'm just gonna quickly plug this article for people who are interested. There is an article called market viability, a neglected concept in implementation science, and it was published in implement in, um, implement, in the journal of implementation science in 2021. And it's by Proctor et al. I'll have the reference in the show notes, but I, I, what I what's important for me, it, for our listeners to take home aside from every, all the knowledge that you're about to share with us is that, What I learned from this article is that marketing is not icky. It does not have to give you those uncomfortable feelings. It really is providing a health related service that can improve your community. And without marketing and business savvy, you're not able to do that as effectively. And that's, that's my only soapbox. [00:12:00] This entire episode is literally all I have to offer is this one research article. So I will make sure it's listed  [00:12:05] Jill Woods:  perfect, but it, but to me in your practice, marketing is one of the most ethical things you can do because it's connecting you and your services to people in pain and, and, you know, with the speech and language patients and clients, they're not necessarily in physical pain, but they're struggling with an emotional pain of some sort because of this communication difficulty or swallowing problems. So, you know, it, it, it is important, but it to understand that it's ethical, what I'm about to tell you is not snake oil. It's not glass smoke mirrors. It's, it's how marketing can help you help more people.  Kate Grandbois: I love that.  Jill Woods: Okay. So the first thing we're gonna talk about is this seven point marketing cycle. So we've got seven points. I'm gonna go through them really quickly. And then I'm gonna go back and talk to each one of them. So you kind of understand what it is. So the seven point cycle is made up of know, like, trust, try, buy, repeat, [00:13:00] refer. Okay. Those are the seven points that sit on this cycle and every single potential patient, as they convert from being a potential patient into a paying patient, they work their way around this cycle. All right. Some of them hop maybe one step, but very few hop, big chunks. Most people go at some way around this cycle. Know, number one, know, people have to know you exist. So this means are you showing up on Google maps? Are you showing up in a Google search? Are, have you got something outside your business, your practice, your physical space that says we are in here. This is the practice and we are in this space. Okay. So people get to know that you exist. That's number one, number two. Like. They need to like you as a person. And we're gonna dwell on this a little bit further down the line, but people buy from people, especially in healthcare. Alright. And so [00:14:00] you have to, through the means of your seven piece of marketing, you have to let people get to know you as a person. All right. I'm entrusting you with my health for lots of healthcare practitioners. That means you are physically gonna be in my personal space. Like I have to like you as a person to, to entrust my health to you. All right. So that's step number two.  [00:14:23] Kate Grandbois:  There's a lot of, of intimacy when you're a clinician. Yeah. In terms of, you know, letting someone feel vulnerable, we do a lot of counseling work in speech pathology, even though we don't necessarily get training in it. So I, I think that likability carries a really, a really heavy weight anyway, continue. [00:14:36] Jill Woods:  It's it's really important. It's really important. And we're gonna talk a lot about that bit further down the line. The third one is trust, and this is, can they trust you as a clinician? So the likability is you as the person. The trust is you as a clinician. All right. So we're gonna look at things we can do in our marketing that will help us. Build that trust. So have we got videos on YouTube that show [00:15:00] before and after, you know, have we got reviews and, um, patient testimonials testimonials on our website reviews on our Google business page. Have we got that stuff there that will show that we are a trustworthy clinician? Are we talking about our CPD and our continual professional development that we're doing? So people know we're keeping with the times we're up to date, we're current, there's lots and lots of things you can do with your marketing that will help build that trust. Okay. Then the fourth thing is try, and this is missing from virtually every single practice I start working with in their marketing and try is can a potential patient try your expertise before they buy from you? Okay. So this looks like things like, have you got videos on YouTube demonstrating exercises people can do at home to alleviate symptoms. Okay. Have you got downloads on your website, information leaflets that they can download that teaches them how to prevent injury or prevent a problem? [00:16:00] Okay. So have you got a blog on your website where we can, you know, month from month, you're sharing new snippets of your knowledge, your knowhow, that's gonna help people from a distance. Podcasts. Have you been on a podcast? Okay. And done an interview to help people at a distance. And that's what the try is about. No money is exchanging hands, but you are enabling them to take a little bit of your information and try it for themselves. Nine times out of 10, they won't do it. And nine and a half times out of 10, it won't have any impact. But the fact that you are freely giving builds reciprocity. So there is this sense that I've, I've, I've got something for free from this expert. So now I'm gonna invest a bit more in learning to get to know them a bit more. Okay. Does that make sense? [00:16:49] Kate Grandbois:  I love that. It makes perfect sense. And I, I have to admit that I never would've thought of that. And even though I'm sitting here on a podcast, That makes a lot of sense.  [00:16:59] Jill Woods:  so [00:17:00] let's try then number five is by, and this is the obvious bit. This is your sales process. This is the actual delivery of the service. So the arrival, if they're coming to a clinic or the zoom call, if you're doing a virtual appointment, but the buy section is making sure that your sales and your payment operations are really slick and easy to follow and that your actual delivery of the service is up to par. So you're delivering what you say you are going to deliver in your, in your promotional marketing. Okay. Then number six is repeat. Now this is obviously there's an ethical issue around this. And I always tell the story that when I very first qualified the first practice I went to work in, we routinely rebooked our patients every six weeks. And I was like, oh, I don't need to see this patient in six weeks time. No, that's what we do here. So. Oh, interesting. I like that practice  [00:17:51] Kate Grandbois:  yeah. Yeah, because services need to be provided. I mean, that's a huge comp component of our ethical code too. Yeah. Making sure that our, our services are [00:18:00] matched to the need of the patient. [00:18:01] Jill Woods:  Yeah. So the repeat element is only where ethically necessary of course. But if people are willing to repeat, that's a really good indicator that they've liked what you've done, that you've really helped them, that you've had an impact, you know, the whole experience for them has been a positive one. All right. So we need to look at repeat, and have we got any marketing activities at all, where we are enabling that to be an easy process, can, can existing patients come onto our website and book their next appointment online really simply, you know, are there things that we can do to facilitate that repeating as long as it's ethical? [00:18:37] Kate Grandbois:  Okay. Interesting. Interesting.  [00:18:40] Jill Woods:  And then the final one is refer, and this is why it's a cycle. It comes all the way around. Cuz remember the very first thing we talked about is know people have to know we exist. And the last one before we get back to know is to refer. So we're going to see if there are ways we can encourage our existing patients to refer their friends, their family, to us, for the [00:19:00] problems that they know we can fix. [00:19:02] Kate Grandbois:  I love this, this whole cycle. And I'm sorry to interrupt you, but I'm having so many thoughts about this. A lot of what we talk about on this podcast is clinical skill. And I have to, I keep having these thoughts about how this marketing cycle, if you are in private practice and looking for ways, presumably you're listening to look for ways to improve your marketing in your private practice, but thinking about the connection between that and your clinical skills. So if you don't have patients who are repeating service or who are staying in your service past when ethically and clinically appropriate, mm-hmm, you know, That's a really good indicator that maybe you do need to look at your clinical skills or you, you know, or the component of trying, creating videos, creating materials to help people from afar. What are your clinical skills? What knowledge do you have that you can share with others? I, I think that there's a really interesting connection there. And probably once this set, once [00:20:00] this cycle is implemented, can give you some really nice feedback in terms of how you are doing as a clinician in your professional development. Just like a random little side note.  [00:20:10] Jill Woods:  Yeah, I know it it's perfectly true because as much as, you know, our clinical skills are part of our service delivery, our clinical skills and the clinical outcomes that we achieve for our patients are absolutely part of that patient experience that, that service, that product, whatever, however you wanna call it, but they're, they are part of it. But hopefully you'll start to see as we go through more of this, that they're not the only thing. Too many practitioners cling to their qualifications and their CPD and their piece of wizardry bit of kit, the fancy bit of kit that we've got. Yeah. But in fact, the patient experience is way more than that. Okay. And so this repeat concept is not, is not purely about clinical skills, but it is about your clinical skills. You've gotta be good. You don't have to be brilliant, but you've got to be good in order to facilitate this process and have good  [00:20:59] Kate Grandbois:  and have good [00:21:00] rapport that like know and trust so that someone feels comfortable, repeatedly being vulnerable. With you. I mean, even, you know, a lot of what we do requires a lot of vulnerability, but I'm thinking even as my experience, as a person, having gone to PT for my knee, you know, I'm laying on the table, my I'm in these weird gym shorts, you know, it's, it's not, I'm a patient in a clinical setting. Yeah. So I think all of us as humans have had that experience where we're feeling a little bit more vulnerable and wanting to make sure we're cultivating environments where the patient does feel  [00:21:29] Jill Woods:  comfortable. Yeah, absolutely. And this whole cycle, if you kind of. Stop and go back and re just quickly whiz back around this cycle, getting to know you exist to like you as a person, to trust you, to try your expertise, to buy from you, to repeat and to refer people to you. It's all about relationships. Your whole business is founded on that relationship that you can nurture from the minute they spot you on Google or the minute they walk past your premises and see an, a board outside or the minute they see you doing a [00:22:00] presentation at a local health group or something from that moment, you are curating a relationship with those people. And this process facilitates that building and nurturing from no somebody who doesn't even know you exist all the way through to being an absolute advocate and referring patients to you.  [00:22:17] Kate Grandbois:  Interesting. Well, I didn't know. I had heard the like no and trust. Okay. But the rest of that cycle was totally new to me. I mean, I'm not saying that I have implemented any of those things. Or I'm good at any of them necessarily, but, but that seems that the whole seven point cycle seems so comprehensive. Yeah.  [00:22:36] Jill Woods:  And the thing to, to understand is that to move somebody from 0.1 to 0.2, two to three, three to four, and so on, you've got to have marketing activity of some kind so that you've got, there could be gaps. We're gonna talk about that later, but you need to make sure that you've got a system and a process so that you are facilitating that progress around the cycle.  [00:22:59] Kate Grandbois:  Yes. I [00:23:00] can see unpacking each one of those points and needing to make multiple procedures or processes to support each one of them separately. [00:23:07] Jill Woods:  Yeah. And it, and, and you know, you, we are gonna talk about the safety, but don't overthink it. Like there, there, there's, there's simple ways to do this. You don't have to be flogging yourself, mercilessly with marketing to make this effective. Okay.  [00:23:20] Kate Grandbois:  Okay. I can do better. I'm here. Okay. Let's keep going. I'm learning  [00:23:24] Jill Woods:  so much. It's great. Yeah. Okay. So the next thing I really want to impress on people is the three kind of marketing success principles. These are the things that people, again, people come to me and say, Jill, can you teach me how to use Twitter? Can you teach me what to do on Instagram? What do I need to put on my website? They, they they're jumping. They're so far up the curve of marketing activity. They've missed some of the fundamental basics that you need in place before that stuff will succeed. Okay. Okay. So these three success principles are really part that they're part of that foundation to make sure people have got it [00:24:00] before they start wasting time, money and energy on marketing that is not gonna achieve their aim. All right. So your three marketing success principles are number one, clarity, number two, the human and number three consistency. Okay. Okay. So I'm gonna go back through and then unpick each one of those. So number one, clarity. So there are three things that you have got to be really clear about before you start paying money for Facebook ads. And before you start rebuilding your website. A- what do you want to create? Like, what is the practice you want to build?  [00:24:44] Kate Grandbois:  That's such a good question. It's like a vision board kind of question.  Jill Woods: That's it. Kate Grandbois: Right? I mean like, what is your big picture?  Jill Woods: Correct Kate Grandbois:  goal. Yeah. And I assume that has many, many facets. I mean, everything from the customer patient [00:25:00] experience to professional workplace culture, to  [00:25:04] Jill Woods:  how much money you want to make, how much time uou want to work each week?  [00:25:09] Kate Grandbois:  Yes. Oh my gosh. There's so many questions there. [00:25:11] Jill Woods:  Yeah. What kind of building do you want to work in? What kind of colleagues do you want to work with? Do you want to be in a multidisciplinary practice? Do you want a single disciplinary practice? You know you, but if you, as you go through building a business, you make decisions every single day and you should be running every single one of those decisions through a couple of filters. And this is filter. Number one, is it moving me towards what I want to create? Or is it moving me away from what I want to create? But in order to ask that question, you have to know what it is you want to create.  [00:25:44] Kate Grandbois:  I feel like I need to have someone embroider that quote on my office wall in my office because as a business owner, the, the phrase that we use internally here is it's so easy to get distracted by the shiny penny or a great [00:26:00] idea, or, you know, something that is exciting to you, but not moving you towards your goal and keeping you focused. And if you are listening out there and you are a private practice owner and you've experienced this, you are not alone. I am the shiny penny. I'm constantly chasing the shiny pennies and needing to be reminded to stay focused. I love the way you framed that about putting those thoughts and decisions through a filter related to moving towards your goals. I think that's such a great perspective.  [00:26:29] Jill Woods:  Yeah. So, so that's really where you need to start. If you are currently throwing spaghetti at the walls, Stop breathe. Number one, what's your vision? Where are we going? What are we trying to create? That's the first bit of clarity that you need. The second bit of clarity and this freaks quite a lot of cl clinicians out is who is your dream patient? Kate Grandbois: Interesting.  And I'm saying this in a singular, not patient patient, who is your dream [00:27:00] patient. Okay? Because if you are going to build a practice that serves you as much as it serves your patients and as clinicians, we're hell bent on helping other people and not helping ourselves. So this is the point in the conversation where we start talking about what do we want? So if the, the patients that are coming into our practice are going to be our dream patient, a life is gonna be much nicer. Much happier, much easier, much, much more flow to it, much more relaxed, much more may be potentially much more, um, uh, effective because they, these might be patients who are coming with very specific pathologies that we're excluding everybody else, because we really want to see these patients with a very specific pathology. Now in the UK, I work with a speech language therapist and she, we was like, she threw her hands up when I asked you this question, I,  [00:27:54] Kate Grandbois:  I was gonna say, I was gonna say this. I can see how this gives people very uncomfortable feelings. Yeah.  [00:27:59] Jill Woods:  So, but we, Kate Grandbois:  are you [00:28:00] gonna talk me off the ledge? Sorry.  Are you gonna talk me off the ledge? Jill Woods: Yeah. totally so we, so we talked through this process and we went back really deep. Like what, which, if I said to you, here's a, here's a, is a roster of all of your patients and you just quickly scanned the names. Which name would you stop at when you thought? Oh, they're brilliant. I love them. I love when I get to go and see them. And when I work with them, Because that's gonna start giving you clues as to who your dream patient is. Okay. But by the time I'd finished working with Ruth, she'd gone from, she wasn't. She had said she was gonna be an adult speech and language therapist, but by the time we finished and her, I want to tell you, her practice is really thriving. By the time we finished, we'd narrowed that down to stroke, adult stroke survivors, with speech problems, she wasn't interested in swallowing. She just wanted to do speech problems. So she now specializes it and they [00:29:00] were at least 18 months post-stroke. So all the ones that a lot of therapists had given up on, she was that the clinician for those people. [00:29:10] Kate Grandbois:  Okay. I, I hope do I hope we have time to sit and unpack this for a second because I have a lot of, I'm having a lot of thoughts and feelings on I'd like, I, I wanna share them with you. So. I'm thinking first and foremost, about the first of all in our profession, we're often expected to be generalists. So we are expected in a school setting often or in an outpatient hospital setting to treat what walks through the door, treat who's on your caseload. We're expected to be expert. Our scope of practice is incredibly wide. And we talk about that on this podcast a lot. When you're in private practice, you have a little bit more control over your caseload, but I have to assume that these uncomfortable feelings are either rooted in the expectation that we are generalists or [00:30:00] in feeling that it is unethical to turn someone away who needs our help. Jill Woods: Mm-hmm .  Kate Grandbois: So how do you navigate that discomfort with ethics? I know when I first started my practice, I remember getting worried that if I turned someone away, they would sue me for some sort of discrimination against, you know, not providing a service that I was qualified, quote, qualified to provide. I mean, now as a more seasoned clinician, I understand that scope of competence is really important and I cannot just treat everything regardless of whether or not it falls under my license. But what is the advice you have for anybody listening, who is having that moment of discomfort, because they want, they feel that they're ethically obligated to treat everybody who gets referred to them.  [00:30:42] Jill Woods: Yeah. So there's, I think there's two things here. There's the personal feeling of, I just wanna help everybody and there's the, the, the ethical piece. So I want to just backtrack a little bit. So the way that you choose your dream [00:31:00] patient, it doesn't have to be through a clinical pathology like Ruth did. It can be by its person type. So again, let's, let's, let's helicopter above your practice and let's look at your marketing assets. You've got a website, you've got a social media profile. You've probably got a, a premises of some sort. Maybe you are going out and doing talks and all the rest of it. Maybe you've got a blog on your website. You've got all this stuff going on. I am a patient and I come to your website and I've got about 10 seconds before I decide I'm in the wrong or the right place. Now, if you are trying to make the homepage of your website attract everyone, it's gonna fail miserably. Okay. You can. This is a fantastic Seth Godin is a marketing God. And he has a quote that says if you're marketing to everybody, you're marketing to no one. [00:32:00]  Kate Grandbois: Interesting.  Jill Woods: Okay. So that's, that's kind of point number one is that you don't have to go by, by pathology. You can go by person type. So what I mean by that is, for example, you might say, actually, I want to target young moms who are inexperienced, maybe it's first child, they're nervous about development, developmental issues. That's gonna be my target audience. Okay. And if you do that, then I can make the homepage of my website really resonate with that woman. I can make my social media profile resonate with that woman. I can make my physical surroundings resonate with that woman when she walks in the door. It doesn't have to be pathology specific. It can be person type. Does that make sense and answer that question [00:32:48] Kate Grandbois:  does it does. I'm not sure I'm feeling any less uncomfortable  [00:32:52] Jill Woods:  anxious. Okay. Two, the two other things,  [00:32:54] Kate Grandbois:  keep going, keep going. I know you're gonna get  me there. [00:32:55] Jill Woods:  So ethically let's talk about ethically and ethics. [00:33:00] So in medicine, who are the people in the senior positions in your industry? Usually they're the people that specialize. Okay. They're the people that specialize, and those are the ones who are respected in their industry. They might be hospital consultants. They might be private consultants. They might be surgeons. They might be whoever they might be. But usually those people have specialized in some area of clinical practice to, to become super good at that very small thing. Mm-hmm okay. Those are the people that we really entrust with our health because they've become specialist mm-hmm , they are day by day, turning away patients that are not their niche market. If you wanna put it into marketing terms  [00:33:50] Kate Grandbois:  you're right. I’m just realizing that. And that's not, I think the only thing that makes it feel uncomfortable is because it's through the marketing lens, but that's absolutely true [00:34:00] of all aspects of medicine. I do not go to a knee doctor for my elbow pain. Jill Woods: no, the weird analogy, but you know, no, no, but it's you get the idea? Yes. Yes.  Kate Grandbois: You're absolutely right. Okay. I keep going, keep going.  [00:34:13] So I've just had some, some dental work done. I had an abscess behind a tooth, so I went to my dentist and my dentist said, Nope, not my bag. You need to go and see an endodontist. I went to the endodontist and they said, Nope, not my bag. You need to go see a Perry penny, anywhere that one of them, the other dentist. And eventually I got to the right person who specializes in opening a gum up and taking all the gunge out and all of that stuff. Like I would not entrust that procedure to my dentist. Yeah,  [00:34:43] Kate Grandbois:  yes. Okay. I see it now. And I think that this is very, this perspective is very complimentary to what we talk about clinically all the time about your scope of competence, that if you are interested in developing a specialty and in speech pathology, we have many, because our [00:35:00] spoke scope of practice is so wide. And I often talk about how I'm an AAC specialist, and I always put it in air quotes, cuz it's just a, an area of clinical specialty, not necessarily a certification. Um, but I'm no longer qualified to treat someone with a stutter. I haven't treated someone with a, someone with a stutter since I didn't even do it in graduate school, through my clinical placement. So there is a component of ethical behavior. When you are, in other words, when you first started this conversation, it felt, it felt uncomfortable, but it's actually more it's as you spin it through a clinical competency lens. It's more ethical to turn people away who don't fall within your targeted scope of competence than it is to market and take everybody and put everyone on your caseload. Jill Woods: Correct.  Kate Grandbois: So that makes a lot of sense.  [00:35:50] Jill Woods:  Okay. So you're feeling like you were step back to the ledge now?  [00:35:54] Kate Grandbois:  Yes, I'm, I'm I'm way back from the ledge. Okay. And I see a beautiful view. It's a beautiful vista way back from the [00:36:00] ledge.  [00:36:00] Jill Woods:  So the final element of this is if we go back to the marketing, so we've kind of got over the, the clinical thing. We go back to the marketing. If you imagine three concentric circles, um, there's a red circle and then outside that there's a white circle and outside that there's a blue circle. Okay. In the, in the UK, that's our rural air force signature, um, insignia. But they're in the red circle. These are your dream patients. They're in the middle. Okay. Now, if you start building a clinical experience, you hone your clinical skills to serve these patients, patients better. You make your website attractive to them. You think about them on your social media and your Google profile. You're gonna start to attract more of those, those patients. Okay. But what happens? We move out to the white circle. You're going to attract patients who are a lot like those patients too. And the people in the blue circle are people who are quite like those patients. So you're gonna attract them too. So you are not, it's focusing on [00:37:00] one person is not at the exclusion of absolutely everybody else. But what you are doing is kind of pinning your colors to the mast and saying, these are the patients. I get good results for. These are the patients I enjoy seeing these are the patients who, you know, get a good for me, good for my business. And what I can do is good for them.  [00:37:22] Kate Grandbois:  That's what I was gonna say. Those are the people that you serve best. Those are the people that are, that's the word I was looking for are best matched to your clinical yes. Products. I mean, I, to just, what's so interesting about this is it's so much of what we already know and do it's just reframed with different vocabulary. Yeah. Yeah. So instead of targeting a customer, we would say, you know, tar a target patient, we would say. Someone who within with a clinical presentation within your scope. Yeah. Or within your area of clinical expertise. Yeah. But it's the same, it's just a different spin.  [00:37:53] Jill Woods:  Yeah. And so, and so ethically you are the best, you, you are the best person to treat this patient, but you are [00:38:00] not the best person to treat that patient. Therefore you should be referring that patient on. You shouldn't be seeing some of those patients in your practice. And you probably do that already. You know, you might, if you get a stutter patient, you might say, no, that's not my bag that, but, but I know somebody who can help you. Yeah. Here's a quality referral. I'm not just shutting the door in your face. Here's a quality referral. Go and see. So and so, and they, they will be able to help you. So it's I, oh,  [00:38:24] Kate Grandbois:  I feel so much better. I feel so much better. yeah. Cool. Good job. high five. [00:38:29] Jill Woods:  OK. So, so you, you need to identify that one person. And I always say to my patient, my, my clients give them a name. So every single time you are doing something with your marketing, you're saying, would Jennifer like this, would this work for Jennifer? Would this help Jennifer? And you're thinking about doing more CPD. Yeah. And that's exactly it. I get some of my, some of my clients are mad on Pinterest and I get them to set up a Pinterest board for their per, for their dream patients. And you can put their car and their house and their holidays and their [00:39:00] kids and their husbands and oh, and you can build a real picture of who this person is because the more, you know, and understand them the better here's your second filter, the better your dream patient filter becomes. Okay.  [00:39:14] Kate Grandbois:  Okay. So what's the second, the, the first filter just to recap is the first filter is, is this decision moving me towards my goal? And what's the second filter? [00:39:23] Jill Woods:  Would this help or serve Jennifer? Would she like it? Would she appreciate it? Would she prepare to pay for it? Does the dream patient filter.  [00:39:33] Kate Grandbois:  Okay. Your, so does what I'm is what I'm doing, going to help my avatar, my dream patient,  [00:39:37] Jill Woods:  correct. Or serve them better. It doesn't have to be help in a clinical term. It could be, am I moving to new premises that's got better parking, you know, that would serve them better. Do you know? It's a wider picture than, than just the clinical stuff?  [00:39:50] Kate Grandbois:  Yeah. Gotcha. Yep. I see it. Okay. I see, I see the whole vista. Yes, I think. [00:39:54] Jill Woods:  Okay. So, and then we've kind of overlapped with the third bit of clarity, but the third bit of [00:40:00] clarity is how do I help them? So clarity, number one, what do I want to do? What's my big vision, clarity, number two, who is my dream patient and clarity, number three, how do I help them? And this is where you start looking at that wider patient experience and saying, am I running my appointments at an appropriate timeframe? Are my clinical facilities appropriate for them? Can they easily get their buggies or the strollers in or whatever it might be. You, you, you are looking to serve that per that patient better. Okay. Okay. And so that is your third bit of clarity. How do we best serve these people?  [00:40:35] Kate Grandbois:  And when you are, out, out of those three is one more important than the other, or do they always go in that sequence? [00:40:42] Jill Woods:  Um, I would, I would personally always put 'em in that sequence because until you are clear about your big vision. What you want to achieve with the practice who your dream patient is, is not gonna be obvious. And then once you, if you don't know who your dream patient is, you can't say how you're gonna serve them. So they need to come in that [00:41:00] order. Okay. You can't say how you're gonna serve somebody. If you don't know who they are, what they likes and dislikes and yep. You know, and it's down to things like what magazine before COVID what magazines have you got in your waiting area, you know? Right. You would choose those based on who your dream client is. [00:41:17] Kate Grandbois:  Interesting. This is a really important filter. Yes. Okay. You know what, the next I go. The next time I go to the PT office. The next time I go to the endodontist or wherever I'm going, I'm gonna be looking around and wondering if I'm Jennifer.  [00:41:33] Jill Woods: Exactly, exactly, Exactly. All right. So, so hopefully that's clarity makes sense. Yes.  [00:41:40] Kate Grandbois:  Yes, it does. I'm here.  [00:41:41] Jill Woods:  Yep. Clear. Okay. Um, so once you've got that clarity, then you can move onto the next bit. And the next bit with the next kind of marketing success bit is to be human. All right. And this is super simple. People buy from people, especially in healthcare, we're invading people's space. We're asking them to be intimate and, [00:42:00] and, and, and, and, um, vulnerable with us. So this is really important. And I see too many healthcare practices who their, their profile picture on Instagram is their logo guilty. Yeah. I wanna see your face. Like, who am I gonna see when I come to the practice? All  [00:42:17] Kate Grandbois:  right. What would you say for practices though? Who have multiple clinicians working for them? [00:42:20] Jill Woods:  That's amazing. You can do some really fun stuff. I've got a, I've got a, as an example, I've got a fantastic photograph, which was taken at a, in a surgical unit and they've basically got a surgical light above them and they've all stood around in a circle and it's a circle photograph of all their heads in a circle with the light in the middle. It's stunning. It's really, really,  [00:42:40] Kate Grandbois:  oh, that's beautiful. So including your staff, including. Multiple human aspects of your business. [00:42:46] Jill Woods:  Yes. Oh, you can do fun stuff. The other one that I've seen that's really good fun is they've got, they've taken a picture on a timer thing and they've got, they've got all their staff out at sunset and they're all just stood in a line and it's just their silhouettes, but they're [00:43:00] real,  [00:43:00] Kate Grandbois: so nice. But they're people they're not a logo [00:43:02] Jill Woods:  is the real people. Yes. Okay. Starting to remember, it's all about relationships. We need human connection to build relationships.  [00:43:09] Kate Grandbois:  Yep. Oh man. I'm failing in this bad. It's okay. It's a learning moment. We're here. Yeah.  [00:43:13] Jill Woods:  This is why we're here. Okay, good. So don't hide behind your logos and also be, be prepared to share a little bit of you. Remember people got to like you as a person. Okay, so share a little bit about what makes you tick? Are you a dog owner? You know, do you like yoga? Do you, what do you do? Like crafting for a hobby? Do you love gardening? Do you go hiking? Do you, are you ski? Are you adrenaline junkie? Are you, are you, are you, are you a, and any of those things that you feel you have in common with Jennifer, those are the things that you should be talking about because that's gonna pull more of those Jennifers towards you. It  [00:43:52] Kate Grandbois:  also goes, this is so funny. It's like world's colliding because we've talked about this recently on an episode, [00:44:00] funny enough about stuttering and how important it is to let down some of those boundaries and be a human in therapy to create safe spaces for people to have more improved therapeutic interactions. And so again, here we are, it's the same, but through a marketing lens and how important that is for your entire practice. I I'm, my I'm having little brain explosion emojis happen as you're, as you're talking about all of these things.  [00:44:30] Jill Woods:  Awesome. That's exactly why we're here. Why are we doing this? So, so it's it's so it's super important to be prepared. You are asking your patients to be vulnerable with you. It's very important that you, to an extent can be a little bit vulnerable with them. All right. At the outset, even before you've met them. So some of the stuff you put on social media, here's me on a dog walk, first thing in the morning, look at this gorgeous sunrise, you know, all of that kind of stuff, or, oh my God. I just dropped the box of eggs all over the floor. Who else has done that when you've the fridge? You know, [00:45:00] just some of those little honest snippets that give people insight into who you are as a P excuse me as a person. Okay. Right? Yes. But this comes with a warning.    Kate Grandbois:  Oh, oh God. Okay. Okay.  Jill Woods: You ready?    Kate Grandbois:  I'm ready. Jill Woods: The home page of your website is all about the patient. Not about you,   Kate Grandbois:   right. That make sense.  Jill Woods: Okay. Because I, Jennifer, I come to your website and on your website, if you're talking about me, be, if you're talking about your moms, toddler tantrums, pathologies that you I'm as a new mom worrying about, right. I am in, I've come home. I'm in the right place. If I land on your website and all you are telling me is about, I've been qualified for 27 years. And I did my first degree at such and such a university I'm out of here. I'm going somewhere else.  [00:45:53] Kate Grandbois:  Yeah, man. I really got, I have a lot of work to do  [00:45:55] Jill Woods:  okay. Thoughts? Thoughts.  [00:45:58] Kate Grandbois: This is great. No, it's so important. [00:46:00] I think. And, and again, going back to where, who, how we were trained as clinicians. So thinking about to my graduate school experience, not only was I told explicitly to keep boundaries with patients and tell them nothing about myself. Yeah. I was also told that I was the expert and that I, you know, I, I was the one who knew everything. And now as an experienced clinician that nobody wants to hear about those things that just says nothing but ego. It has nothing, but there's no human softer element to that at all. And so when you, again, just looking at this theme, the same things that we always say clinically, but through a marketing lens, How important it is to connect with your patient and say things that are clinically relevant, but not, I know everything look at all my degrees, look at all the training I've had. That's not, you're right. That's not helpful. Cause it's, it's not, it's not humble. At all.  [00:46:57] Jill Woods:  There's a place for [00:47:00] that, but it's not the homepage of your website. Interesting. Okay. Okay. You know, absolutely. If you are, I mean, it's hard work getting a clinical qualification, like you've got your certificate in a big frame on the wall, take a photograph of that and share that on your social media, but don't put it on the homepage of your website and don't ram it down people's throats, you know? Right. It's yes. Painting. It's those gentle strokes that paint a picture.  [00:47:23] Kate Grandbois:  Another quote, to be embroidered on my wall. I'm gonna have to start writing these down [00:47:29] Jill Woods:  alright so, so, so you, so we're getting a bit sidetracked, but your about your home page is not about you. It's about the patient. Okay. Your about page is where you tell people about you. Okay. Okay. So the, the key with your about page is this, this a few things, first of all, each of those paragraphs that are about you, about the person you work with about your receptionist, about, about, about, they should be written by that person in the first [00:48:00] person. So I, me, my not Kate, this Kate, that Kate, the other. Okay. Okay. And the skill in doing this is to write, get them to write it and then read it aloud. And when they read it aloud, does it sound like them speaking. Or are they using long flowery words that they would never use in conversation. Okay. Okay. Try and make it as personal as possible on that page. So about sections written in the first person by the person, some really great photographs. That's not just you in your polo show or your uniform or whatever it is you wear in clinic, but it's you walking the dog or it's you like being mom taxi to, you know, four teenage kids. You don't have to put your kids in the photographs, but just that whole right. Paint that picture. What have you got in common with Jennifer? Paint that in some pictures that are on your, about page, on your website. Okay. Okay. Um, and keep the qualifications to the end. [00:49:00] Absolutely put them in that section, but people don't really care so they can just go at the end people. What here's a, a rabbit hole. We just go down another rabbit hill very quickly. What people care about is I have a problem. I want that transformation. They don't give a what comes in the middle. Okay. If I can see that you understand my pain and I can see that you've done this for other people, and you've created this transformation for other people in my similar situation, then I'm gonna invest a more time in getting to know you better. Okay. So the qualifications and stuff are, are nice to have, but in that initial engagement, they're not essential. Okay. So they can be on the about section, but they can be at the bottom of your blurb, like, oh, by the way, you know, I've been qualified 27 years or whatever it might be. Okay.  [00:49:52] Kate Grandbois:  Right. Exactly. Jill Woods:  Does that make sense?  Kate Grandbois:  You're qualified for 27 years. Doesn't mean you're a nice person or you're in somebody or you're in a good clinic. You're comfortable, right? [00:50:00] Exactly.  [00:50:02] Jill Woods:  You know,so does that make sense? Kate Grandbois:   It does. It makes perfect sense.  Jill Woods:  Okay, awesome. So then just another couple of things about that, this being personal videos, if you, if you're brave enough to do videos, videos are a great way of connecting with people. I can look you in the eye. I can get a sense from your body language, your vibe, your energy, all of that stuff comes through on video. So video's a great marketing tool to use. If you are comfortable in front of the camera, if you're just gonna stand there and read really rigidly from a note like this, it's not gonna serve you at all. All right. You've got to be somebody who's comfortable in front of the camera and you can learn that that's not, that's not inherent that you can learn that stuff. So that's fine. Okay. Um, and just, just remembering all of this, people have got to get, decide if they like and trust you. So you need both elements, clinical and personal. Make that combination work. Okay. Yep. Right. So that's number two. And then number three, the marketing thing that you must must, must get right. Is [00:51:00] consistency. And this means two  [00:51:03] Kate Grandbois:  things, no spaghetti.  [00:51:04] Jill Woods:  It means no spaghetti. It means no spaghetti um, but it means two things. You need to be consistent with your branding. We've not talked about branding at all, but you need to be consistent with your branding. Now, remember back at the beginning, I said, your objective is to be famous locally for the thing that you do. So your branding has two elements to it. It's got visual branding, which are your colors, your logo, your fonts, all of that stuff that you use consistently, hopefully. Um, and then you've also got your brand messaging and these are your strap line that you use everywhere. You create a value statement that you use as your bio on every single social media profile. Every time you write something you include that strap line or a bit from your bio repetition, repetition, repetition. Think about the big brands and they are constantly running ads that just share one thing over and over and over and over. [00:52:00] I'm thinking of  [00:52:00] Kate Grandbois:  Nike. Just do it.  [00:52:02] Jill Woods:  Correct. That was exact, it's a perfect example. Perfect example. Interesting. Okay, so you've got to show up consistently with a consistent message. Okay. In order to be famous locally for the thing you do.  [00:52:15] Kate Grandbois:  Yeah, we can do that. I'm thinking about all the listeners who are listening and I'm here by myself. I'm thinking it. I mean, there's just, there's, you're just, you've got so much wisdom and I'm, this is like, I, I need to be furiously taking notes about all of these things, but I love that. I think that the consistency piece is so simple, but maybe so hard to do so.  [00:52:33] Jill Woods:  And, and it is hard, but I've got, I've got a little get out of jail free card. So, so consistency, first of all, get consistent with your branding. Before you start running Facebook ads, before you start building a new website and before you do money, time and energy into all the other marketing stuff, get consistent with your branding so that all the stuff you do going out is gonna be accurate. It's gonna work is gonna talk to Jennifer. It's gonna do the job you need it to do. [00:53:00] Okay. Okay.  [00:53:01] Kate Grandbois:  Okay. I can do that. I'm feeling very motivated.  [00:53:03] Jill Woods:  And the second, second, the second bit of consistency is actually showing up. Right [00:53:08] Kate Grandbois: . You mean like showing up to work [00:53:09] Jill Woods:  with this is with your promotional marketing and with your PR your, um, uh, project development and all of that other stuff. Okay. So, but as an example, with regard to your promotional marketing, there's timelines to marketing. So if I say to you, are you showing up on social media every day? Okay in your practice, are you sharing something on social media every day, quick sideline, if you know Jennifer, you know which social media platform she's on. Just use that one platform scrap the rest. Okay. Interesting. Don't waste your time, money and energy going down all the Facebook or wherever all those other rabbit holes. You only need the platform where the eyeballs of your dream patients. Okay. Okay. So are you showing up social media daily? Are you showing up [00:54:00] on your Google business profile weekly and sharing new content on there on a weekly basis? Are you sending out email communication to your patient cohort and your potential patients on a monthly basis? Are you creating some kind of new content on your website or on your YouTube channel on a monthly basis? And are you going to live events quarterly? And are you maybe running some bigger marketing campaigns once every six months, those kind of timelines, you need to start showing up consistently with a consistent message. [00:54:32] Kate Grandbois: That makes a lot of sense. Yeah. Yes. I mean, it's, I, I can, okay. I can feel a lot of the, the energy and time requirements, but I can also see how necessary and how beneficial that could be. [00:54:45] Jill Woods:  Yeah. So the, and again, this isn't, there's an order to this. So start with your branding, get your brand messaging and your visual branding done, sorted, done, and then move on and start showing up and, and commit to showing up and [00:55:00] start at the bottom of that list. So start, but I commit to posting something daily on social media. Okay. Or I, if you, if you are already doing that, go up a level. Okay. I commit to posting weekly on my Google business profile. Okay. If you're already committing to that, what's the next one. I commit to monthly getting in touch and communicating with my patients via email. Okay. And you just work your way up that, that, that sort of ladder, if you like. Okay. Mm-hmm now the thing here is you do not have to do this all you can outsource. You can delegate. This is not all on you. Right. As long as I can still see your face and I can potentially hear your voice in your marketing, it doesn't have to be you doing the doing  [00:55:44] Kate Grandbois:  right. We like to delegate. We need to embrace delegating de delegation, our in a small private  [00:55:51] Jill Woods:  practice owners and outsourcing and outsourcing. Yes. Because outsourcing is gonna get you, um, people who know what they're doing, they're [00:56:00] skilled at that thing, whether it's Instagram or whether it's video editing or whatever it is, mm-hmm And you can find people who will do that for a fraction of the price. So outsourcing is perfectly doable within the budget that you've already got. Like, you can start somewhere with some of this stuff.  That tho those that's my seven, um, my cycle of seven elements of marketing and the three founding principles of marketing that are gonna make sure that your marketing is effective.  [00:56:29] Kate Grandbois:  That all sounds, it makes perfect sense. And I'm, I'm looking at our learning objectives and wondering how this ties into the exercises or, and I assume those are like action steps. [00:56:39] Jill Woods:  Yes, absolutely. Yes.  Kate Grandbois:  Okay, good.  Jill Woods: Yes. Okay. So number one. So I've got three, three kind of actions or exercises or action steps for you that you can have a go at doing. So, number one, not surprisingly, probably is gonna be to create your patient avatar. Okay. To literally get a cup of [00:57:00] tea, cuz I'm British. We drink tea, but doesn't matter. Get a cup of something coffee. If you're American, get a cup of tea, get a blank piece of paper. And just sit quietly with no distractions and start to think about who is this person who is the person that I can serve best? Who is the person that I can enjoy spending time with? Who is the person I'm gonna get good clinical outcomes from? Who is the person I can connect with on a personal basis? Who is that person? And just with a blank sheet of paper, just start writing, write random stuff that comes into your head. Who is she? Who is he? What do they do for a living? Do they have a family? Are they married? Are they not married? Do they? Where do they live? What kind of house do they live in? What hobbies do they have? What blogs do they read? What podcast do they listen to? You know, just, just brain dump, all of this kind of stuff onto, onto a page. So you're starting to really scratch the surface on this person so you can understand them.  [00:57:58] Kate Grandbois:  Okay. [00:58:00] And that, I mean, I, I would imagine that this exercise is critically important for your second filter. Right? I mean, all of those steps that you've taught us through, because you can't ask whether or not something you're doing helps, Jennifer, if you don't who Jennifer is.  [00:58:14] Jill Woods:  Correct. So that's, that is the first thing I would encourage. If you've never done this before, there'll be some resistance. Often clients are like, oh, can I not have five? No, you get one, you can have one dream patient and you need to get, literally get inside their head and learn who they are. And you can lit, you can do it with a piece of paper and a pencil. And just some time to figure out who this person is. And once you know her or him or them, it doesn't matter. You can then use that information to make sure that your, your, your, your promotional marketing, your product development, everything can be run through that filter so that you are going to become famous locally for the thing that you do, because you are serving that person with real intent.[00:59:00]  [00:59:00] Kate Grandbois:  Okay. I, I love how all of these things come full circle. Yeah. It's like magic. It's all connected.  [00:59:07] Jill Woods:  Any you just thought I might have planned this? Maybe.  [00:59:12] Kate Grandbois:  It's not like you do this for a living or anything. of course.  [00:59:15] Jill Woods:  Okay. So that's, that's, that's kind of like that's number one. That's the, the activity number one that you can go away and have a go is really spend some time getting clear on who that person is, because that is really gonna serve you well, going forward. All right. Okay. And I say, you can, you can be specific about the person and or pathology. It's entirely up to you. You get to choose.  Okay.  [00:59:35] Kate Grandbois:  Okay. Okay. Action step number one. I can do that.  [00:59:38] Jill Woods:  Yes. Okay. Number two, we're gonna run an audit for personality and human touch [00:59:47] Kate Grandbois:  love it. Like looking at your own goodies. Jill Woods: Yeah. Kate Grandbois: Oh boy.  [00:59:51] Jill Woods: So we're gonna look at your website. We're gonna look at your social media. We're gonna look at your very first [01:00:00] patient email. What's the very, like, what's your welcome email that you're sending out to your patients. Are they, do they get a sense of you or is it really formal?  [01:00:08] Kate Grandbois:  Well, well, as of this moment, they don't get one at all. So maybe that's something I have to do too. I hope everyone listening is having many of these light bulb moments so that I don't feel so alone and vulnerable as I sit here and learn with you. Anyway, move on. [01:00:20] Jill Woods: . You are, you are not having done this for over 10 years. I can guarantee you are not alone. Not alone. [01:00:27] Kate Grandbois:  It's like email. Whoops. Okay. Just  totally forgot. [01:00:28] Jill Woods:  So, or this, so this is gonna blow your mind then. So your new patient information pack. Yep. Okay. That is, does that feel personal? Can I see a photograph of you in that information pack, whether that's digital or a paper thing that you're sending out in the post and new patients, you know, so you need to audit all of those kind of touches that you are doing in your marketing and see, is there, is there an element of personality. Okay, because don't be afraid to, to share some of your personality. If you [01:01:00] are a bit hyper like me, all right. If you, if it's not there at the moment, but if you'd have gone to my website, literally a few weeks ago, the, the picture on the front page is me hula hooping in a field like, you know, that's me, that's, that's kind of like who I am and I'm not hiding behind a stiff shirt and a, and high heels and being very corporate marketing. Like you get who I am in my business. Right, right. That's so important. So run an audit of what you are currently doing. And the two kind of elements you're looking for are personality. And human touch. So human touch is, can I see you? Can I hear you, but also personality. Am I getting a feel that you are fun, that you are relaxed, that you are outgoing or that you are a details person or that you are into your research, and that's a big thing for you doing research based medicine. What, it doesn't matter what it is, but you need to be starting to portray that in your marketing.  [01:01:55] Kate Grandbois:  Yep. Yeah. I can see how all of that is connected to all of the things, [01:02:00] all of the filters, all of the mm-hmm the, the foundational perspectives. Yeah. Makes a lot of sense. Okay. All right. Well, you've given us two action steps. I haven't done either of them. And I have, I have with the third one I'm dying to know.  [01:02:13] Jill Woods:  And the third one we've already touched on the third one, but the third one is to look at, um, your, the list of consistency, consistent marketing and commit. I would love if everybody listening to this podcast in the comments. Could leave a comment that basically said today, I commit to and commit to one of those levels of marketing. Okay. Because it's that commitment to consistency. So is, is it gonna be every day, every week, every month, every quarter, every six months. What, on that scale, can you, are you going to commit to put it in the comments? Kate. I'm sure we'll watch. I might look I'm  [01:02:58] Kate Grandbois:  and I thought you were gonna say, [01:03:00] I'm gonna have to comment.  [01:03:03] Jill Woods: I'm gonna come I'll I'll come back. And now what people doing, but, but, but it, you've got to start being consistent. And the only way you're gonna start being consistent is to make a commitment. Now, whether you make that commitment to Kate and I, or whether you make that commitment to somebody else in your practice or somebody in your family or your best friend, it doesn't matter, but you need some accountability so that you are then gonna do it. Otherwise you'll procrastinate. You won't do it. It'll get lost. It'll get lost in the Melay of everything else that's going on in the practice. And it won't happen. But this well, and marketing is consistency.  [01:03:36] Kate Grandbois:  And I I'm sorry that I interrupted you, but I have to assume that those who are listening may have the same experiences that I've had in that it, the marketing piece genuinely feels a little uncomfortable or feels a little unnatural. So I just don't do it. I, or, or I avoid it or it gets pushed down on my to-do list or it's not as important as my billing or [01:04:00] the patients that I have scheduled, or my employee who needs my support or, you know, add it to the list when you're an entre. When, when you're a small business owner, you wear a million hats. I see. So, but, and I know, go  ahead. [01:04:10] Jill Woods:  That's why the vision, the starting point is so important. Mm-hmm because if I am hell bent on achieving that. Then that becomes my filter. And that means that I understand that I am gonna have to create some new digital content once a month, because I need something to talk about on my social media. I need something to talk about on my Google business profile. I need something to email my clients about. So if I know that, because I've got this big vision, this is where we are going, guys. This is what our practice is gonna be. And it can be practiced stroke life. The two are very closely intermeshed. Um, but I've got a, you probably can't see I've got a vision board on my wall.  [01:04:56] Kate Grandbois:  No you don't. It's beautiful for everybody listening, who can't see, there's this [01:05:00] beautiful thing hanging in her office. That's got a frame and all of these photos and some beautiful quotes that I can't quite read, but I'm sure are very inspiring  [01:05:09] Jill Woods:  in the, in the middle. It just says, it always seems impossible until it's done.  [01:05:14] Kate Grandbois:  Yes, it does. It always seems impossible until it’s done.  [01:05:17] Jill Woods:  It's the point? The point I want to make is that vision board is a mix of my business and my personal and home life. So it's a whole mele of, because the two are so closely connected. [01:05:29] Kate Grandbois:  You're so closely connected when you own a business and your business. The way I explain it to people is that the business sometimes feels like my third child, you know, it's, it's something that I I'm up at night worrying about and I am constantly trying to make sure it's okay. Um, and I think I have taken away so much from everything you have shared, and I also need to find someone to embroider some things from my office and now I need to also get a vision board. So to keep me focused, cuz as I have already admitted, the shiny [01:06:00] penny gets me every time and staying focused can be really, really challenging. I, I have,  [01:06:06] Jill Woods:  if you've got that clarity, like of what you're trying to achieve and you anchor everything to that, it takes away some of that chasing rabbits and squirrels. Yeah, because is this, but you've gotta have an awareness like watching this YouTube video of America's got talent. Is that moving me towards my vision or away from my vision? it's not certainly not moving me towards it. Right.  [01:06:28] Kate Grandbois:  Not told exactly, exactly. But I think you, even your recommendation of taking a minute to write down the vision or really consider the vision. I mean, I think a lot of us get into private practice because we wanna help because we want the flexibility because we wanna be our own boss because we wanna, we we're interested in business because we have a clinical expertise that we think is, is a value to our communities. But the actual exercise of sitting down and writing down what we want, I mean, I've never done it. I'm sure there's someone listening who has done it, but I'm also willing to bet there are a lot [01:07:00] of business owners out there who haven't done it. No. Um, I think even starting there is such wonderful advice. [01:07:05] Jill Woods:  Yeah. That's, that's my experiences. Often, if you ask people, what do you want? They can't tell you. They don't know.  Kate Grandbois Don't ask me  Jill Woods: but every day, but, but every day they're getting up and they're dedicating hours of their life that they'll never get back money. That they've, you know, hard earned money to build something that they don't actually know what they're building, right. And what they're working towards, but yet unwittingly, every single day, they invest time, money, and energy in the thing.without actually thinking through what is it? [01:07:38] Kate Grandbois:   It needs a name and it, it needs a, it needs some legs. It needs some structure. It needs, it needs a vision board. Now I, I'm never going to snarkily laugh at about a vision board ever again, the rest of my life. I so appreciate all of this. Before we wrap up. Do you have any final words or words of advice, parting words of wisdom [01:08:00] for people in the audience?  [01:08:02] Jill Woods:  I would just say, I know we've covered a lot of ground today, so I'm very aware that probably people's heads might be exploding just a little bit. Um, but I would say, no, nobody is born knowing this stuff, you have trained to be a clinician. You have not trained to be a marketer. I was very fortunate that I trained in marketing before I trained to be a podiatrist, but you haven't got those skills, but you can choose to start somewhere. And if you choose today to be that day, then I am gonna champion you. I will be here cheering you on all the way, because I know what an impact good marketing can have in your practice and in your personal life. Like if your practice is flourishing, you are less stressed, you've got more available cash. Like you can take more time off. Like if you've got a flourishing practice that comes from good solid marketing, your life is transformed.  [01:08:55] Kate Grandbois:  That's again, such wonderfully Sage advice and [01:09:00] I'm so, so grateful. Thank you so much for being here and teaching, teaching me so much, teaching our audience so much. Um, everybody who is listening Jill is obviously a wealth of knowledge. You are available to our audience for questions. This is your business. This is what you do. All of your contact information and practice information will be listed in the show notes. Um, you also have a YouTube channel that I, I will admit I was creeping on it before I had a chance to, to meet you and ask you questions. Um, your YouTube channel has so much more information on it, um, in case anybody does want to learn more. Thank you wo, so, so much for joining us today, this was a real treat.  [01:09:40] Jill Woods:  It's my absolute pleasure. I, I love what I do, and I feel very blessed to be able to do this as a job. Um, and so, yeah, just thanks so much, Kate for inviting me. I'm very, very grateful. [01:09:49] Kate Grandbois:  Well, it was wonderful to have you. Thanks again.  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. [01:10:00] 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 November 28th, 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. [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:  Hello, everyone. Welcome to today's episode. We are so excited to welcome back. Some of our favorite guests. Welcome back. Ingrid Owens-Gonzalez, Liza Selvarajah and Desi Pena. Welcome back. [00:02:00]  [00:02:00] Liza Selvarajah:  Thank you. We're so happy.  [00:02:04] Amy Wonkka:  We're so happy to see you here. Ingrid, Liza and Desi. You are here to discuss issues related to culture bilingualism and speech language pathology. But before we get started, please tell us in our listeners a little bit yourselves.  [00:02:20] Liza Selvarajah:  Oh my goodness. I didn't know we were doing that again. Okay. um, I am a bilingual S L P French and English. Based in Montreal. Uh, let's say I have a private practice called Montreal speech therapy, and I just love, love, love, mentorship, and supporting just a multicultural way of thinking and working and learning. [00:02:48] Desi Pena:  I'll jump in. Um, so I'm Desi. And actually now that you mentioned your own private practice, I realize I never mentioned my own last time. Um, so I'm again, like I said, I'm Desi, uh, [00:03:00] Spanish, English, bilingual, SLP. Um, I also own a private practice here in Maine called Panorama speech therapy, LLC. Um, I'm still mostly contracting, um, with schools and agencies in the state of Maine. Um, and I guess another fun fact about me is that I've lived all over the east coast. Um, but most recently landed in Maine. So I’ll hand it over to Ingrid.  [00:03:27] Ingrid Owens-Gonzalez:  Hi guys. Um, my name is Ingrid. I am a school based SLP, Spanish bilingual, I'm based out of Northern New Mexico. I'm first gen Mexican American. And, um, I just love working with kids. I love working with multilingual multicultural kids, and I have a lot of things going on, um, that Kate will share with you on the disclosure section. But right now, uh, mentorship is really at the forefront of what I'm doing online. And I [00:04:00] just launched my speech place, LLC this summer. So [00:04:04] Kate Grandbois:  we're so glad to have you all back with us, and we're really excited to continue the conversation that we started with you during your last episode. Here with us. Um, and I wanted to take a minute before we start our conversation to read our learning objectives and our financial and non-financial disclosures. So everyone bear with me. We will try to get through this part as quickly as possible. We've got five people here today, so it's a, it's a lot of disclosing, uh, but we're gonna get through it. Okay. Learning objective number one, describe the potential harms of over-relying on external evidence for multicultural and multilingual learners  Learning objective number two, list at least two strategies to prevent harm in evaluations during the diagnostic process and learning objective number three, describe the importance of balancing the three pronged evidence based practice model when determining treatment. [00:05:00]  Disclosures. Ingrid's financial disclosures. Ingrid is the owner of my speech place, LLC. And is the employee of a public school. Ingrid also received an honorarium for participating in this course. Ingrid's non-financial disclosures. Ingrid is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast. Ingrid is also the co-founder and lead mentor of the bilingual empowerment through allied mentorship program and an Asha step mentor. Ingrid is also the mother of two bilingual and bicultural children. Liza's financial disclosures. Liza owns a private practice called Montreal speech therapy. Liza received an honorarium for participating in this course. Liza's non-financial disclosures. Liza is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast, and is a mentor of the bilingual empowerment through allied mentorship program. She is the mother of a bilingual and bicultural child. Desi's financial disclosures. Desi is the owner of Panorama speech therapy and [00:06:00] is faculty of the main New Hampshire leadership education and neurodevelopmental disabilities program. Desi also received an honorarium for participating in this course. Desi's non-financial disclosures. Desi is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast. She has a mentor of the bilingual empowerment through allied mentorship, and she is a child of Cuban exiles and is also raising a bilingual bicultural child.  Kate Grandbois that's me, my financial disclosures. I am the owner and founder of Grandbois therapy and consulting LLC, and the co-founder of SLP nerd. 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, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. I am a person of monolingual experience and a person of cultural privilege as a CIS white woman [00:07:00] in the United States of America.  [00:07:02] 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 non-financial disclosures are that I'm a member of ASHA. I'm part of special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. I also come to this discussion as a person who's experienced cultural privilege, uh, being a white cisgender woman in the United States of America. All right. We've made it through everybody's disclosures, learning objectives. Um, Ingrid Liza and Desi. Why don't you start us off with the first learning objective and talk to us about the potential harms of over-relying on external evidence for multilingual and multicultural clients. And maybe before we start just a little recap on external evidence, what is that [00:07:50] Ingrid Owens-Gonzalez:  you want me to jump in or Desi.  [00:07:53] Desi Pena:  You go first Ingrid you're up. okay.  [00:07:58] Ingrid Owens-Gonzalez:  So objective one [00:08:00] potential harms. I mean, they're really, truly immeasurable because you're impacting people's lives. So it's not something to look over. It really like sit in that word causing harm. Um, but external evidence is pretty much everything that is standardized or data driven outside of who you're looking at. So all the things that have been done outside of the person that you're treating, uh, more formally, it would be like standardized assessment, criterion, uh, checklists, things like that. That really don't have anything to do with who you have in front of you. Um, so that, that's kind of what we're like talking about when we say external evidence. And then as we know, we are very, very comfortable with that triangle. Uh that's. It irks me to see it written in black and white letters. It says that that's the best available information [00:09:00] gathered. Um, it's right on the ASHA website. And I know they're talking out about what the best available scientific evidence that's available, but just by putting that word right there, that's the best available information, then it makes it kind of imbalanced. Right. And that's kind of like our whole goal with this conversation. Um, it is just available information. We don't have to call it the best. Um, but it's just data and, you know, there's other forms of data. Like the ones you collect from your client and from the family and their perspectives.  [00:09:35] Desi Pena:  Um, and I just. Wanted to jump in just quickly to say that, um, the reason that the data isn't necessarily the best for multilingual or multicultural learners is because a lot of the data is really centered or gathered from children of, uh, a white mainstream general American English background, um, children who are not exposed to more [00:10:00] than one culture. And so it's the harmful piece about relying on that evidence is that you may be over or under diagnosing children with communication needs. Um, and what was really interesting, we recently. Recorded an episode, um, with Dr. V. Um, she's a professor at Howard and she really highlighted the point that, um, you know, everybody's comes from an individual place, right? We, we say, you know, multilingual multicultural, it, it's not, there's no such thing as a monolith, right? Like each child has a certain dialect that they're exposed to, whether that's mainstream English, speakers, whether that's Spanish speakers, whether that's, you know, people who may speak, you know, one of the many languages and for example, India, right? Like everyone has a dialect within a language. So it's something that, again, the external evidence isn't really accounting for [00:11:00] external evidence really looks at not so, so much like the granular details, pieces, but it looks at populations as a whole, which can be really harmful because then we're not individualizing our evaluation and our treatment, which is the whole point. [00:11:16] Ingrid Owens-Gonzalez:  So, well then you're looking at, if you're not represented in that external evidence, then it doesn't apply to you. Right. And so then. You get to the point where you're like, do I need to do research on every single population? It's like, no, you need to make smarter research. Mm-hmm that applies to every single population  [00:11:36] Desi Pena:  or be a better clinician, getting your clinical eye in tune with the fact that, oh, someone from the north of Mexico doesn't speak the same way as somebody from the south of Mexico, I should be accounting for the fact that there are dialectical differences and this happens to bilingual SLP all the time, too. So, um, I think it's really important to sharpen your critical tool kit, you know, critical eye in your [00:12:00] critical thinking toolbox rather than assuming that the evidence is the best thing you can lean on.  [00:12:07] Liza Selvarajah:  Mm-hmm  [00:12:08] Ingrid Owens-Gonzalez:  mm-hmm and in terms of harm, um, I just wanted to highlight that I know that we're coming from a, um, pediatrics centered lens here, but when I was working with adults, Whenever you're using external evidence to make decisions about dysphagia and not making decisions based on the patient that's in front of you. You can cause a lot of harm, not just physically, but also culturally to that family, putting a lot of undue burden for not considering their cultural practices. Um, you can cause a lot of harm if you're serving a family, um, who has a family member, who's had a TBI, and if you don't consider their cultural, uh, practices, then you make recommendations based on external evidence instead of what this family really needs or what this patient [00:13:00] really values. Um, so it goes across, um, our scope, even though all three of us are now are more school based pediatric, but like relying on external evidence, like Desi said, um, can lead to over identification in the schools or under identification. And it's the same in outpatient. It's the same in acute care. It's the same, uh, in a SNF. [00:13:27] Liza Selvarajah:  I just think of who had access to education back in the day, who was all of this written for, who were the norms standardized on? What was one's best practice? What was one standard is no longer the standard. And if we could reflect on that and see that the standards themselves, the external evidence is no longer good. What do we do? And how do we create these new ways of thinking? I, I was thinking how I was a little bit caught off guard at the beginning when I was asked to introduce myself thinking, oh, this is a [00:14:00] part two. I don't need to introduce myself. And I did. And my introduction was so different from the last time I introduced myself just one week ago and I am the same person. And within a week I've evolved into something new and something different. And to compare me to like a little white kid is so different. So how can that be the standard? Um, I think of setting kids up for failure. This is what it feels like. You are setting them up for failure, testing them on things that they are not familiar with that are not part of their culture, not part of their background. If you set them up for failure, then they will fail. And that is the harmful effect of it. Uh, effect of it. They're failing at something because we set them up to fail.  [00:14:44] Kate Grandbois:  I wanna piggyback on something that you said. So, if you're listening to this episode and you haven't yet gone back and listened to the first episode that we published with you all in that previous episode, we talked a lot about cultural [00:15:00] competency. We talked a lot about, um, how you can do harm by not doing the work of cultural competency first, when working with children who are not monolingual, who are bilingual, who are multicultural. Um, so if you're listening, I just encourage you, today's episode. We are gonna be diving into the, the clinical application. So please go back and listen to that. If you haven't. The second piece is I, I, as you were talking, as all of you were talking, I was reflecting on our jobs, which as I know a very general perspective, but we are trained as I'm putting this in air quotes experts, right? We are the commun. We are trained in communication, diagnosis, and intervention. That is what we go to graduate school for. I don't believe in the term experts. So air quotes, but you get my flavor, right? And if we don't, what I'm hearing about this potential harm, I think it's, it's goes [00:16:00] without saying that many of us, most of us are taught in graduate school to rely on external evidence. We are taught when we go through the evaluation process and we practice, sorry, I'm imagining myself as a grad student, I've got my easel, I've got my booklet. You know, I'm, I'm doing an evaluation for the first time and I am taught that assessment. Is a norm reference test. I am pretty confident that that is a standard experience. And yet there are so many people, not at all represented in that test. That is in fact, not my understanding is that this not an accurate measurement. It has, maybe it has its place. But what I am appreciate so much about your perspective is not only is it not an accurate measurement, but it is harmful to rely on that as a measurement. Um, Desi, I think, or Ingrid, I think you were the one who just mentioned the potential harm, not just of the over diagnosing and underdiagnosing, but the cultural harm, the emotional [00:17:00] harm. Uh, and that's what made me think of going back and really looking at this through the cultural competency piece, um, because the potential for harm is, is multifold. [00:17:12] Desi Pena:  I wanted to add on to that, that when in reading about, um, approaching evidence based practice from a, a legit three pronged approach. Um, and I know this is jumping into a different objective, so I'm gonna say it very quickly. Um, there is a standardization approach and that's a term from this one, um, article, uh, in social work that is linked in the show notes, I think, um, and just seeing standardization approach. Oh, and this ties back to what I was thinking about. Um, seeing that, that written out, it kind of made me feel seen too in a way. Um, I think about this recent mentorship meeting, we were, um, meeting for the BSLP program. We met with students who are trying to enter the field of speech pathology [00:18:00] and they all had concerns about the GRE. The GRE was not designed for any one of us. Um, you know, I was labeled as an English language learner when I entered school. Funny enough, I kind of questioned that now, if I should have even been labeled and received those services, um, You know, and I think that because of the fact that I'm bilingual, I just didn't, I'm not accurately represented those scores don't represent my actual abilities. And so I remember feeling that anxiety of I'm not gonna, I know I'm not gonna look good on paper, um, or on these standardized test scores. And it's because I'm not the standard. And I know that when those students brought those questions up to us, um, we all felt the same way. We all felt seen. It, you know, these tests don't, don't act, don't accurately capture our abilities. And so it's really nerve wracking when it's part of an admissions process. Um, and I think that it's great that more [00:19:00] universities are moving away from those standardized tests, cuz they just don't really give you a sense at all of who that person is. Um, when I taught, um, Uh, I, I did a master's degree in, in Spanish. Um, before I became a speech pathologist, um, I had a student who, um, they had to show proof of placement, right. That they could be placed in this, in this certain level of a Spanish course. And I had a student who showed me, uh, a copy of her SAT two scores, I think it was. And so it gave me the whole report, you know, what she got on her SATs. I mean, I don't, I'm not sure that that person broke 1000, um, you know, on the SATs, which back in the day, I don't know what, you know, what the numbers are now, but, you know, it was not a great score. Um, you know, it, in terms of like getting admitted to a university. It just, it's something that really I held onto. She was my best student that semester. I mean, she just got like a 98 in the course [00:20:00] or something and she was super dedicated and it meant nothing to, you know, to see those numbers. Um, and it just made me so angry because of course she was a student of color. Um, and. Sh, you know, again, like put her, put her on paper, she doesn't look that great. You put her in front of me. She's a wonderful student. It just, you know, I'm, I'm glad that she made it to that level of achievement. And I wasn't a barrier. Like thankfully her university saw something in her. Um, but it makes me angry at the same time. So I think it's hard to remove that piece here. Right? Like it's not all it's, it's harm in the sense of emotional harm, um, cultural harm. But then we're also talking about harming people who may, you know, who, who are successful or who can be successful. And it really kills me, uh to bring this up. But I think it's also something that, um, is a necessary part of this conversation. It goes beyond whatever [00:21:00] pathology, right? Air quotes, um, or disability like this affects people from all backgrounds, um, who may or may not have a disability. Yeah.  [00:21:10] Ingrid Owens-Gonzalez:  And to wrap up, um, learning objective one. I wanted to walk you through a scenario, uh, that I see in the schools a lot whenever, um, a bilingual S L P or any really bilingual professional is not involved. Um, you see a student come in in kindergarten, who is coming from a bilingual home. They get screened right away. Uh, maybe they fail the kindergarten English screener. And so they get referred to the bilingual department or to the RTI department, whatever you call your RTI team at your school and your district. Uh, and then they get further into their career kindergarten, first grade, and they're struggling to communicate. They're struggling to read, [00:22:00] and then you either can go one direction with it and say, oh, let's just wait, because he's bilingual. Or you can go the other direction with it and say, oh, we gotta put him, gotta test him, gotta test him. They gotta be in, in special education. And so if you're over relying on these tests, how do you know which way is the right way? If you don't have the other two pieces of that triangle, if all you have is, oh, he didn't pass the kindergarten screener and oh, he's not doing well on insert, whatever standardized tests your school uses to measure reading. You know, we used to use DIBELS and now we use, um, something station, you know, insert, whatever test. Um, how do you know what recommendation to make if all you have are numbers? Um, and so that's kind of what I wanted [00:23:00] to pause it to you guys in terms of harm. Um, If the student truly has a, a communication disorder, you have now waited two years to support them. And if the student doesn't have a communication disorder and instead is, uh, emergent bilingual, you have now waited two years to support them in another capacity, right? Because we have systems in place to support English language learners, but you were just waiting, waiting for what, for him to fail another test, you know, when all that other piece of the triangle was there to begin with, you could have talked to the parent, looked at their language, history, uh, looked at their background. Have they been to daycare? Have they been to preschool? Are they the youngest sibling? Are they the oldest sibling? Uh, is there a history of communication disorders in the family is their parent concern and [00:24:00] you just sitting there waiting. To find out. Um, so that's kind of where I'm coming from in terms of that learning objective. And I hope that kind of wraps it up pretty well. And then we can go to learning objective number two.  [00:24:17] Kate Grandbois:  No, it does. And I just, for the sake of our listeners who we've been referencing, this triangle, we've called it a three pronged approach. Um, I was not aware that this was our, our, that our evidence based practice model was three pronged until pro, maybe it might have gotten shown to me in graduate school, but it wasn't the way I practiced. Um, and so for anyone listening, if this is a novel concept to you, you are not alone. Um, I didn't learn about it in, in terms of embracing it as part of my practice until I had probably been practicing for a handful of years and for the sake of leveling the playing field and making sure everybody who's listening knows what we're talking about. Our evidence based practice model and speech pathology [00:25:00] is three-pronged as a triangle. I bet you could have guessed that given that's what we, what we've been calling it so far. Um, and that triangle is made up of evidence, which is both internal and external evidence, cultural per, um, client perspectives and values and clinical judgment. So again, often in speech pathology, we tend to think of quote, evidence as hard numbers research this component of external evidence. But that is one third, maybe even less than one third, because evidence is broken less than one third internal and external, right? So, so the, um, we really need to make sure that we are moving through evidence based practice as a process. With equal reliance on at least three of those components and they influence one another. Um, for anybody who wants to learn more about that, we actually have an episode with, um, Dr. Mary Beth Schmidt who wrote the EBP, uh, briefs about this process. [00:26:00] Um, so if you wanna learn more about the evidence based practice process and speech pathology, I will, uh, link that episode in the show notes. Anyway, carry on. I love that.  [00:26:10] Ingrid Owens-Gonzalez:  You said that like you haven't, you weren't trained in EBP and yet, you know, you weren't practicing at the beginning. I feel like none of us, well, maybe Desi, but, um, I went to grad school 11 years ago. I definitely was not trained on EBP. Yeah, I was. I think we don't talk about that enough. Like you come out and you're still learning. [00:26:28] Desi Pena:  I think the, the problem. I went into the, my assessments in grad school, the same way. Carry in your kit, bring your protocol, come on down. You know, like I never felt like, I, I mean, I, I had a, I think a few nuanced evaluations, like they were very excited cuz they had a bilingual client for me to evaluate as my first client. And it, it was a scramble. I mean, I don't mean to put down anyone from my program. They did the best they could. Um, [00:27:00] but I. I felt like my evaluations were test after test after test. Um, and I, you know, I know that we're, we read the manuals, we look at what evidence is in them that they'll work, you know, reliability, validity, sensitivity, specificity, but a lot of our instruments are not that great or robust even with the populations that form the standard sample. So, you know, it's really disappointing, um, to over rely on them so much. And I feel like, you know, you're very kind and , I'm not saying that I got bad training, but I, I think that one of the things that happens when you're a bilingual speech pathologist is you quickly pivot away from that training you might have, or you might start questioning things. Um, why is it this way? Why. Why are we using this as the baseline? When our [00:28:00] clients aren't in here, right? They're not, they're not represented here heavily. It's not super well designed or, you know, part of my diagnostic class was looking at sensitivity and specificity and reporting it out. We all had to do, take a test and, and spell it out. Um, and I, it was shocking after weeks of talking about what is sensitivity, what is specificity? What is content validity? I feel like when we started looking at all of those different elements, we quickly realized, wait a minute, those aren't all spelled out in these manuals. we were just like, oh, Hmm. So I wish my direct, my, I wish my professors had been like, Hey, they're not great. And I wish that that had been a conversation from the beginning, but it felt like the unspoken piece of grad school.  [00:28:50] Liza Selvarajah:  That's that's it right there, the unspoken piece. So no one ever said rely the most on the evidence, but that's what we saw. So when I [00:29:00] think of the triangle and, and thinking back to grad school, to me, I was like, okay, again, we talked about me thinking in pictures. So I was like, okay, what does client values mean? What does clinical judgment mean? What does evidence based mean? Okay. To me client values, they filled out the intake. So I've got their values right there on this piece of paper. So check, I did that part of the triangle, which is of course ridiculous. Now that I think about it, cuz it's so much deeper and a vested relationship is necessary and all these things. Anyway, so I checked off intake, got the client value. Then I was like clinical judgment. I don't have any, I better go really hard on the external editing.  [00:29:35] Kate Grandbois:  I love that. I feels that way sometimes I'm laughing [00:29:37] Desi Pena: . No, but. And you, they make you feel like you don't have any either. Sometimes, like not to, again, I'm not trying to crap on, like,  [00:29:47] Ingrid Owens-Gonzalez:  you didn't just finish a whole bachelor's degree on something else and pass the GREs and no. [00:29:56] Liza Selvarajah:  But here's, here's the crazy part. So I would like you have my whole kit read the [00:30:00] manual, like I'm so stressed about, did I turn the page at the right time? And am I reducing the validity? Because I oh yeah. Oh yeah. Teared the child down. Did I look at the answer? And that's why they pointed. I don't. So the stress was high. [00:30:13] Kate Grandbois:  It's so stressful.  [00:30:15] Liza Selvarajah: And then this is, again, this is a grad school experience. Not today. Now I'm just like, yeah, flip it. It's all good. So, so then once I get all my data, my, uh, my excellent data from this child that it definitely was not normed on. Then I put in receptive skills, this based on the score, expressive skills, this, oh, there's my clinical judgment, severe diagnosis and check. So I've got my three prong triangle, not realizing it's basically like a isosceles, you know, just like super heavy on this, these couple tests.  [00:30:45] Desi Pena:  Look that you're bringing out the geometry. I can't.  [00:30:47] Liza Selvarajah:  I had to look, I looked it up while you were talking [00:30:48] Ingrid Owens-Gonzalez:  what's the tangent, Liza.  [00:30:55] Kate Grandbois:  This is the first time geometry has made an experience on this show.[00:31:00]  [00:31:00] Ingrid Owens-Gonzalez:  why aren't we naing  [00:31:01] Desi Pena:  on the I'm sweating bullets a second. You say I saw solo.  [00:31:04] Liza Selvarajah:  So I brought up the isosceles triangle because the point to me was that it was so heavily based on external evidence. And the other two were just little ch little ticks, little check boxes. They weren't actually equally being weighed. And when we talk about Bicultural bilingual kids, we actually have to weigh much, much more of it on the client values and our clinical judgment, because the external evidence doesn't match. So that's yeah. That's why I brought up the new triangle. you're welcome. [00:31:36] Ingrid Owens-Gonzalez:  Love it. I just wanted to add that through that, like even within evidence, we tend to value external evidence over internal, and I kind of feel like we group internal evidence with. Client values, cultural values, further, you know, diminishing the importance [00:32:00] there, like, oh, what we see about their, their culture or their language is more important than what they're sharing with us. So, yeah, it's the mess of a geometry. It's not a triangle. It should be, but it's not. [00:32:12] Desi Pena:  I was gonna say, and if we're trying to get to the second objective about naming solutions, um, I wanted to share one of the things that I use the most is, um, resources from the leaders project, which is through Columbia university. It's run by Dr. Kate Crowley. Um, so website, it has free, um, CEUs, um, or continuing education on performing, um, reliable and, you know, balanced as possible, um, bilingual or multilingual evaluations. And one of the tools that's on there, um, is, and it is one of these interview. So again, I, I wouldn't necessarily call it like, you know, you download [00:33:00] this interview questionnaire and you're done. Um, I would say that it's good to consult with. And one of my favorite questions on that form that is available through the leaders project is to ask parents to compare that child, to other children within their community, even amongst their own kids. And I recently mentioned this to, um, a special educator, you know, that I always ask to compare to other children. And she's like, oh, but we're always told never to compare. I'm like, no, like, it's so important because you know, if the parents have concerns, they're gonna tell you immediately, this is not like my other children. And that to me is a big red flag in terms of trying to balance this evidence based triangle, you know, evidence based decision making in an, an assessment. If a parent tells me no, they're so different from my other children, I wanna know why that's my starting point in an evaluation. So I think it's really important to [00:34:00] list this solution, cuz I think this is a good starting point for anyone who may be wondering, where do I start these evaluations? You know, if, if we're not gonna weigh heavily, if we're not gonna lean it toward an isosceles triangle, how do I pivot it back toward the middle? That might be a good starting point.  [00:34:18] Liza Selvarajah:  I just wanna jump on your, your word comparison, because I feel that we hide a lot of what we truly do with scientific jargon. So we tell teachers and parents don't compare, but when we put in a standardized score, what are we doing? We are comparing, we are comparing [00:34:38] Kate Grandbois:  that's exactly what I was just thinking.You 're absolutely correct. It is like the whole point is comparison except, and I know we're going sort of back to this harm, but you're comparing it. It's apples and oranges. You cannot compare with a norm reference. It's not an appropriate comparison. Um, I love the, the concept of the leaders project and we'll link that in the show notes for anybody who's [00:35:00] listening. Tell us more about what strategies we can use to not rely so heavily on the external, components of external evidence.  [00:35:10] Ingrid Owens-Gonzalez:  From the leaders project. I also use the non-word repetition tasks a lot. They have a lot of them free for you to look on there. Uh, they have 'em in English, in Spanish, in Mandarin, uh, and there's, um, several different versions of them, uh, depending on what your, uh, your age group is. Um, so look into those, the non word repetition tasks on the leaders project, uh, that really kind of gives you another piece of the picture. It's not a whole picture, but it gives you another piece to add to your, uh, data to your portfolio on that child. If you're questioning some things, um, I always tend to use it, um, towards the end, if I'm still not sure with my other measures. Um, but the, to get to the meat of [00:36:00] what we're here, um, the, my strategy is using dynamic assessment and I always like to joke and people are like, what is that? I'm like, it's not, not static and they just look at me like, okay, I need to, I need to know more. Um, but if I never learned about dynamic assessment in grad school, so I wanted to point that out because I hear a lot of SLPs kind of feel, not shame, but like a little bit embarrassed or I don't know if there's a better word cuz it's professional, but they feel a little bit less than if they've never heard it before. And I wanted y'all to know, like I just started using that term four years ago and I don't even know if I even used it in the right context. Um, I used it, I heard it from, from uh, Dr. Edith Strand on her, [00:37:00] uh, childhood apraxia of speech course and free videos. She talks about, um, dynamic motor speech evaluation. And I was like, oh, that's what I'm doing. Um, but I come from a psychology background and I learned about mediated learning in my undergrad and a little bit in grad school. So that's kind of my perspective of where I started. And of course it came from an area of, I needed to do something because all these tests were not, uh, working for my population, but that's where I come from. So if you are feeling a certain way, because you've never heard of these things before, like, forget about that, that's just like we know about it now and we'll move forward. Um, because that's kind of how it happens for all of us. But, um, it really is just looking at a skill, figuring out where the student is at and then doing a little bit of teaching or support and then figuring out where the student [00:38:00] is at after. So whether you look at it from a lens of mediated learning, like, uh, Vygotsky, Zone of proximal development, or whether you look at it from a lens of, uh, dynamic assessment and levels of prompting, uh, it's all just, Hey, what can this child actually dowhen I help 'em or when I remove an obstacle, um, and for me and bicultural, bilingual children, a lot of the times is what can this child do if I just explain this in their home language, or what can this child do if I take this really, uh, niche, vocabulary word, like s'mores, you know, that maybe not culturally appropriate to their life, what if I substitute s'mores for something that's culturally appropriate for them and see if they can make me that sentence? Um, so that's what dynamic assessment looks like. [00:39:00] And that's been my biggest tool for becoming, uh, more culturally competent in my evaluations. But I feel like a lot of people look it up and they see mediated learning and test retest through all of these big words. And they're like, I don't have time for that. Um, I would say to them just, um, I think we linked it to the BIS examples on what to do. You can do it so quickly, just on a couple of items on the owls, say that a student had a hard time on a couple of items on the owls and you're done. And you did your clinician thing, your ones and zeros, which my favorite thing that I learned from Dr. Strand on that video was free on YouTube. Uh, she says we are clinicians, not technicians. And I, I always, I love that because you need to look be beyond all those ones and. So I will go to those zeros and figure out like, okay, if I [00:40:00] let them hear it one more time, does that help? If I, you know, say it in Spanish, does it help? If I provide pictures, does it help? And yes, I'm taking a little bit more time to do these things, but it makes my report writing that much easier. It makes my goal writing that much easier. My present levels writing, uh, even just your justification on eligibility forms, you have more than numbers to give. Uh, and I think we had that conversation yesterday with Dr. V as well. You have an actual, really good picture of the student and parents really connect to that when they feel like you really got to know that child, when you give an example of a response they gave and they're like, oh yeah, that sounds like my child. You really dug in there. I feel like I find more buy in anyway. Cause they're like, oh, you really are giving me the best picture of my kid. Um, so that's kind [00:41:00] of where I wanted to start off the discussion.  [00:41:01] Amy Wonkka:  I have a comment and a question. [00:41:03] Ingrid Owens-Gonzalez:  Yeah.  [00:41:05] Amy Wonkka:  Comment is that it sounds like you are being so thoughtful and that the example you gave with owls was really helpful for me. And you're being so thoughtful in asking further questions about, okay. So before, when I was being a technician, maybe I'm like, plus minus saying, going through and saying, these are the minuses, and you're asking more questions about why are these minuses? Are there things that I could change that would make them no longer be minuses. And so my comment with that is that any of that information you find out as a school based person, I think is also awesome stuff to put in the accommodation section of the IEP, if your state has an accommodation section. Um, and I guess a question I had that that may not be super answerable in this modality, but if somebody's used to kind of relying on that more technician type approach and saying like, okay, here are [00:42:00] the pluses, the minuses I've identified the deficits. Um, are there, are there helpful tips about the types of questions we might wanna ask as clinicians to dig a little bit more deeply? And then also how, how we can think about interpreting the information that we get. So if I haven't done this before and I feel a little uncomfortable, but I, I know I wanna start doing incorporating dynamic assessment more into my work. Um, are there patterns I look for? And that might make me think, okay, this, this is sort of tipping the scale for me in terms of. I I'm more likely to make this client be eligible for services versus, oh, no, actually I don't really think this person, um, should be receiving services. I didn't know if you, if you could talk us through a little bit of that. [00:42:45] Ingrid Owens-Gonzalez:  I can, unless Liza, Desi  [00:42:48] Desi Pena:  I can jump in. I wanted to add before we get a little bit too far, so. Part of this, um, objective that we're reviewing today, we actually covered in the first episode as well, when we talked [00:43:00] about ethnographic interviewing. So hopefully in your ethnographic interview, you've gotten some information from the parent valuable information, unbiased information. The whole idea with dynamic assessment also is it's an unbiased approach. So you've hopefully already gotten from them a sense of whether they're concerned or not. So I would say start there if the parent is concerned and they're saying, yeah, you know what? This kid is just not like my other kids, you know, they're highly distractable or I don't understand them or yeah, whenever we go to Abuelita's house, like nobody really understands what message they're trying to share with anybody. Right? Like you already have that in the background. Right? So then you go into your test and let's say, um, let's say the parent isn't concerned. And then you go run into this question with the s'more. I love that example. Right? So you run into this question with the s'more and you're like, okay, well really we're talking about like in this subtest they didn't [00:44:00] understand this question and there's a s'more they didn't understand this question. And it's about going to the veterinarian. They didn't understand this question. And it's about, um, uh, swimming in a, in the ocean, right? Well, maybe they don't have a pet. I mean, I know that in my family, like having pets, my family thinks pets are gross. Like, it just, you know what I mean? Like, I, it might be something worth asking yourself like, Hey, do you guys have a pet? Do you know anybody who has a pet? Do you know what a veterinarian is? Like, that's a new term for my son, cuz we don't have a pet. Right. Um, thinking about, okay, maybe they don't swim. Maybe culturally there is a boundary, like some swimming isn't part of something that they do. Maybe they've never been to the beach. Right. We're looking at what experiences they may have had and may have not had. Right. So I'd say that that's really important, especially if the parent's not concerned. Um, And I don't know, you guys can back me up on this or shoot me down. Um, but I feel like that's when I would start saying what's the [00:45:00] cultural load in these questions that they missed. So looking specifically at the ones that they didn't get, what is the cultural load? What's the cultural exposure they would need to those concepts to get those questions right. Um, so I don't know. Do you guys have an opinion on anything I've said? I don't. I also don't wanna,  [00:45:19] Liza Selvarajah:  I support everything you're saying. Um, I'm thinking about food. Food is a big cultural thing.  [00:45:25] Desi Pena:  Food is big [00:45:27] Liza Selvarajah:  and in our initial interviews with the parents. I wanna know what kind of food your child eats that way. I'm not using a standardized test with cultural food from, you know, Canada, America, that this child is not exposed to. Cuz let's say the goal with this kiddo is intelligibility, but they're out here trying to say smore, but you're trying to find an SM blend in a word that they've never heard. Now I'm here trying to teach vocabulary that's irrelevant to their life. And then pronunciation, when I could be targeting words that are meaningful to them, that [00:46:00] they want to be requesting at home and that parents understand. So I'm thinking about, um, Amy your question about like a, a data driven kind of clinician, which is what we were taught to be. And if you get a list from home of what the child eats and you find pictures, like you're even developing that relationship with the family and the child, I care about you and what your life is like. I'm not trying to pull you into mind. I'm here to support you, not fix you. . So all of that in there just plays into the relationship, which builds stronger communication skills. Cuz how much stronger are we as communicators when we feel a connection with the person that we're talking to. So I know I'm jumping into a lot of different things here, but to go back to the original question, I would get a list from the parents of food that the child eats. And I would show them that food and have them label the food as I would on a standardized test, but now more cater to this child. Um, and then from there we could, we could write up some goals.  [00:46:56] Desi Pena:  And I was gonna say, this is a nice thing too, like for a [00:47:00] private practitioner or somebody works outpatient, you can have them do this at home. Like this is like the intake call when you're calling them to get a sense of what's going on. These are all things that the parents can just prepare and bring. And, you know, in the two weeks before they come to your evaluation and hopefully you've explained to them the value of doing it. And so they, therefore they bring it. It's not to say that they will cuz sometimes it doesn't happen. But, um, you know, I think that there's so much, uh, again, value in giving them, let, letting them know that collaborative, Hey, I need to know what you culturally value, bring it with you. Don't leave it out. Like I know that that's the, the, the general feeling, right? That that's, that's separate. It's not, it's essential.  [00:47:48] Liza Selvarajah:   I have a quick story to share and I, I may have shared it on the last episode. So you could take it out if I'm repeating myself, but during COVID when we started zooming in with the families and seeing kind of like the home [00:48:00] life, it really broke that barrier of like professional in school. And it wasn't just a progress report the parent was getting or, or an evaluation. They were really like there for the sessions. And one big thing when I, it was really eye opening for me, I was doing, um, a little standard test with a kiddo and the parent was like, oh, they don't know that. We don't eat that at home. Just putting it out there. And I, I can imagine myself in grad school being like, well, this is the test, please be quiet. you know, and like trying to really meet this like experimental type of, uh, controlled. I wanna, I would want it to control every variable so that I have like the most reliable data back in the day. Now I'm like, you're so right. I turned off, I like stopped sharing screen. And I was like, why don't you open your fridge and tell me what's in there.  And she really pulled up her kid and her kid started labeling different things. And then she said, oh, she never says milk because I don't know that word is hard for her. Like, it was [00:49:00] so much easier for me to draw these, like, um, I wanna say a treatment plan, but draw goals and objectives. Very measurable ones right there in front of me all because we just broke that whole evidence based. I need all this external, I need to test it this way. And yeah.  [00:49:18] Kate Grandbois:  And just for the sake of coming full circle and moving into our third learning objective, I just wanna point out how in that story in, in most of what, what you all said is really focusing on client perspectives and values, client perspective, caregiver values, which is evidence based practice. So again, we think so often in our, in our professional culture, how we are, you know, the messages we receive and how we approach an evaluation or how we approach the story that you just told of, of assessing someone over zoom, um, and relying on this component of external evidence, but taking the child and lifting them into the, using the [00:50:00] vocabulary. That's evidence based practice because it is patient centered client centered care. Um, before we talk more about our final learning objective, I just wanted to go back quickly to the concept of dynamic assessment. And piggyback a little bit on something. You said Ingrid about how dynamic assessment can feel like a very intimidating term, because it's not necessarily something that we've taught. It feels very elusive, sort of like, oh, this mysterious assessment that I've never, cuz it's not a, it's not a test booklet necessarily. It's not something that you buy. There's no directions that you follow. It's not, it doesn't live in a box. Right. And in the assessment world, sometimes we feel more comfortable in a box with our directions. And what, and what have you. Um, I, we had, we've interviewed some researchers on dynamic assessment on the podcast before, so we can link some references in the show notes to talk a little bit more about what dynamic assessment is. It's a whole field of study. We're never gonna cover it in the context of this episode, but I wonder [00:51:00] if you could tell us for our listeners who might not be as familiar, what does dynamic assessment look like for you? If someone is listening and thinking, okay, now I know I need to do dynamic assessment or rely on that as a strategy. What's next? What does that mean? Like what does it, what does it look like?  [00:51:18] Ingrid Owens-Gonzalez:  I'll answer your question by answering Amy's because, oh, this is interesting. My grad, my graduate students and, um, that I've supervised and clinical fellows that I've supervised. Whenever I talk about dynamic assessment, they get that we have to do ethnographic interviews that we have to balance the triangle, um, that we still have to do some, um, standardized assessments because of the. You know, field that we're in because of, uh, the setting that we're in. Um, and then they stare at me and they're like, well, then now what? Um, so Amy, my answer to your question, and hopefully Kate's is, start with a test that you're comfortable with. [00:52:00] So we'll go with the owls example you gave the owls, you did perfect, totally controlled everything, you know, perfectly chef's kiss. Uh, the authors would be so proud and then you go back and you look just, they have it for you. They have the patterns for you in the back, what each one in zero meets. And I think a lot of people don't go back there to see what does this zero in question number 33 mean, oh, it's about syntax. What does the zero in question number 63 mean? Oh, it's about synonyms, uh, or 45 is about opposites. And you start there, you build that pattern. If you're not comfortable with gleaning information from a family interview, uh, gleaning information from their work samples or from their teacher, um, observations, start there, start with the test and then go see the [00:53:00] patterns. And from there you see what tasks is this student having a hard time with? And those are the tasks that you go back to, whatever framework you prefer. I like the test. You already did it right. Then go to their teach and then retest or teach retest. So test retest, I'm getting all confused. Test, test, teach, teach retest test. So you already tested and you already found some patterns and you wanna go back and see if with some support. Visual support, explaining it a different way. Uh, maybe in a different modality with some manipulatives, if they can get that concept, all dynamic assessment is, is taking away the bias of learning because you're not testing learning, we're not psychologists, we're testing language. So that's what I would say to my [00:54:00] students. Go to what you already have, what you're already comfortable with, what was drilled to you in grad school yeah. And then leave up behind and trust in your clinical experience because it's not ephemeral like clinical experience is just what it is. You've learned patterns from living through different sessions, different meetings, different clients, different CEU providers, speaking to other professionals. You're just picking up information, just like we pick up everything else. Um, you know, we all get better and better at driving somehow and we never take a driving class again. so that's kind of how I look at it. and I hope that I answered the question, Kate and Amy,  Kate Grandbois: you did.  [00:54:48] Desi Pena:  I was gonna say, I was gonna say the really cool thing too. I don't actually use the owls, but I use the CELF, um, unfortunately, um, but I use it, um, and I do the [00:55:00] same thing. I just literally see which ones they got wrong. So like on the CELF preschool, if anyone, you know, has access to the protocol or can think of the protocol, it has like a little box, a little grid at the bottom right hand. I just circle the ones they got wrong. And that's where I start looking for those patterns. Oh, it's always, when there's a descriptor, you know, on adjective use in the sentence. Oh, it's always when or when it's an ordinal concept, right? Like I start there and think. Oh, okay. Let me go back. And, and it's that, it's that teaching phase that is the most important part of a dynamic assessment. Okay. You got it wrong. Let me teach you how many times do I have to teach you? What visual, you know, am I using visual supports? What kind of queuing, how much queuing, how accurate are you after I remove all those cues and prompts? Um, and that's I, and I, I think what's also fascinating about this conversation is I think we should, we should already be doing this. Like, I, I think [00:56:00] that the thing that's shocking to people is the name dynamic assessment, but we should be doing this. Like I think about, um, testing articulation. Well, I wanna know how stimulable they are. Right. So I'm gonna go through my Goldman Fristo for anybody, everybody, right? Like, let's just say it's somebody who is a general American English speaker. Right. And there's no other culture. There's no other language. I'm gonna go through and say, wow, they got all those words with final consonants wrong. Okay. I'm gonna probe for, uh, final consonant deletion as a chronological process. So let me pull out these few words. Let me teach the child. Hey, you know what? This word has a tail or this word. Um, you know what I hear at the end, I hear this sound and see if they can do it alone, or if they need more support from me. So I feel like, you know, again, not to make anyone feel uncomfortable or like this is super basic and what are you doing? No, no, no, no, no. [00:57:00] Like let's undress the term because the more we undress it, the more we understand, oh, this is just probing. Like we're just taking a treatment target and trying it out. That's essentially what dynamic assessment is. And it's so important for multilingual, um, students, multicultural students, because they're at an unfair disadvantage when we lean so heavily on those standardized assessments that were not based on them. [00:57:30] Kate Grandbois:  That was so well said. I love the term undressing. Um, and, and just breaking it down, demystifying it so that it's not as intimidating so that clinicians can apply this, um, and be more effective in their, in, in their assessments. Um, in our last couple of minutes, I know we've, we've woven conversations about the three-pronged evidence based practice model throughout this conversation, but I just wanted to wrap up by, you know, really taking a minute to talk [00:58:00] about the importance of balancing those three components and what that feels like. I know in a lot of the stories that you've told you've illustrated, what balance feels like in terms of integrating, um, client perspectives and values with maybe, uh, with maybe the external evidence that you need to take. So, um, in some of our previous coursework on assessment, we acknowledge that in some instances, you, in some instances, instances, you have to conduct a norm referenced assessment because insurance will require it or your state requires it for eligibility. Um, so I, I love the term balancing in the subjective because it does encompass how you can move through this experience with prioritizing what you need to prioritize, to do an effective, uh, to conduct an effective comprehensive assessment. So what can you tell us about, um, the balancing act that clinicians may need to do when, when moving through this experience,  [00:58:58] Liza Selvarajah:  I think not being afraid [00:59:00] to firstly, the dynamic assessment just , it makes me laugh because every case becomes a complex case when they don't fit our usual way of testing. So if you run into a complex case, which is basically everyone, now you have to dynamically assess. So that's just, [ [00:59:17] Kate Grandbois:   I wanna some air quotes happening here for lots of air quotes. Sorry, lots of air quotes [00:59:22] Kate Grandbois:  No, no, no, it's fine. But you know, but you're right. Any quote complex, um, situation is, is, is not necessarily complex.  [00:59:32] Liza Selvarajah:  So now that, so now that we're dynamically assessing, there's a lot of teaching happening within the dynamic assessment and that's where I feel the client values and, um, our clinical judgment comes in and I feel that's where the balancing act is. If you do appropriate. Assessment. So within it, if you're teaching, if you're listening to parent feedback, you know, not being so, um, sciencey about it, I think we're really trying to [01:00:00] turn these kids into tiny little science experiments, where you got this score. Therefore you fall into this category, therefore this is your diagnosis, but it isn't like that. So if you really wanna balance that triangle, it all starts with like an appropriate assessment.  [01:00:16] Desi Pena:  And I was thinking, cuz I know you guys, you Kate and Amy do a lot of AAC evaluations, right? Those are complex. Let's put the air quotes in there. You know, you can't necessarily give a full standardized speaking language assessment to children who are non-speaking,  [01:00:39] Amy Wonkka: who are also not in the norms, usually correct. Captured in the normative sample. Right.  [01:00:44] Desi Pena:  So maybe if that maybe if we tie it back to that, um, you know, again, in, in, in the hopes of demystifying this whole process, right? Like. It's the same exact process, right? If you're confronted with a child who is exposed to [01:01:00] general American English, and they are, um, you know, monocultural, I'm trying to think of a they're, they're only exposed to one culture, right? Um, it's the same process, right? Just to, I, it, this is out of your comfort level, um, potentially because of what we discussed in the first episode of this series. Let's try to think of it this way. Maybe if it's harnessed this way, it will feel a little bit less complex to per se. But I think that, um, you know, really going back to the idea of, okay, this tool, isn't giving me the information I need. Uh, so what Liza was saying, right? This tool, isn't giving me the information I need. What is the information I need? And just asking yourself that question and then trying to balance it out. Okay. I've not had this situation before, but I am a clinician. I've not had this situation before, I have, but I have this parent, how can I level these two things? How can [01:02:00] I operationalize these two things so that I can move toward a better decision making process? Cuz that's what, you know, again, we, we talked about this very briefly, but evidence based practice is a process. So even if you have to like sketch this out, you know what I mean? Like I, I feel like again, If you can find, um, if you can find or advocate for yourself as a clinician for more time for these evaluations, I think that's another piece too, you know, as another solution or strategy, you know, say, Hey, this isn't straightforward. I need to do my ethical best by this child. If you expect me to take on a complex evaluation, uh, for example, for a non-speaking child and use X amount of time, this is this, this should be dedicated and we should really be spending a lot more time in making sure that we get this right for this family, for this culture, for this community. Um, so that's something else to consider adding to your [01:03:00] toolkit. Um, it's really the idea of how do I peel back the layers of my cultural discomfort and enter this space to do right by this child and this family.  [01:03:11] Amy Wonkka:  I just wanna say I 1000% agree. That's all. Thank you. [01:03:14] Liza Selvarajah:  Just listening, just really just listening to the kid, not through your lens, but through theirs, going back to the interview process, we talked about last time, last time on the CELF, there is a question with a banana and an apple and a glass of milk. And the child is meant to say apple and banana, uh, because that's the fruit and my kiddo said banana milk. And I said, why did you say that? And he said, every morning I have a glass of milk with a banana. That is correct to me, that is clinical judgment. That is a clear explanation to how those two went together. And if you're stuck in, but the norm and the standard says that only fruit should be placed together. That to me is a dynamic assessment, even though you're [01:04:00] using a standardized tool,  [01:04:03] Kate Grandbois:  that's such a great story and such a great point. Um, and I know as clinicians, you know, when we are experiencing, are going to write these up, right. And going to explain the findings of our assessment, and maybe we're in a situation where we had to use that assessment and we had to score it. But then just being able to explain that those scores don't represent the child's actual functional skill, because that is not the point of a norm reference assessment, norm reference assessment don't measure idiosyncratic skill changes. They don't, they don't account for, for personal experience or, or culture. That's not, that's not what they're there for. So even if you are and listening, and you're in a situation where in that exact story you felt even, you know, reflecting back on a choice you made you've, you did score that as quote, wrong. You can still use narrative and clinical judgment. Again, balancing this triangle to explain that score to [01:05:00] diminish that score, to put context around that score. Um, and of course, if you're in a position where you don't have to use that score, don't use it because it's not accurate, valid and reliable measurement. [01:05:11] Desi Pena:  Yes. That's it. I mean, yeah. Why use something that you don't need? Um, again, I feel like we're gonna we should like link this episode to the episode we just did with Dr. V's because she said the same thing use a checklist. Why are, why are you using like use an observational checklist go to that child's classroom? Ask the teacher, like, why are we relying on, you know, can they repeat this sentence about a nurse? Right? Like, this is one of the questions on the CELF,  [01:05:44] Ingrid Owens-Gonzalez:  my mom is a nurse at the community clinic.  [01:05:47] Desi Pena:  Oh, my word, right? Um, no, maybe my mom, I maybe, I don't know what a community clinic is. Um, but  [01:05:56] Ingrid Owens-Gonzalez:  I think it says my mom is the nurse at the community clinic. I'm like, [01:06:00] who talks like that?  [01:06:01] Desi Pena:  The nurse. Wow. Yes. Is it really the nurse? Okay, well, um, . Yeah, but I, you know, I think that we've come to this point where it's really crucial to set standards for ourselves, um, and to make sure that we are carrying out these evaluations also, just so we can make good treatment decisions too. Um, you know, obviously we wanna rule in and rule out, but no standardized tests and unfortunately I've seen this way too much, but no standardized tests should be dictating your goals. I've seen it way too often.  Kate Grandbois: Here here  [01:06:40] Ingrid Owens-Gonzalez:  standard. We get a little,  [01:06:43] Liza Selvarajah:  yeah.  [01:06:45] Desi Pena:  Yeah, pricing. One more goal about adjectives and a verbs. I'm gonna lose it.  [01:06:51] Kate Grandbois:  we, we, we, and there are lots of references for that. There that's been well documented in the literature that writing goals and objectives based on scores of a test [01:07:00] is inappropriate for a whole host of reasons that we obviously do not have time to get into, but we can link some of those previous episodes we've done. And some other additional literature in the show notes for anybody who does wanna learn more about that relationship. Um,  [01:07:14] Ingrid Owens-Gonzalez:  yeah, I just wanted to add to that last objective. I always go back to my question from last episode, who are you doing this for? Who are you doing all of these batteries for? Um, it's not gonna help the parents understand the teachers, understand it's not gonna help you understand. It's just gonna, what make it easy to fill in some boxes on your report template? I know it seems daunting, but really whenever you do dynamic assessment, the reports write themselves when you have all this information. And the thing that I like to tell my students, whenever they're like, oh, it's, it's more time. I'm like, not really. You're giving yourself credit for things that you already do. You're just putting them on your report so people can see [01:08:00] all the things that go into you making this recommendation. And even as an 11 year old veteran yesterday, I learned a new thing that I need to give myself credit for, that I never have before from Dr.V she talked about portfolio. Um, what was the word she used portfolio review assessment or review? Yeah, maybe portfolio review. I'm like I do that all the time. I don't receive a referral and that's credit to our, um, counselors and educational diagnosticians in my district is not coming from me, but my referral packets always include work samples and I always review them. And I always use them to inform what I'm doing, and I've never known how to give myself credit for that until Dr. V yesterday gave me the words for it. And so if you're looking at this, this is new, this is different. This is daunting. I really urge you and challenge you to twist that lens back and say, I already am great at this. I already did this master's degree. I already have all these years under my belt or [01:09:00] even months under my belt. And I already think about all of these things when I'm making these choices. And I want to give myself credit for them. [01:09:08] Desi Pena:  Yeah. Be a clinician, not a technician.  [01:09:14] Kate Grandbois:  it's a great quote. It's a really, really great quote.  [01:09:17] Ingrid Owens-Gonzalez: Yeah. That's  all Dr. Strand. Yeah. It's on the YouTube [01:09:19] Kate Grandbois:  and we we'll link we'll link all of the link, all of the references and resources. We've mentioned a lot  throughout the course of, of this episode. [01:09:26] Ingrid Owens-Gonzalez:  I need to give you more links. [01:09:29] Kate Grandbois:  Yes. Yes, we will. We will get them. Don't worry. In our, before we say goodbye, do you all have any advice for any of our listeners who maybe would like to learn more if this is their first, um, time coming in contact with these concepts of evidence based practice, balancing the three-pronged approach, dynamic assessment, potential harm of norm reference tests? What, what final parting words of wisdom can you, can you leave our audience with  [01:09:55] Desi Pena:  this isn't wisdom? But DM us, send us a message on Instagram. [01:10:00] Um, listened to our podcast, shameless plug, shameless plug. Um, I just think that the conversation shouldn't stop here. And if you're at the point where this is an uncomfortable topic and you're still like, wait a minute, what, please reach out. Um, we always try to respond to DMS. Um, and you know, the three of us are open to connecting. Um, So I think and finding a mentor. That's the other thing I don't know. I know that Ingrid and, uh, Liza mentioned mentorship, but it's so important, especially if you're navigating new waters. So I'll let you guys,Yeah. If you have anything else to add,  [01:10:44] Liza Selvarajah:  I get DMs on TikTok and Montreal speech therapy, and I just like tell a story so that everyone can hear it. So they get the question and the story so that I could support a lot of other SLPs out there.  Uh, but there's a quote I saw [01:11:00] on JRC, the SLPs, Instagram, uh, connection over data collection. So that's what I hold true  [01:11:07] Desi Pena:  here. I think Ingrid came up with that, right? Mm-hmm  [01:11:11] Liza Selvarajah:  stop.  [01:11:13] Ingrid Owens-Gonzalez:  I was so proud whenever she DMed me and she said, do you mind if I print this? But mine's a little different cuz I did connection. And then I did the greater than yeah. Back to my math nerdiness. I did connection greater than data collection and [01:11:31] Liza Selvarajah: oh my gosh, Ingrid, look at that. And I was like, there was a quote  that Ingrid came up with  [01:11:35] Kate Grandbois:  no cause connection is greater than I love it. Yes. Yes.  [01:11:39] Ingrid Owens-Gonzalez:  Oh, I love, I love Jordan. Uh, my last word as we do on our podcast, I think my last thing would be don't confuse internal evidence with client perspectives and culture. The triangle's already heavy on the evidence and then we're adding a whole nother wrench in the system. [01:12:00] Uh, I think that that happens a lot more than we think, like Liza was saying. Um, so that would be mine. And then give yourself credit. I think you're already doing a lot of these things. You just don't know how to write them down.  [01:12:14] Kate Grandbois:  That's awesome. Those were great. So good. As you say, the last words, those were great last words. Thank you all so much for joining us today, having you here is always such a treat we've learned so much from you. Um, as I mentioned, we will link all of the resources in the show notes. We will put a link to the bold SLP collective and podcast. Um, I can confirm everyone here on this panel is so friendly and so warm and so open to conversation. So if you are listening and you have additional questions or you wanna reach out, please don't hesitate. This is a, a very welcoming and curious and wonderful group of women. Um, Thank you again so much for being here. We're so grateful for [01:13:00] your time and I am a hundred percent sure we will find a way to collaborate with you again soon. So thanks so much for being here. [01:13:07] Desi Pena:  Thank you. [01:13:13] 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.