This is a transcript from our podcast episode published December 13th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:02:03] Kate Grandbois:  While our intro is very long. We're really glad that everybody listening, stuck, stuck with us because we're super excited for today. And I have a little story to tell. You ready for some story time Amy? Amy Wonkka:  Yes, please.  So once upon a time, I worked with a lady who was a lovely lady. She was a fellow AAC person and she moved away and in her new state and her new job, she met someone who was another AAC person. And they, this woman that I worked with got us together. It turns out it was Vicki Clark, who we have seen speak at conferences. Um, and we're so familiar with her work. Um, and so we got together over zoom and had a conversation and two and a half hours later, we decided that maybe we should collaborate and record a podcast episode. So here we are. After that long journey of friends introducing friends, Vicki, we are so excited to welcome you [00:03:00] today. Welcome to the nerdcast.  [00:03:02] Vicki Clarke:  Hi nerds. I'm glad to be here. I've been listening to you for a long time. And, um, I was really excited to get the chance to make that connection. I was a little freaked out, to be honest, when I was, I was telling this young lady that I worked with a sec, oh, I love this podcast. And I was telling her all about it. And she was like, oh, I know those guys. And I'm like, what do you mean? You know, those guys? Right?  [00:03:23] Kate Grandbois:  We’re nobody's, that's why we just sit here in a zoom room and have conversations with each other. But regardless, we're very, very excited. We're excited that she got us in touch. [00:03:32] Vicki Clarke:  Yeah, me too. Me too.  [00:03:34] Amy Wonkka:  you're here to discuss AAC implementation in schools. And before we get started, can you tell listeners who haven't been going to your conference presentations and kind of following you around virtually a little bit about yourself  [00:03:47] Vicki Clarke:  well, I am an AAC specialist, SLP AAC specialist. And, um, this year I hit my 30th year in the profession, which is, it makes me sound horrifically old, but anyway, [00:04:00] um,  [00:04:00] Kate Grandbois:  Golf clap for those of you who can't hear. [00:04:03] Vicki Clarke:  Right? Right. So, um, I have a, I started my, my career in the schools. I worked for about five years, um, as a SLP. And then I was fortunate enough. I lived in Raleigh, North Carolina, and I was in a hotbed of AAC and literacy at the time and got hooked in to that part of the field. When I was in Raleigh and looking to do something different, I went and did an interview with a, um, a psychologist who had a clinic. Right. I wanted to go get this job, um, as a speech pathologist. And I told him, I said, what I really want to do is I really want a job where I can work on working AAC. Like that's all I want to do. Just AAC. And he said, Vicky, that's admirable, but there's no way you're going to have a practice fully involved with AAC. So now I have a practice, Dynamic Therapy Associates that's been in place since 1997. We have, um, 11 employees. We have six full-time [00:05:00] AAC, specialized speech pathologists. Um, in our clinic, we see patients, families in the clinic. And then in addition to that, we have DTA schools, which is our school-based program, where we support individual students. So we go out, we do evaluations, um, and help kids get equipment and, uh, do programming customization. And then we also do training with, the entire team. So SLPs and teachers on AAC implementation. So that's about it. I do a lot of other stuff too. I consult and train and speak and stuff too, but, um, I'm kind of dabble in everything AAC. [00:05:42] Kate Grandbois:  That's awesome. We're very excited because as, um, many of our audience members know Amy and I are also employed as quote AAC specialists. And we put that in quotes. I think every time we say it, because it is the job, it's our job title, but it's not really a real [00:06:00] certification. It's not really a real thing. So as to people who are trained in AAC and do nothing but work in AAC all day long, we're very excited for this conversation and to not to overuse the term, but you know, nerd out with you and stuff, it's going to be super fun. Um, so before we jump into, um, the meat of the episode, if you will. Um, we are, and you know, before we really sort of unpack the AAC implementation in schools, component of this, I'm going to read our learning objectives and financial and non-financial disclosures. Some people, sometimes people write in and ask us to skip this part. I can't skip it. ASHA makes me read it. We'll try to get through it as quickly as possible. So hang in there  [00:06:40] Vicki Clarke:   [00:06:41] Kate Grandbois:  Learning objective number one, listeners will be able to identify the two primary categories of barriers to AAC implementation in schools as defined by Buechel men and Miranda's participation model. Learning objective number two listeners will be able to identify three specific barriers faced in their setting. And learning objective number three, listeners will be able to identify three [00:07:00] solutions to explore, to address barriers present in their setting, financial and nonfinancial disclosures, Vicky Clark's financial disclosures. Vicki is a co-owner of dynamic therapy, associates and DTA schools. She's also the owner of AAC chicks at teachers pay teachers except she's an exceptional education leader and is a paid speaker at state and national. Vicky Clarks non-financial disclosures. Vicky has a nonfinancial. Vicky has a nonfinancial working relationship with SGD manufacturers, AAC, app developers, and materials and materials developers for students with special needs, including news2you, Tobii Dynavox, PRC-Saltillo control, Bionics Forbes rehab services. AbleNet iTech and Avaaz Vicky consults pro bono for various speech generating device manufacturers, app developers, including educational AAC and speech pathology related. You might win the prize Vicki for a long disclosure. I'm just saying. Kate that's me. My financial disclosure is I'm the owner and founder of groundwater therapy and consulting LLC, and co-founder of [00:08:00] SLP nerd cast. My nonfinancial disclosure is 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. [00:08:17] 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 nerd cast. And my non-financial disclosures that I am 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 stuff. Vickie, why don't you tell us a little bit about kind of how this, how this talk came to be? Kate gave us the nice backstory, but how we all connected. Um, why, why barriers? Why is this an important thing for us to talk about or think about?  [00:08:50] Vicki Clarke:  Well, I think that, you know, when I first, when I was working, I worked in my clinic for a number of years, and then I started getting involved in the school districts. They called me [00:09:00] because they wanted to get equipment funded. Literally. They said they saw, okay, we can, we could get these, you know, 5,000, $10,000 devices funded and we don't have to pay for it. So they called me because we're pretty good at that in our clinic. And I would go out and do evaluations and then we would get the devices. They would magically appear, hand them over to the families in the schools. And then that was it. That's all they want. And not because we thought that was the best thing to do, but that's what the school was willing to pay for. And after a couple of years of this, the schools came back and they're like, Hey, this isn't working right. Thanks for the device, but it's not really working. And we, and which opened the door really nicely for us to go. And there's more to this, right? We need to be, um, planning, implementation. We need to be training the teams. We need to create an environment that supports the student using their system. Um, and I, so I started really doing more of this, kind of wraparound services, right? So we [00:10:00] support, we felt, I feel like that there's two, two things that I have to do in the schools. I have to support an individual student. Um, and then I have to support the actual staff members, the teachers, the SLPs, the administrators, right. It's tough to do both of those, both of those things. Um, and when I began this process, I actually had a conversation with a, um, a gentleman who used to do this job at the state level in Georgia. And, you know, we were talking, we met at a conference and he said, so, so what are you up to? And I told him, you know, I'm all excited. I'm getting ready to do more of this work in the schools and all that. And he laughed in my face, like laughed at me. And he was like, good luck with that. And I thought, oh my gosh, he's crazy. Cause this is going to be super easy. Right. Okay. So it's not, right. And anybody that's listening to this, that's working in schools or in humans working in AAC in general, who's trying to do a good job implementing, making it work, knows what I'm talking about. Right. It's [00:11:00] not the easiest thing to do. And so, you know, I start looking at, you know, when things don't work, I want to find the solutions. Right. I start looking for what are the, um, the ways to solve the problem because I don't give up very easily, you know? So here's a problem. I'm like, this definitely can be solved. Right. Um, but it turns out, you know, I didn't create this concept of barriers to communication. And I don't know, maybe, maybe I think about this a lot, because early on I was influenced, um, I was really fortunate in my first year as a therapist to, um, to get to go see Pat Miranda talk, which was amazing. Right. And, um, she blew my mind, but she talked about, um, her participation model. The participation model said basically that the way we judge success in AAC is how much the person's participating, able to participate in their environment and [00:12:00] that she and, um, David Bucholman identified two main barriers to communication success in AAC. Right? The first was access barriers. And, um, the second one is, um, opportunity barriers. So. Looking at that. It really, it really match, and this is a long answer to a short question. I'm sorry.  Kate Grandbois: No, no, no. I love it.  Vicki Clarke: So it matches my ideas about, um, that we need to address both the individual students. So that's those access things like, how are they they're they're struggling to speak, right. So is it due to a, um, cognitive challenge, a learning challenge? Is it due to language impairment? Is it due to, um, um, a motor impairment? Right. Um, so that's kind of our access, right? Opportunity barriers are, what do you, what happens when you take that child and you put them into a classroom that has maybe staff that doesn't know how to support them in communication, that doesn't know strategies, right. [00:13:00] That, um, maybe doesn't give them the materials that they need to communicate. So, or an administration that doesn't pay for devices, you know, Or doesn't, um, doesn't feel like that they need to, um, give the teachers in the self-contained classroom access to a smart board where we can put communication programs. Right. So all of those things come together to cause challenges with our students, um, gaining AAC, gaining skills and communication. Um, and I think that, so that, that's why I kind of bumped back into it because we can't do anything. If we don't address those barriers, we can not be successful. So  [00:13:41] Kate Grandbois:  I love that you've thinking of it through that lens because you're sort of backing into the problem, right? So instead of having the focus be on the AAC user, oh, I need to teach you this. I need to teach you this. I need to teach you this. You're really looking at the, the whole, the whole environment, all of the aspects that have [00:14:00] a role in communication. I love that approach [00:14:02] Vicki Clarke:  Right. Not my approach, obviously, but you know, that's why I followed around pat Miranda for a long time. Like I think that, I think that this concept was brilliant, you know? And I think we make this mistake all the time with students who use AAC is that we put so much of our focus on the child or the individual, right. Adults too. Right. I just deal with children a lot, but, um, we put all the focus there and the problem, there's a big problem with that. When it doesn't work, what happens is people say, well, this child is in special education. And they struggle with learning. And so the reason that they're not successful is that they do not have the quote unquote capacity to use the system. And then that's the end of it. Like, sorry, that's the deal. You know, and [00:15:00] really what I will say is that when I look at problems with getting AAC implemented in all environments, and it's not just in the schools, but in homes too, the issue, and I'm just going to totally make up a percentage here. But the issue in my mind is about 15% related to the student and about 85% related to the environment around the student. So. I've been trying to solve that problem for a long time.  [00:15:26] Amy Wonkka:  And this, this construct works so well for thinking about those, those problems. And you can't really identify solutions until you identify the problems. And so if you're trying to find all of these solutions that are centered on the communicator, and you're not zooming back, I mean, we talk on here all the time about the SETT framework from Dr. Zabala, which is such a contribution to the field and completely has changed my practice.  So this really makes me think about the SETT framework, which is just an invaluable tool from Dr. Zabala, [00:16:00] um, that looks at all of these factors, looks at the environment, looks at, you know, the communication tasks and recognizes those as is true variables that you need to be cognizant of and plan around as a clinician. [00:16:13] Vicki Clarke:  Right. Uh, you know, Amy w when I, um, I first learned about the SETT framework, um, I I'm. I, I was, I think I really, it really stuck with me because that's exactly what it does. It says, you know, and I think like, I think that, um, that, um, Joy Zabala was just really a visionary, right? She was able to kind of look at this and go, Hey, guess what? It's not, it's not just about this piece of equipment. Like I'm saying, it's not just about this kiddo, this, the student it's it's, it's about more than that. Right? So the SETT framework for those of you who maybe haven't used, although so many people have heard of it, but if you haven't go look it up, it's S E T T framework go look that up, Google search it, you'll find all the information about it, but it stands for, um, student [00:17:00] task. I mean, I'm sorry, student environment, task and tool. And what it asks to do is look at the student. We look at the student first, when we're trying to decide what kind of assistive technology would help them. We look at the student's strengths first, right? We look at the environment around them, meaning their whole context of the people around them, in the family, the school team, the context, the, the classroom, the home. Um, and we consider the things in that, in those situations with, um, in those contexts that, that help the student and the things that are challenging. Right. And then we look at the tasks, that's the first T that the student has to, um, accomplish. And then for our purposes, um, the communication task, what do they have to be able to do? Do you have to greet people or they have to be able to ask for things that they want, or they have to be able to offer their opinion. Right. And then finally, once we look at all of that, then we pick out the piece of equipment. And I think so much, like when you look [00:18:00] at, you know, you listen to people talk about, about AAC. They, they go first to the child. And they look at all the child's challenges. And then the second step, the second stop is at which, which app is the perfect app for this particular status.  Kate Grandbois: That is absolutely what happens.  Vicki Clarke: And it should be totally the opposite of that. We have to look at the student. Absolutely. But not just their, their, their challenges. Right. We're looking at their strengths. And then, then we go at environment tasks. And finally, after we've done all of that stuff, finally, we get to what is the tool that will help in this circumstance with this child accomplish these tasks. Right. Um, and I think we, we have to like constantly go back to that. And it's funny when I do, when I do set, set. Meetings, I guess, with our teams. And when I do those, you would not believe how often I have to pull people back, like, like throw the rope around them and yank them [00:19:00] back away from the discussion about the tools. Right. And get them back to the discussion around the environment and the tasks and the demands on the student. [00:19:09] Kate Grandbois: One of the things that, I mean, I know where this episode is not, excuse me completely about the set framework, but one of the things that I learned from, from Amy, let's be honest. And the set framework is, um, related to the role of the communication partners in that environment. Um, and I think that's, you know, very directly related to this, these concepts of the participation model that you were, that you were talking about. Um, and again, you can Google the SETT framework. Um, Joy Zabala also has a website that's full of information and we'll list everything in the show notes for anyone who wants to go find more, um, in case you're driving and you can't Google something, don't worry. We'll write it down for you. It'll be there. Um, I wonder if you could hop back if we could hop back for a second, at some point [00:20:00] in, earlier in the episode, you mentioned the term wraparound services. And I wonder if you could elaborate on that a little bit in terms of like, what are you wrapping the, who are you supporting? Nobody can see me. I'm making this ridiculous circle gesture with my hands. Like, what is the, what is, what are you supporting when you're talking about wrapping around serving wraparound services? [00:20:22] Vicki Clarke:  Okay. So that term is something that as, as I, you know, when I started working in the schools, um, like I said, I originally really thought I was just working with this child. I was just evaluating this child and finding the perfect solution for their, you know, their communication challenges. And, um, so it was me and the child. And then I realized, okay, I need to get the family, obviously the family involved. Right. So that's another, another personal, kind of, to work with me, with the child. And then we, then I thought, well, that's great, but they're in the classroom 30 hours a week. So we got to get the teacher involved. So now we have me, the [00:21:00] teacher and the family, and then, oh, by the way, the parapro is the paraprofessional is also teaching. So now we gotta have me, the teacher, the family, and the paraprofessional. Oh. And the kid, the child is also surrounded by their peers. So now we have to have me, the teacher, the parapro, um, and the peers. Oh. And then there's an SLP that shows up a couple of times a week. Right. So it's me, the teacher of the family, the SLP and the peers. Right. And then all of us are plopped in the middle of this context of the school, where everything that we do is in somehow, somehow managed by the administration. Right. We have that. And all of the things that go along with the administration, you know, what they do and don't do to help, to, to help support us. Right? So we have to have all of these people and this environment kind of surrounding the student to help them. But the problem is when, when you have all of these people in this environment surrounding the student with all, with good intentions to help them, but you have a lot of the [00:22:00] people around the student who don't have the knowledge or the skills or the attitude that is necessary in order to make this work. We don't, we have kind of, we have, we have little holes in our dam, right. That's helping this kid. Right. So I think. What we do. So our services in the schools it's called DTA. We call our services, DTA schools. And so I started developing these little supports within the content, within DTA schools. Right. So it was me, the AAC specialist who came out and did the evaluation. Um, then I started training the teachers. Um, then I started training the SLPs. So we started training the supports around the student, right then. The administration kind of caught wind of what was going on. Of course they were paying for it in the first place. So they were a little bit aware, but, but you know, sometimes administration, you, you, you tell them what you're doing and they they're, it all sounds good. And they're like, okay here, fine. We'll pay you. And then they kind of check out, well, I was lucky in, [00:23:00] um, most of my school districts to have administrators that really actually wanted the information and wanted to participate. So I started training the, the, the lead teachers, you know, so in some, one of my districts, I have an amazing lead SLP. I have a lead, um, intellectual disabilities teacher, lead autism teacher and assistive technology specialist, um, OTs and vision, um, vision and hearing, um, professionals who all work together. So we train, train those lead teachers as well. So now, now our little, our little circle around the student where we're filling in. Those tolls are in, in our little circle. Right. Um, and then recently we just started last year providing contracted speech therapy services to the schools. And what I'm doing is I don't, I don't want to be like a placement service. You know, I don't want to be one of those people that you call when you need an SLP. And I just slapped my, my most recent graduate into your, into your position. Um, I [00:24:00] wanted to be able to provide SLPs, who I trained, who I supported, who I gave materials and equipment to, to go into the setting. So we've actually had now, um, we now have two, just two, um, AAC SLPs that are, are filling, um, positions in, uh, two of our school districts, um, as just the regular SLP on site, which is the coolest thing. So now I have, I feel like I have everybody involved. Um, and the piece that we're really trying to do better at this year is really getting more involvement from the families. That's the tricky part in the schools I think.  [00:24:36] Kate Grandbois:  Uh, you said so many things I want to touch on Amy. When I can see you're raising your hand to you. Go ahead.  Amy Wonkka: Are you sure?  [00:24:46] Kate Grandbois:  Yeah. Go for it. Go off on the whole thing. Like the long grocery store line, where you're like, I got so much stuff in my cart and you let someone go in front of you Amy Wonkka:   just get a quarter pound of cheese.  Kate Grandbois:  Exactly.  [00:24:56] Amy Wonkka:  SoI had a couple of thoughts too. I think number one, and somebody that Kate will [00:25:00] talk about is the need for indirect services in schools. So I'll let you save that. I'll let you save that. Get it all.  [00:25:06] Kate Grandbois:  Hold it. No, go ahead.  [00:25:11] Amy Wonkka:  No, whatI, what I was hoping you would talk a little bit about is, I've seen you speak, um, recently through an asynchronous conference presentation, and you talked a little bit about having, helping people who are stakeholders to have realistic expectations about outcomes and about the kind of effort and changes needed. Th that people need to implement the work that people need to put into expect those outcomes. And it, as you were talking about the training, it just made me think, I would love you to speak a little bit about that because I think sometimes we hear training and we think just procedural training, we think just that we're training people. This is how you do aided language stimulation. And this is how you program the kid's device. Um, but I'd imagine you also do some pieces around, like, everybody's got an important [00:26:00] role to play here. I don't know if you could talk about that a little.  [00:26:02] Vicki Clarke:  Absolutely. Absolutely. So I think so if we, if we go back to Beukelman and Miranda's participation model, um, we're talking about, I think we're talking about, um, um, changing people's attitudes, right. About what AAC means and what AAC will do for them. Right. And it is, this is not just a school district thing at all. We have to do this with our families, too. People call us, we used to have this running joke in our office. People will call and, um, you know, we were in Georgia. I don't know if you can hear the accent, but, um, we're in Georgia. So I had this woman call one time and she goes, I need one of those Dinah boxes for my kid. And I'm like, okay, let's back up a little bit. We could help you potentially with one of the Dyna boxes, but, um, but let's actually look at what, you know, what's going on with your child and why, why, you know, obviously you feel like that they need some [00:27:00] supports and all that, but you know, I think people look for the bandaid, right? They look for, um, the, the, you know, the, the tool that we're going to slap on the, on the problem and it's gonna, it's gonna miraculously be solved. Um, and everyone who is not involved in the AAC field, I think feels that way, right. Teachers feel that way, SLPs feel that way that aren't working in AAC. A lot families feel that way. Right. Um, administrators feel that way. That's what people were hiring me to get devices for people. Right. And it's just utterly not true. Right? So we have to do a lot of, um, um, we have to do a lot of expectation setting at the beginning. When people come, people call us and come into the office. We start right there. We used to do, um, we used to do single shot A, we call them single shot, AAC evaluations. And I know a lot of people still do that. Right. Where the, [00:28:00] the child comes to you or the, the adult comes to you. And, um, we do an evaluation. We decide what is going to be the perfect fit for them in two hours because we know them so well. Right. And then, and then we buy the equipment and then hand it to them. Now I've never just shipped the device to people, but I know people that do that too. They do the evaluation and then the device met miraculously gets funded and appears on the family's doorstep. Craziness. I mean like, and  [00:28:29] Kate Grandbois:  we're making very angry faces for people,  [00:28:32] Vicki Clarke:  but here's the thing. Some of the people that I know that do that they do it not because they know, they think it's right, they do it because their setting will not allow them, does not fund them to do more than just that. Right.  [00:28:52] Kate Grandbois:  This is what I was going to say. You've teed me up beautifully here.  Vicki Clarke: You're welcome. I'm here for you. Teamwork makes the dream work guys. So this is, this is where I was going to go with the indirect service. Grumpiness [00:29:00] is that indirect service. It has a place across the continuum of our entire field, no matter what population you're working with, no matter what age you're working with. And I, I have evidence for that across the board. However, when you were talking about prescribing equipment and you are talking about a service delivery, that is, as you so beautifully described, wrapped around a student that where the success is defined by the environmental changes as much as if not more than the student or client changes, how are you possibly going to do that without funding for indirect service? And if you're in a school, you might have a little bit more flexibility with being able to put indirect service on your grid, but you might not have, you might have a caseload of 115 with no time to really communicate with the family about what's happening outside of your school setting. Conversely, if you're in a hospital setting, which is where Amy and I met, you're in an [00:30:00] outplacement, in an outpatient setting, or you're like me, and you're technically in private practice and your funding is insurance. That's not even a choice. There is not even a choice for that. So that is in terms of like in terms of identi-, I am looking at our second learning objective in terms of identifying barriers in your setting, the lack of funding for indirect service is a massive, massive barrier, depending on your setting, to be able to do the kind of intervention that you're talking about and do it sic- And so that this, your client, student patient has success,  [00:30:32] Vicki Clarke:  absolutely creating  [00:30:34] Amy Wonkka:  we need to have advocacy in our field around this, we really do  [00:30:37] Vicki Clarke:  every time we do this, now we do, and we need little signs to, to March around with, right. Um, I'll tell you,  Kate Grandbois:  I want to make a t-shirt that's what I’m going to do , that's what we're going to wear a t-shirt to link in the show notes Vicki Clarke: now. I mean, you know, but talking about, so I think like, thinking about this, this, so this is a. [00:31:00] Policy and practice problem. Right. Which are also by the way, goes back to the participation model with Beukelman and Miranda because they talk about policy barrier, part of access up access. I mean, I'm sorry. Opportunity barriers include policy barriers and practice barriers, right? So when you have an ed at administrative level, you have someone saying, um, this piece, this indirect service, this consultation and training is not really a real service, right? Not right. Not  [00:31:34] Amy Wonkka:  a billable code. It's  [00:31:35] Vicki Clarke:  not, there's no code for, right. Exactly. And I'll tell you, when you have it at an administrative level, nationally, you have leaders in national organizations saying things like. SGD modification. So device communication device modification is a lesser service than speech language therapy, and therefore should [00:32:00] be charged less true. Yes. [00:32:04] Kate Grandbois:  I’m becoming enraged, as you are speaking, I did not know that.  [00:32:08] Vicki Clarke:  So, so that was there, there was an issue around that with how so in, in the AAC world. And this is kind of, I'm kind of going off into a, a little rabbit hole here, but, um, in terms of AAC services, there was a question there are two codes that, that we predominantly use in AAC world. Um, and so th this is skews us school people, excuse us for just a second. Okay. But we're sliding over into billing insurance. All right. Um, there's two codes that we use, uh, a speech language therapy code and the speech generating device modification and customization or modification and training code. And there's been a lot of discussion about whether you could do use that SGD speed sharing device modification code for customization and training. Right. And, um, when this, we, we first started asking about this many [00:33:00] years ago, we were told that at that, um, our large organization. It's said that it was, it might be considered a lesser service. So, and you know, in my mind, one of the primary services that we provide for people is we individualize, customize their communication system, which is imperative for them to be able to use it. Well, you cannot buy something off the shelf and slap it in front of a kid and say, here, use this, right. It has to have their favorite stuff in it. You know, it's got to have SpongeBob, it's got to have puppy pals or whatever. Right. I'm so old. I don't even know the cool things anymore. Right. But it's got to have those things in it, whatever. I don't know. Paw patrol there. I don't know  [00:33:42] Kate Grandbois:  what, I don't know what any of these things are. I just thought  [00:33:45] Vicki Clarke:  my kids are older than you. I mean, my Barney is my era. Okay.  [00:33:51] Kate Grandbois:  Sesame street, Sesame street.  [00:33:55] Vicki Clarke:  Yeah, no, you're, you're not cool either.  [00:33:59] Kate Grandbois:  [00:34:00] Sorry, I'm just going to stay quiet over here, it’s fine.  [00:34:01] Vicki Clarke:  If those findings aren't there, it matters for whether the child is going to accept the piece of equipment. Right. That matters. So if we say it's a lesser service and it's not paid for. Okay. So there's that rabbit hole. So pulling back from that rabbit hole, back off into the school land, right? We still have those policies or those policies in place that say, okay, on the IEP, when it says speech language therapy services, you must be in the classroom in front of the student to provide those services. When we all know a lot of times what we really need to do, and probably more than that is we need to be sitting in the corner with the parapro, helping them understand how to use the device or behind the parapro, coaching them while they're using the, working with the student. And so we have that expectation that our, what happens is we go into their classrooms and I know Amy's like chomping at the bit. I'm watching her. Right. I'm keeping on talking just to see how long she'll not interrupt me. Right. So true. Right? It's [00:35:00] look, she still hasn’t spoken, but now I have her dad. That's fine. Um, but you know, you go, I think the teach the teachers now, a lot of teachers fully expect that if you don't pull the, go in as a speech therapist and grab the student, take them away to your magic therapy room, wave your wand and sprinkle your fairy dust and fix them and bring them back, it's not speech therapy services. So we have a lot of education to do, um, to help people understand what that is. Right. Go Amy. I know you've got to say it.  [00:35:29] Amy Wonkka:  Well, obviously I agree based on my face, but people can't see, but just picture an enthusiastic agreement. Um, I would say too, I know you've said, you know, the school-based people, the billing and the coding piece doesn't really apply to you, but it does. It applies to all of us because in a field where we are allied health providers, All of all of those administrative and policy decisions in Medicare, Medicaid trickle down and influence our ability to practice in whatever setting. So even though a school [00:36:00] environment is not the same thing as you know, a hospital environment, our practices are influenced. I, I really have big feelings about this. I do think it's something that we should advocate for because it's a way to advocate for our clients because what our clients need is exactly the wraparound service that you're talking about and that you're describing. And if we don't make broader change as a field to shift the value and the perceived value of those essential services. Then we're going to be stuck in a place like we are. And in some places we'll be able to do this amazing wraparound service that you're describing, but there will be so many places that aren't able and just  [00:36:41] Kate Grandbois:  guys I'm having, I feel like I want to say something, but I shouldn't say it, but I'm going to say it a little bit and then I'm not going to say anymore. And I hope nobody gets frustrated with me. Do you know what this is making me think of? Guess who has codes for indirect service and billing.  [00:36:59] Kate Grandbois:  [00:37:00]ABA, this whole issue of encroachment is extremely related to policy barriers, because there are other professionals who we share a scope of practice with, like it or not, who may or may not have the content knowledge and the competency to do this, but they are given a significantly different model to operate in to support students with communication disorders like it or not. So this is a legitimate, this issue of not having indirect service touches our field in so many places. And for individuals with complex communication needs, who are minimally speaking or non-speaking, and our AAC users are impacted tenfold by this issue. That's my opinion. And then I will not, I will say nothing else and I hope  [00:37:48] Vicki Clarke:  I'm going to second, that opinion wholeheartedly  Amy Wonkka:  third, really.  [00:37:54] Kate Grandbois:  Because I'm having some insecure feelings about it. Somebody driving in their car, listening to this, getting enraged, we're going to [00:38:00] try and do something about it. You can't fix it unless we know the problem. Let's start there, the barriers so that we can try and move forward with some positive solution. [00:38:09] Vicki Clarke:  Exactly. And so there's barriers, there's big, big barriers, right. At a big, broad national level, right then that we need to talk about. And so talking about it, I think is a really good thing, and this is a good place, you know, a good place to continue the discussion. Cause I know other people are having this conversation as well. Um, so anyway, policy barrier, right? So what do we do now? That's another thing I think, you know, we said, we're going to talk about solutions and not just barriers. So what do you do about this? Like that's a big barrier, right? So that's something that I think, uh, talking about it at this level is good. And continuing to talk about it on a national level at conferences is a really, really, really good thing. Right? I think we need to continue to have that conversation and make sure that we,who are in the field or educating the people that are making policy decisions, for sure. Right. I'm now pulling it into a school in this school environment.[00:39:00]  Truthfully, our SLPs down here in Georgia, bill Medicaid. So it is actually an issue for our schools are our SLPs in the schools here too. Right. So that is a part of it as well. Um, I do think too, for us, with DTA schools, I think one of the things that we do, um, is we come in and we say the things that, um, maybe the SLPs have been saying, but they need a little backup. Right. It's hard to be, you know, you can't be a visionary in your own backyard. Right. We know that, right. That's why I drive 50 miles away. And then I'm the expert, right? You're right.  Kate Grandbois:  I love that expression. That was amazing.  Vicki Clarke: The further away I am, the more expertise I gather. Right. So, um, I think, you know, I think that, that it does help the SLPs that the SLP that's in the, in the school environment to have this other person coming from. An hour away, come in and say, actually, you know what her job really is, is to be training of the pair of professionals. But, you know, I told you before, I'd had some really good, um, I'd had some success really [00:40:00] working with the, um, the administrative, the leads, right? The lead SLP, the lead OTs, the lead the AT specialist. That's been really, really great because those people set policies, right. So if by working with them and kind of helping them to see the vision that, that I have about what the, what wraparound AAC services is explaining that to them. I've I have had so much positive response. I've never actually had anybody that was a lead SLP or, uh, in a, in a lead instructional role ever go, oh, you know, that really that's the stupidest thing I've ever heard. I've never had anybody respond to me negatively. Everybody has been very, very positive once we talk about it. So I think there's one of the solutions is go to these people and work with administrators to get them to understand why we're doing what we're doing\. Right. Um, so, you know, I think that that's one, one solution because those people will carry it on. Even when you're gone, when you've left that school and you've gone to another school, the [00:41:00] people that are still there they'll carry on what you started. So that's that's, that is something that's really positive to do. So anyway, we had these, meetings, You know, we, you know, we do think, we talk about things, like find your why, right? What is the why behind what we're doing. Right. And we talk about, about people's rights to communication and, um, and how communication impacts everything that they do in academics and have those conversations with teachers. Because that really helps. Cause I think when teachers have curriculums that they have to follow, so they have to follow the math curriculum and social studies, curriculum and science curriculum. They have all these standards that, that they have to follow and they have English language arts, which by the way, is where communication fits on those ELA standards. Right. Um, I think that, um, there are, they have programs that they can use. They have curriculums that they can use to teach social studies and science and math, and it offers legitimacy to that instruction. And you go, go find yourself a communication [00:42:00] curriculum. Go ahead, go find that. Okay. So I can't, I have not been able to find that, right. So of course, because it's a problem, I had to go find that solution. And so that's what we've been doing. That's what's been going on at DTA schools for numerous years, as we've been trying to build something that gives us a, a scope and sequence of communication instruction. Um, so on part of our DTA schools, trainings, and our website, we have, um, we have tools to assess a child's communication in the classroom. In a context of the classroom setting. We have checklists for teachers to look at their communication supports in their classroom. So they're the materials that they have and the training that they have and the, the, um, the, um, supports that they're sending home with the children, to their families, the equipment that the students have, their big smart boards. We have a list of all of these possible [00:43:00] supports that you can add into your classroom to make your classroom really focused on communication, uh, so that they can now have for themselves some sort of rubric of what makes a good communication classroom. So. Go ahead. I saw Amy pause. She looked like she had something to say. [00:43:20] Amy Wonkka:  It was just, it was making me think. So we've talked about policy barriers, right? Policy barriers are a type of barrier. And I feel like now what you're talking about are sort of invited potential environmental barriers and the possible solution to sort of shift toward a UDL type model and UDL being universal design for learning and just making everything more accessible for everybody. [00:43:44] Vicki Clarke:  Right. [00:43:48] Amy Wonkka:  So policy environmental, I'm feeling good about like right. [00:43:51] Vicki Clarke:  Attitude barriers, for sure. That's  [00:43:56] Kate Grandbois:  I have a lot of experience with that one. I have, I have found that [00:44:00] sometimes that is the one that is most resistant because what we do as clinicians I see often is we try to teach, we try to over teach. We try to give information and there is a component of counseling involved in meeting a learner where they are and getting buy-in and changing someone's attitude. I mean, think about how difficult that is. If they have strong feelings about maybe it's their child and they have, you know, very strong feelings because they're a parent and this is really going to have a big impact on, on their daily existence. Or maybe they have strong feelings because they think that they know better than you and they have different ideas about this is the wrong device and there's an ego component. So when you start talking about solutions to attitude, barriers that for, for me personally in my practice has been. Something that it's taken a lot of professional growth because I have to check my ego at the door. I had to [00:45:00] embrace more of a counseling strategy. I have to make myself a positive reinforcing presence to get my foot in the door so that I can then slowly educate someone at the rate that they are comfortable with. I think as a younger clinician, I would walk into that, into that interaction and say, well, you're wrong. And this is why this is why. And this is why, this is why this is why. And that still might be true, but it doesn't matter because you're just talking to a wall. If you don't have someone. Open and willing to learn based on, on where they are. I'm sorry. I just want to find them a whole tangent. I'm not even sure if anybody agrees with that. I could be alone.  [00:45:33] Vicki Clarke:  I'm so glad you said that because it really real, it just like queues up the whole conversation about, um, people's teachers, special education teachers, thoughts about AAC implementation in their classroom, which is what I've recently been reading a lot about. Um, I mean, I'm so glad you brought this up cause I was going to totally forget to talk about it. But, um, so I read, uh, I do, I read, um, [00:46:00] a lot about AAC implementation and listened to a lot about AAC implementation, but I recently pulled out Gloria Soto's, um, article from 1997, she wrote an article. I think it was actually her doctoral project. I'm not sure about that, but anyway, and what they did is they did, they did a survey looking at what do teachers believe about, um, what do teachers believe affects successful implementation of AAC in their classroom? And they had all these questions and, and kind of figured out what they, they believed in what they said. And I thought this was a really positive thing. They said, the teachers believe that I'm going to read this. So I'd say it right. The teachers believe that communication training for students is positive. That's a positive thing. And teachers believe that communication training is a collaborative, um, uh, collaborative effort between the SLP and the teacher themselves. So they all that, that was very clear that that teachers have a pos, they, they come at this with a positive attitude. [00:47:00] But then there's a big, but here, their willingness to use AAC in the classroom is based, and I'm quoting this on their perception of their students' ability to learn to communicate effectively. So if they do not believe their student can learn to communicate effectively, they will not implement AAC in their classroom. Okay. So now our first thing is to get ourselves all up in a wad about this and go those teachers!  [00:47:27] Kate Grandbois:  your expressions are fantastic. [00:47:29] Vicki Clarke:  Sorry. I've lived in Georgia way too long and I'm holding down the accent. Okay. All right. But anyway, so, so we first get like really excited. We're like, oh, golly, you know, these, these, these teachers don't, they don't believe in their students, you know what terrible teachers that don't believe in their students. Okay. But that's not actually what's going on. So they dug a little deeper into that. Cause that sounds, that sounds terrible. Right? Who wants to say they don't believe their students can learn? Nobody wants to [00:48:00] say that. Right. Um, but what they, what this survey did talked about is they said, well, actually this teacher's belief that their students could learn was less about the student and it was highly dependent. And I'm going to read this part too, on their perception of their own skills and responsibilities and their ability to teach their students to use AAC effectively. So it's not really that they don't believe in our students, it's that they are nervous about their own skills and ability to teach their students. So now that now comes back to us. Right. We need to figure out how we are, we're not going to come in punitively and say, why aren't you doing this? Like Kate young, Kate would not have been allowed in the door. So, you know,  [00:48:46] Kate Grandbois:  guys, I just made so many mistakes. It's okay.  [00:48:48] Vicki Clarke:  Oh please. I think we all did it. We all were like, you know, on our bandwagon. Right? Exactly. I think all of us, I think we've all made those mistakes of trying to, um, [00:49:00] trying to go in and tell people what to do. And assuming that, um, that this kind of, mal-intent why people weren't just didn't believe what we were saying about, uh, about AAC. And if you want to, I mean, you go, go hang out on social media and you can see people get all, all dramatic about, well, these teachers won't do this and you know, they get very upset about it. But I think we really have to look at now, not what do we, what do, what are the teachers not doing? What are we not doing? In supporting the teachers, we need to help them. They be it's because we know it goes back to that first conclusion that, um, Gloria Soto’s paper said that teacher believed positively, that children can, can learn to communicate. And this is a positive thing. So if that's, what's at the, at the, the, the kind of back of the brain, right, then we gonna have to get back to that. They want the support, they want to make this work. So what can we do to make it [00:50:00] better for them? So one of the things that I do, and I think you said this really nicely, Kate, um, w I, we want to meet them where they are. Right. We want to see what is it that they're doing successfully. And we want to build on that. So that's been one of the things that I've done. Over the past few years is I've gone into the classrooms and I've watched what the teachers are already doing. And then I've been sneaking AAC into it. So you tell me that you're, that you want to do, um, that you want to do, um, interactive PowerPoints. That's your thing. You love interactive PowerPoints. So what, what I did this past year, cause every, all the special ed director said, okay, we're all on zoom. Just give us interactive PowerPoints. So we, I made interactive PowerPoints, but in the interactive PowerPoints are screenshots of Touchchat and screenshots of Snap+Core and screenshots of LAMP. And we're finding and learning vocabulary by looking at them on our, on our device pages. Within this PowerPoint, the teachers are [00:51:00] willing to use it because they know how to use the interactive PowerPoint. And we're starting to make, we're starting to normalize the instruction of AAC, they're starting to, they see these boards and they're like, and they become comfortable with the boards. So when we pull the device out, it's not so scary. Cause it looks like the thing that they've been working on with their PowerPoints. Right. Um, so that's kinda, that's been one of the things that I've been trying to do. We had another teacher that, that really liked literacy. She wanted to do literacy units and she was buying them all on teachers pay teachers. So I said, all right, give me the, tell me what you're buying. I went and bought it myself and said, all right, now, how can I take this literacy unit and add AAC into it? So we started, we started inserting AAC into this literacy unit that the, that the teacher was already using. Um, you can go, we have, um, teachers using, um, unique learning and we go into unique learning and we, and we, and we add supports into that, that add more communication as well. So trying to embed, um, and normalize [00:52:00] the instruction of AAC into something that they already know how to do.  [00:52:03] Kate Grandbois:  And I, I just, for the sake of saying it again, everything that you're saying is so critical and, and robust and dynamic and it's, but it's making me think of the, the level of vulnerability that a person has to feel, to feel comfortable coming to you for help and how critical those working relationships are and how we so often I've had, I've mentored many SLPs over the years. And one of my mentors said to me once, but I don't want to, I brought up the issue of working relationships as a consultant, um, as an area to sort of work on with her. And she said, but I don't want to be friends with these people. I said, well, that's fine. You don't have to be friends with any of it. You can do whatever you want, but you need to have some sort of respectful working relationship with your coworkers. Because in all of the examples that you're just sharing that teacher who had vulnerable, uncomfortable, insecure feelings, right? [00:53:00] We've all had those. Those are not happy feelings. Those are uncomfortable feelings. And if we're trying to meet our learners where they are. Who are our peers in age or education and educate them and support them. We have to also create a safe place for them to feel vulnerable and seek you out for help and feel. I feel comfortable saying, you know what? I don't know how to do this. And it's, I am the barrier to this student. I think that they are doing great. They can do great, but I am the barrier that takes a tremendous amount of professional maturity. And as the SLP, it's our responsibility to check the ego at the door, do the work on ourselves to make sure that we can create those safe spaces for those working relationships to improve and create education.  [00:53:50] Vicki Clarke:  Yes. I totally agree with that. And I think that, you know, if you're, if you're coming at this and you're saying, I don't want to be friends with these people, it's not really about friendship. It's about respect and, and [00:54:00] not an authentic respect. Yes. You have to be able to look at what you have to be able to look at what they are, um, what they're doing well. Right. What are they doing really, really well find those, you know, I think that those shining moments, right? Those things that they do well and, and, and, and authentically, authentically appreciate that about them and let them know that, let them see that you appreciate the things that they're doing. And by adding in your, your supports, your materials to what they're already doing, you're doing that you are providing that, that, that respect for them. And it's not just us saying that too. Like, I, I, I spend time reading books by people who work on helping people make changes right across all industries and the Heath brothers Chip Heath, and Dan Heath are two of my favorites. They did a book called, Made to Stick, which is still of all the books I've read on the subject. One of my [00:55:00] most favorite. And it talks about how you help people make changes, whether it's changes in their diet or their exercise, or change just like this, like by providing AAC supports for your classroom. And one of the things they talk about is being able to recognize when someone is at 5% towards the goal, right. Giving saying to them, you're, you're, you're doing this thing right now we're going to do is add one more thing onto it, you know, giving them little bitty successes and genuinely, genuinely, um, celebrating those successes with people. Right? So, um, all the things,  [00:55:35] Kate Grandbois:  all the things, all of the things. So in our last couple of minutes, I'm wondering if, um, we've already just to sort of quickly recap, we've reviewed the participation model. We've reviewed several barriers and strategies to those identified barriers. So we've thoroughly unpacked a lot through these learning objectives. I'm wondering if in our last minute you have any final resources [00:56:00] or words of wisdom that you want to leave our listeners.  [00:56:04] Vicki Clarke:  Well, there's so much to say, right? And I will say this, we do, we do have, we do have a website. DTA schools is our website it’s a membership based website. And pretty much everything I've ever done is on there. And all the things that are on there are my attempts and my team's attempts to solve some of these problems to meet some of these barriers. Um, so that's certainly a resource right, for people, but, but truthfully, um, if you're willing to go look, there are resources everywhere. There's so many, there's so many materials out there. There's so many people that are, that are working really hard in this field. And finding those leaders I think is really important. Good people to follow. Right. I know what I know because I followed pat pat Miranda. Right. I, you know, I follow Carol Zengari. I consider a friend and his is amazing with her resource collecting, you know, aggregating information following people like that [00:57:00] price. So Carol's and Gary's on practical AAC. It's P R a C practical AAC. Fantastic website, perfectly free. Everything you could ever want to know is on there. It's amazing. I think falling what, webcasts, like what, I mean podcasts, like what you all do is really good. Talking with tech. Another really good one. Um, so finding those people that will, then you start going down that rabbit hole, one person connects you to the next person who connects you to the next person. And I think honestly the best, probably the best piece of advice that I could give anybody that's really trying to build their AAC skills is to recognize what you don't know, know what you don't know, and be willing to live in the messiness of this. It's going to be messy. It's not going to be great at first. And that's okay. You take something, you take your mistakes, you learn from them and you move forward and that's okay. And acknowledge that, know that you don't know at all in the age of where you can Google search anything in the world. That doesn't mean you have knowledge. So sometimes what we need to do is shut [00:58:00] up and listen to people, right? I'm just sorry. Like we need to listen.  [00:58:04] Kate Grandbois:  It's like aggressively hand pumping over here with them and support. Nobody can see us, but I had to say that.  [00:58:09] Vicki Clarke:  Right. So there you go. That's all I got.  [00:58:16] Kate Grandbois:  I shouldn't interrupt your, interrupted your amazing stream of consciousness. Well, this has been so chocked full of resources and knowledge, and we're so grateful to you for coming on here and sharing all of that with us and our listeners. Um, so anybody who is listening and wants to learn more or check out any of the resources that were listed, everything will be in the show notes with hyperlinks. Um, if you would like to use this episode for ASHA CEUs, you can do so by finding the episode page on our website, www.SLPnerdcast.com . If you feel so inclined, please scoot on over and leave us a review or send us a note. We love hearing from our listeners. And I think that's pretty much it. Thank you so much for joining us Vicki and thanks everybody for listening. [00:59:00]  [00:59:00] Vicki Clarke:  My pleasure. I'm ready to come back. I think we could do this for another six or seven hours. Amy Wonkka: Oh my gosh, we definitely could 100%.  Vicki Clarke: Thank you again. Thank you so much. Thank you.

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. [00:01:39] Kate Grandbois:  We are so excited to welcome today's guests, two lovely individuals who have been on the show with us before welcome AC Goldberg and Barb Worth. [00:01:48] Barb Worth:  Thank you. [00:01:50] AC Goldberg:  Thanks for having us.  [00:01:52] Amy Wonkka:  So AC and Barb, you are here to discuss diving into gender, aligning, voice work, underlying principles and [00:02:00] practice. And before we get started, can you tell us in our listeners a little bit about yourself? [00:02:04] Barb Worth:  Sure. I am Barb and I have been doing, uh, this type of work for the last 10 years or so. And I've been a speech pathologist for a little bit longer, like going on 27 years, which is absolutely crazy. And so I I'm so happy to be here because this is something that I feel incredibly passionate about. And I, uh, started, uh, gender aligning voice work about 10 years ago and in a medical setting, but I have switched and I now work at Emerson college, both as a clinical and an academic instructor, and I focus almost exclusively in the area of gender aligning voice work. So I am, I think about myself as sort of teaching and training the next generation. [00:02:50] Kate Grandbois:  That's so awesome. What about you AC?  [00:02:54] AC Goldberg:  Uh, where should I start? I am AC Goldberg. I'm a speech language pathologist, [00:03:00] and I have 17 years of experience now over 17 years of experience, which is so alarming at this point. And I have just made the transition from being a school clinician with a private practice on the side to working for a private practice full time where I'm doing mostly gender voice modification. And I am the founder of transplaining, which is a cultural responsiveness training platform where I offer intersectional educational opportunities to speech language pathologists, and other clinicians who want to learn more about how to best serve the people that we see as SLPs in our, in any setting that we work in. [00:03:40] Kate Grandbois:  And for our listeners who may or may not have, who may or may not have heard you on our show before, do you want to tell us a little bit about transplaining and the resources that you have available? Cause I feel like it really is a wealth of information. And anybody, everybody who's listening should, should know that it's out there. [00:03:57] AC Goldberg:  A short, well Transplaining is now [00:04:00] a a, an interactive educational website that offers both live and prerecorded continuing education opportunities where you can come and listen to me, talk about gender and considerations for working with trans and gender nonconforming people. In the whole field of being a speech language pathologist, whether you're encountering us in a voice setting or you're encountering. And I say us because I am, I am a trans person, but whether you're encountering a trans person in a voice setting or just, you know, as a student in your school how to best how to best be responsive and make sure that your space is microaggression free. And in that vein, I offer this intersectional education on my platform where I invite SLP speakers of all backgrounds to come and speak about their experiences and how to best serve people from their populations as an SLP. For example. Recently I had Joshua Alison Burbank who is Navajo SLP. And that was incredible. And I would highly recommend anyone who [00:05:00] is tuning in to listen to that. I've had Vivian TC come on and talking about being an autistic SLP. I have had so many different, I can't shout out to everyone, but what I would love to any listeners to do is actually I've sent, um a discount code for 50% off monthly memberships to keep me me over here. So, you'll find it in the notes of this episode and you can subscribe for a low monthly fee and have access to all of this continuing education. It's all intersectional. And you know, really, it's gonna make you a better clinician to learn about the people that we work with.  [00:05:32] Kate Grandbois:  Thank you so much. You, you talk to us a little bit in a previous episode and give a discount to our listeners and it's just so incredibly generous. And having, you know, really gone through your website thoroughly, myself, I can't say enough about how many resources you really have on there. And one of the things that we're passionate about doing here is connecting people with resources to continue their learning. So thank you for everything that you do and all the resources that you have. So we're really excited about today. For those of you who are listening and[00:06:00] hearing AC and Barb for the first time they have been with is with us here. Once before the last time you guys were here, your focus was on cultural responsiveness, and today is sort of the second installment of that. And your focus is going to be more diving further into voice mod, the voice modification aspects of what you do. And we're really excited about it. We've had lots of listeners write in looking for this information. Before we get started, I do have to read our financial and nonfinancial disclosures as well as our learning objectives for the day. People do write in and ask me to skip this part. I can't, ASHA makes me read it so I will get through it as fast as I can. AC Goldberg's financial disclosures: AC is employed full-time as a speech pathologist working primarily in gender voice modification and is the founder and co-owner of Transplaining.info AC Goldberg's nonfinancial disclosures AC as a person of transgender experience, which gives him personal perspective. Barb Worth's financial disclosures. Barb is a clinical and academic instructor of communication, sciences and disorders and Emerson college. She instructs students in [00:07:00] the delivery of voice services to all populations, Barb, its nonfinancial disclosures. Barb has a decade of experience working with the TGNC population.  Kate that's made my financial disclosures. I'm the owner and founder of Grandbois therapy and consulting LLC and co-founder of SLP nerd cast my nine 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.  [00:07:32] Amy Wonkka:  Amy's financial disclosures. I am an employee of the 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 on the AAC advisory group for Massachusetts advocates for children.  [00:07:46] Kate Grandbois:  Okay. Slightly more fun than financial and nonfinancial disclosures, learning objectives. Learning objective number one, identify at least two steps you can take towards cultural and clinical competency in the area of gender affirming, voice and [00:08:00] communication training  Learning objective number two, describe at least two components of gender affirming, voice and communication, evaluation. And learning objective number three, describe at least three potential therapy target areas for a client receiving gender affirming, voice and communication. Okay. All the boring stuff is over. We got through it.  [00:08:18] Amy Wonkka:  The good stuff begins now. AC and Barb, why don't you start us off by telling us just a little bit more about cultural responsiveness within gender affirming, voice and communication training.  [00:08:28] AC Goldberg:  So, you know, I think that if you're listening to this episode right now, it would really be a great idea to go back and listen to our first episode because we really covered a lot in that episode that, you know, we don't necessarily have to cover again, but that really, if, if this were courses in order and there were a prerequisite that would be the prerequisite to this and you know, it's something that you can't just learn once it's an ongoing practice. So the practice of cultural responsiveness is a lifelong commitment to learning and [00:09:00] continuing to learn about other people. You know, not just a one-time course about, you know, issues in bilingualism but really learning about every single population you could serve to the best of your ability. So that you're able to bring what you know about that person's history into your treatment, so that you actually are able to form a better clinical relationship because you actually understand where the person is coming from. So, you know, it's really important that you go ahead and engage in the practice of cultural responsiveness and that you go ahead and listen to our first episode. It's really important to learn all of the most current terminology, but terminology that Barbara and I use today might be outdated by the time you listen to this episode, that's something that happens. You know, I I'll write an article, it'll get published by the time it's published. The terminology is outdated. That is one of the things I love most about language is that it's dynamic [00:10:00] and changes over time. And this language is rapidly evolving. Uh, There's so many resources that you can kind of dive into in the area of cultural responsiveness. You can join me on my, on my Transplaining platform. There's what is the Facebook page called Barb? [00:10:20] Barb Worth:  Gender spectrum, voice and communication.  [00:10:23] AC Goldberg:  There are books that you can, that you can purchase. And you know, you can do some, some learning just about the trans population in general by you know, visiting a site like listen or gGLAAD, or even the Trevor project. Just to kind of get some background information, if you haven't listened to our first episode,  [00:10:41] Kate Grandbois:  thank you for that reminder. I think that's really important. And for anybody who's interested in listening to that it was published a ways back. Got to take a listen. [00:10:49] AC Goldberg:  So I'm going to, I'm going to talk a little bit about some terminology. I'm going to give some reminders. So, Gender is not something that you can tell by looking at them. And, you know, it's never something that you [00:11:00] should assume you know, people have a sex assigned at birth. And along with that comes a gender that's assumed at birth, which is a set of societal constructs that somebody kind of puts on them as a set of expectations that somebody puts on them based on sex that they're assigned at birth. So, you know, you've got a sex assigned at birth, gender assumed at birth. And when you are transgender that means that you don't feel comfortable conforming to those conforming, to those expectations that people place on you based on your gender assumed at birth or your sex assigned at birth you might be gender nonconforming which means that you don't fit squarely into sort of any gender box. You might have a non binary gender which can be defined really broadly. It's just a gender that, you know, is neither male nor female. It could be something that has nothing to do with either of those, or it could be a combination of any of those things. You know, that's very unique and individual but you know, all of [00:12:00] what's most important is that if you're dealing with a patient client or student who describes themselves as transgender or having a sort of gender that is neither male nor female, that should mirror their language. You know, and if you mis-gender someone it's really important just to, just to move on. You know, don't apologize profusely. This kind of looks like this, you know, I met Barb the other day. He went, she came into the clinic and it just is, it's a really quick correction. If you can catch yourself, I don't say, oh my gosh, I'm sorry. I'm sorry. I'm sorry, because that really puts the burden on Barb to be like, oh no, it's okay. When really, you know, Barb doesn't want attention called to that. Barb just wants to be gendered correctly. And I modeled that I knew the correct pronoun and then I moved on and that's what you really have to do. If that happens. It's important reminder. [00:12:50] Barb Worth:  So one of the questions that I get a lot is, wow, it's so cool what you're doing that sounds so interesting. How can I start doing [00:13:00] that? You know, I really would like to delve into this area of our field, which is a relatively newer area and, you know, just like any other area of our, of, of our profession, it's so important to develop competency and we've talked about cultural competency and responsiveness, but how will we become clinically competent in this area? So, you know, i think first and foremost, it's really important to understand the function of the voice. You know, I come from a medical background. I was, I was lucky in that I, you know, I had training in voice and anatomy physiology, but also in voice disorders. And so, you know, I, I performed laryngo-video stroboscopy and, uh, comprehensive evaluations. So I come from that perspective and I have to say that I, I really appreciate that. I, I had all that training because I think that it really helps me. To [00:14:00] understand, you know, what, we're, what we may be doing. When we are asking someone to make some modifications to this beautiful, beautiful structure and function of the larynx. So I, you know, I think that, you know, first and foremost, dive into your, your voice textbooks, go back to, you know, uh, Voice 101 that you took and take some courses. And we're going to talk later on about specific courses and things that you, that you might, uh, choose to do in this specific area. You know, one thing that people ask is, you know, how do I find a mentor? How can I find somebody to help me along the way? And, you know, I have to say that most of us in this area are thrilled to help others. And that's part of the reason why AC and I are doing this today is because we want to spread the good news and what we also want people to, and to, to appreciate what a wonderful area of our field this is, but also really [00:15:00] impress upon people how it's important, you know, to really know what you're doing. Right. So, you know, finding a mentor is not always easy, but, you know, AC I don't know if you want to sort of tell our story how we met.  [00:15:11] AC Goldberg:  Oh, my goodness. Well, we met over at Emerson.  [00:15:15] Barb Worth:  We met over at Emerson, right? So Emerson AC was interested in, in, you know, learning a little bit more about this area and you know, had done some observations of my work and you know, we pay it forward now, AC is doing this, this type of work a hundred percent of the time. You know, I'm not only mentoring other, uh, other uh, graduate students, but I'm also mentoring peers.  [00:15:39] AC Goldberg:  And I think it's really important that, you know, there's, there's transgender clinicians now who are doing this work full-time, which is wonderful, but we have a lot of cisgender clinicians who, you know, did kind of come, you know, before us and start this work as it was. And I think that very oftentimes [00:16:00] people are afraid to ask for a mentor in this work. And you know, I identified Barb as someone who I knew was an ally. We had met before. You know, I said like, Hey, you know, I'm going to dive into this work. I've been doing a little bit of it on the side, but I need to see it formally. I need to talk to you. I need to be in the booth with you. And you know, you were like, oh yeah, come on down. Like, you know, I'll see you Tuesday afternoon. And you know, you were so welcoming to me as, you know, as a peer and as someone who who you were just like, oh yeah, that's great. You know, fantastic. Let's do it. And I think that people shouldn't be afraid to kind of dive in and say, you know, I want mentoring in this specific type of work. And there are cisgender and transgender clinicians who are willing to mentor you. So that you have sort of the, like the best lens to, to do this work. And there's, there's plenty of people out there now who know how to do this work, but you know, you shouldn't try to do it unless you actually have experience. [00:16:58] Barb Worth:  So one of the things that, you know, I did, [00:17:00] uh, oh, maybe five or six years ago is we sort of developed, uh, a peer group. So some of us that were doing this work would meet on a monthly or every other month basis. Uh, we would share resources. We would, with clients' permission, we would, uh, we would share a voice samples and sort of having another, another pair of ears to listen and say, Hey, I'm sort of stuck here. What should I do? What would you do if this was your client? And then fast forward to a few months ago, uh, one of my colleagues who I had not met at an area hospital contacted me and said, you know, I'd really like to get into this area. And I said, great, what have you learned so far? And so she, you know, through email and, and eventually a phone call, we started talking and we've reformed our group. And so, you know, we're now going to be meeting on a monthly or quarterly basis. And just again, sharing experiences and supporting one another[00:18:00]  [00:18:00] Kate Grandbois:  So I love what, you're what you're saying about mentorship. I love mentorship. I think it's so important. I think that it's something that our field in general has not embraced enough across all disciplines and all areas of practice. And another reminder, this is something that we talk about a lot here is how scope of competency is the ethical choice. So based on our code of ethics, you are really required to gain competency in an area before practicing and mentorship is one of the best ways to do that. And I'm just so thrilled that you mentioned that this just like my tiny little soap box about mentorship, I'll get off of it now. So as a person, as a clinician, I have zero experience with voice. It is not my area of competency. I took my one graduate school class, and that was it at Emerson, which was a wonderful, uh, but you were not there at the time. So I'm wondering if either of you can tell me a little bit about, I mean, this is a very generic question, but, but what [00:19:00] is it, what is it like, what kind of work are you doing? In, in this, in this world of voice modification,  [00:19:07] AC Goldberg:  Oh, it's so fun. I mean, anyone of any gender can seek gender, voice modification, you know, sometimes you've got older cis-gender women whose vocal register has changed who are feeling, you know, uncomfortable, maybe they're being mis-gendered, maybe they don't, they want their voices to send younger. You've got, you know, people who are, you know, trans feminine, who want to be coded in all of their interactions as female. They don't, you know, they don't want to be mis-gendered. You've got, you know, trans masculine folks. You've got non binary folks. You know, you've got people who are, who are gender fluid, who want to be able to have different sets. But you know, really it's fascinating because everyone's voice is completely different. And I am going to dive in and tell you a little bit about the types of people who you might see because you know, people, when they oftentimes see, like you hear like trans feminine voice care or trans masculine voice care, they kind of assume that, you know, all female voices are gonna sound the [00:20:00] same. You know, you're going to have a higher pitch, more frontal residents, that sort of thing, which we're going to get into, but, you know, people who I see could range from, you know, a butch lesbian trans woman who, you know, doesn't want to doesn't, you know, doesn't want to seem, you know, traditionally feminine, but doesn't want to be mis-gendered to someone who is I, uh, trans, masculine and gay, and doesn't want to be accidentally read as female. You know, I've got there's a lot of crossover there. I've got, you know, people on my caseload who, you know, their primary goal is to not be mis-gendered in any interaction, but others who care less about that and more about how they feel about their voice. So, you know, people come to for a gender voice modification or gender affirming voice modification, because there's a discrepancy between their gender presentation, their outward gender presentation and how what's manifested in their voice and communication. Some people complain about like [00:21:00] strain, fatigue, a lot of effort. Their voices sound thin. They have a hard time projecting you know, people don't want to don't want to be read as the wrong gender in any circumstance. And, you know, you have to talk to clients about phone, voice, and how phone voice is always a little extra you know, believe it or not, you all listeners can hear my, my voice. I am still mis-gendered on the phone sometimes because I default to, you know, my old habitual, polite phone voice. And you know, uh, I got locked out of my bank account the other day and I'm getting, I was getting texts that some, someone was trying to hack into my bank account. And, and it was because I was using my phone polite voice from my old habitual voice, not my current voice that I'm using now. And people try to modify their voices on their own. And they have difficulty because they don't know the proper techniques and they get harmful advice on YouTube a lot of the time. And. Barb, do you want to jump in? So I'm, if [00:22:00] anything, no,  [00:22:01] Barb Worth:  no, I, I think you covered it. I, uh, I think that, you know, our clients will talk a lot about the anxiety that they feel that they may feel. Not everybody has anxiety about their voice, but some people do. We hear about people who say I, and I, and I'm using air quotes here. I pass because that's a, that's a word that I, as a cis person, I wouldn't use unless someone uses it first, one of my clients uses it first. So they might say, you know, I I'm, I, I pass until I open up my mouth. And so this is really creating a lot of issues for me. You know, people, some people are, I hate to say this, but in all areas of our country, you know, people are feeling unsafe. And so, it may, uh, they really might need some help with their voice because they want to feel safe. And some people feel like that they just don't [00:23:00] even want to be communicating or talking because the voice that's coming out, it's just, they don't connect with, with this voice. It doesn't match it. Doesn't align with who they are [00:23:12] AC Goldberg:  You can see gender voice alignment clients anywhere. You know, you can see them in private practice. You could see someone in a medical setting. You know, you can see them over zoom, telepractice and schools and camps are even getting in on the action. So if you're a school SLP, go for it.  [00:23:28] Barb Worth:  You know, I wouldn't know. One question is people always ask about insurance. You know, uh, I love to say that the more I'm in doing this sort of work, the more I see that insurance companies are covering the service. Uh, so it's really important to have an understanding of people's, uh, medical insurance to see if it is a covered service. What I think I cannot say enough about is that we, as, as practitioners must be licensed in [00:24:00] this state in which we are practicing and the person resides. Okay.  [00:24:06] Amy Wonkka:  That's an important technicality. [00:24:08] Barb Worth:  Yes, it is very important. And I know that there are people who don't either don't know that, or maybe perhaps are not conforming to that. So I'll say it again. We need to be prac, you need to be licensed in the state in which you are residing and you are, you are practicing you're in which your client is practicing. Kate.  [00:24:33] Kate Grandbois:  I have a question that might be a little controversial or maybe an interesting question. It recently came to my attention that there are SLPs who are engaging in this work with this community and calling it coaching. Yes. And not clinical service. And by calling it coaching, they are, sir, they're skirting around a lot of the liability. Well, supposedly [00:25:00] skirting around this issue of licensure and liability. I'm wondering if there is any, if you have any like, perspective on that.  [00:25:08] Barb Worth:  Well, AC and I were talking about this yesterday and you know, I, I, yes, it is happening, right. You do not need to be a speech language pathologist to do this work. Okay. So many of the people who were doing this way before I was doing this in the way before AC was doing this were not speech pathologists. A lot of them were actually singing teachers  [00:25:29] AC Goldberg:  And actors and voice coaches. And they’re all also qualified to do this work, but we can't un-be SLPs in order to do this work. So we have to act within our ethical code. At least I feel that way. In terms of where sort of that boundary is you know, and I, I would feel uncomfortable. If I would not practice in a state where I'm not [00:26:00] licensed because I am an SLP.  [00:26:04] Kate Grandbois:  Thank you for answering my question. I think it's an interesting intersection, but, but moving on, so I'm dying to hear more about as again, as a person who knows zero about, I want to say, I know zero about the larynx. I know more than the average, but very little in that part of my brain has, has, you know, I've made room for other knowledge.  [00:26:25] Barb Worth:  All right. So Kate, I want to ask you, do you remember about the three sub-systems speech production? Okay.  [00:26:32] Amy Wonkka:  I'm really glad you're asking Kate. Oh my God.  [00:26:37] Kate Grandbois:  You love it. I'm just, oh no. Okay. Listening. Please. Don't take my license when I can't answer this question. [00:26:42] Barb Worth:  So it's power source and filter.  [00:26:47] Kate Grandbois:  Oh, I wouldn't have said that. I would've said like resonance. I don't know what I would have said. I'm just going to write my mouth here. [00:26:52] Barb Worth:  Right? So power respiration source the larynx, the vibrating, the vibrating source of the larynx and the filters, the resonance. So you, [00:27:00] you got a third of it, right? Yeah. So, you know, when we're doing this type of work, there are other things that we addressed, but those are the three sort of foundational areas. So, you know, looking first at respiration, you know, the respiration is the gas for our voice, right? So, you know, in our practice, we may be depending upon, you know, our, what our assessment entails, we may be addressing sort of, you know, some breathing mechanics, some breathing behaviors. We certainly are going to be addressing the source, which is the larynx. And I think it's important to, to remind our listeners or to educate our listeners. Cause they, they may not know this about, uh, the effect of testosterone specifically on the larynx. Okay. So, you know, a person who has undergone testosterone guided or [00:28:00] related puberty right. Will have some changes to their larynx. So it will, the testosterone will thicken the vocal folds, will lengthen the vocal folds. And actually the larynx itself will, will change slightly in angles so that there's a sharper sort of angle at the front. And it will widen in the back. And that are, those are some of the effects of testosterone for a person who has yes. A you're putting your hand up. Okay.  [00:28:32] AC Goldberg:  I'm putting my finger up because I just want to remind our listeners that this is someone who has gone through a testosterone-driven puberty at an age where they're still growing. And this is not something that occurs with when a person who might be transgender non-binary takes testosterone. Yes, the thickening of the vocal folds occur occurs, but the sort of change to the structure is there's no evidence that that [00:29:00] occurs at this point which can actually result in this thing called in chopped F to M locality, which is, you know, something that we see a lot of the time in the clinic. So, you know, you get, you get a little bit, you get the thickening but you don't actually get the structural differences. Now Amy's got her hand up.  [00:29:17] Amy Wonkka:  Well, I have a question because I've never heard of that entrapped FTM. And what does that do? I assume that that's a result of the smaller laryngeal structure and the larger vocal folds. [00:29:28] Kate Grandbois:   Got it a description of what that is. Cause that was way above my wheelhouse right now. [00:29:33] AC Goldberg:  So you got it [00:29:34] Kate Grandbois:   above my pay grade.  [00:29:34] Barb Worth:  Yeah. So the thickening of the vocal folds, but, but but you know, you have the say th th th the carriage is the same. So what is holding the vocal folds hasn't changed. So that can lead to some, uh, and I think that there is this misconception, perhaps that if an individual [00:30:00] undergoes hormone therapy and takes testosterone, that, that, that voice change will sort of happen and there'll be a hundred percent satisfied. And so there can be some issues with voice projection and the testosterone doesn't change the resonance structures. And we're going to talk about residents. So this is probably a really good segue into talking about resonance. So what is resonance? Resonance is, you know, sort of, I like to think that it's the color of the voice. All right. So you have this vibrating source. These vocal folds are vibrating, you know, 100, 200, 300, 400 times a second. Right. And as the, that's the source, and as that sound comes through, the cavities certain, that's a complex sound and certain sounds are amplified and certain sounds are dampened. And so I love to give the example of it's the [00:31:00] difference between, ah, ah, oh, that was good. Wow. I heard two completely different sounds, but then if you were to measure the pitch of that, that would be the same. Okay. Two completely different sounds. So, you know, so with some of our trans men or people who are trying to masculinize their voices after undergo, after having, having hormone therapy, sometimes we work with them with regards to their resonance because their pitch might be satisfactory to them, but we changed some of the resonant qualities. Yes. Amy, you have your hand up  [00:31:46] Amy Wonkka:  and if you can just explain, because it's a podcast, if you can just explain for the listeners kind of what you did there with your facial structure to change that resonance.  [00:31:56] Barb Worth:  Well, did I change my facial structure, but actually I'm going to do it again and not [00:32:00] change facial structure. So, ah, [00:32:09] AC Goldberg:  what do you think she's doing Amy? I'm so curious as to what your take is because I know exactly what's happening  [00:32:15] Amy Wonkka:  No, I mean, I, I feel like it's something happening in like. The soft palate area. I don't know. I don't know.  [00:32:25] Kate Grandbois:  nasopharynx is, is moving back and forward [00:32:28] Barb Worth: . So I was changing some of the you're right. I was, yes. And I also was changing the tongue. So my tongue for, as my tongue is higher, it's closer to the EE sound. Okay. And when we're feminizing voices, sometimes we look it's called eiffication. So we're actually trying to get that brighter quality by changing the, the, the the, the, the height of the tongue. I was also probably changing my laryngeal position as well. I was probably [00:33:00] raising my larynx slightly.  Kate Grandbois: That's a lot of things to keep track of.  Barb Worth: It is a lot of things to, to keep track of. And can you imagine getting into sort of, you know, voice training, imagine trying to take something that is so habituated that you've been doing one way for so long and not even thought about it and then coming for, you know, to see a voice clinician. Kate Grandbois: No.  Barb Worth: And having to start literally at the phoning level.  Kate Grandbois: Right, right.  Barb Worth: And make these adjustments so that you can achieve the desirable voice.  [00:33:39] Amy Wonkka:  Oh, what, what does the, what does the evaluation process look like? Like what do you, how, how do you get started?  [00:33:48] Kate Grandbois:  So what do you do? I'm very overwhelmed by all of these tiny pieces. So many muscles in there  [00:33:53] AC Goldberg:  At the evaluation, you know, we, we evaluate to, it's not to [00:34:00] pathologize a trans person, but it's just to get baseline data on, you know, where they are, ask them where they want to go and screen them for a voice, voice disorder. You know, sometimes you get someone who, you know, you're like is, is that a polyp I'm hearing? Or, you know, is that GERD like, what's what's, do you have some muscle tension? Dysphonia sometimes we get a lot of that and we refer to an ENT. If we think that there's anything going on prior to starting treatment, we need to see that strobe. Because you know, you really just never know. You don't want to do any harm to, to someone's voice by saying, you know, okay, you should implement these strategies, you know, in order to modify your voice, but you have an underlying voice disorder you want to, you need to know and treat and deal with that underlying voice disorder before before you start and you can get some instrumentals but they're not necessary. Amy, here, you have your hand up. [00:34:48] Amy Wonkka:  Sorry, I'm trying to remember something that I may be remembering wrong. If I go way, way back into my grad school days, I do feel like voice is the one area where you kind of [00:35:00] always need that ENT opinion before you treat, or is that, is that something I'm inventing  [00:35:06] Barb Worth:  if someone has a voice disorder and you are as a speech language pathologist,seeing them for a voice disorder that has been diagnosed by an ENT. Yes. However actually ASHAs, uh, practice preferred practice pattern is that someone needs to be seen by an MD or a medical profession professional, but it actually does not specify an ENT.  Amy Wonkka: Okay. Okay. Barb Worth:  So, but, but in the area of voice modification, the individuals, the individuals not need to see a medical doctor. However, some insurance companies may require a referral from a medical doctor. So, but that's between the person and their insurer. Not. Does not direct our, does that guide our care, but you know, I, I do want to say that I came from, you know, a, sort of a medical background. And so we did an instrumental exams on our, our clients who were [00:36:00] receiving, uh, gender affirming voice therapy. And I have to say, because I came from that sort of mindset, it was really helpful for me as a clinician to see their larynx in action. And I will, and I will say that we did end up diagnosing a lot of people with any, anything from MTD muscle tension dysphonia, to nodules, polyps, you know, what have you. So I guess I would just caution and say that while instrumental exam is not necessary, really use your ears and, you know, gather your information. And we're going to talk more about what else goes into the evaluation, but, you know, use that information. And when in doubt, refer out. Right. When in doubt refer out. [00:36:50] Kate Grandbois:  I like that always. And one other thing it's making me think of is though is the important intersection between those clinical referrals and the, hopefully the [00:37:00] training that you've done in cultural, responsiveness and competency, so that you don't pathologize the individual that you're working with and you don't, you know, oh, this is disordered or in any way advertently or inadvertently. Because I think that I, I assume that that can be a very sensitive or that can be a discussion that takes some, some competency.  [00:37:24] AC Goldberg:  Well, it can be sorry, Barb. Did I cut you off?  [00:37:28] Barb Worth: No, no, no, no.  I was just going to wait. We just went through. Uh, is that it's also, you know, those, those relationships that you have with other providers are really important. And it's also super important that if you're referring your trans clients to a provider that you know, that you're referring them to a trans friendly provider and safe space, I'm sorry.  [00:37:47] AC Goldberg:  I see nicely, precisely what I was going to say. So mind-meld as usual you know, you just have to make sure that, that you're not referring someone because, you know, trans people come with a lot of trauma into these clinical spaces. You know, we [00:38:00] are, we have a lot of medical trauma related to just trying to get, you know, competent care. So we might be resistant to a referral. So if you say like, you know, this is my, you know, this is my colleague. Like they, they see all of my trans patients, like, you know, that you will be treated fine in this office. Like then, you know, that person might be more likely to actually follow through and then see you back in your clinic, as opposed to someone who you're just referring out for something. And they don't really know what they're, where they're going or what they're getting, but you know, more, more evaluation components, you know, you want to do, do your intake and interview and you have to have that culturally responsive lens. You know, you don't, you need to have consent for all sorts of, for the whole interaction. May I ask you some questions, you know, will you tell me a little bit more about your voice use? You, you, you can't. You know, informed consent is not like a one-time sheet of paper that people sign. Informed consent is an ongoing conversation between a client and [00:39:00] clinician that guides a collaborative goal setting agreement. That's extremely important when you're dealing with individuals who come from backgrounds that may have experienced trauma having your client collaborate with you and set their goals, tell you what their, what they want their voice to sound like.  So with regard to the intake, like we talked about in the, in our first appearance here on SLP nerd cast, you obviously have to come at things through a culturally responsive lens with regards to your intake in your interview. And I'm not going to relive that whole podcast because you really should listen to it. Barbara, you want to take this one?  [00:39:37] Barb Worth:  Sure. So I, you know, there have been some published quality of life measures that I think can be very helpful to get some information, you know, from your clients. There's, uh, something called the trans woman voice questionnaire. It used to be called the TBQ. There is the trans voice questionnaire which is F to M, which is outdated terminology, but that is one that we are using for our transmasculine folks.[00:40:00]  Unfortunately, there are no published nonbinary measures, hopefully that will happen in the, in the future that they will be a quality of life measure. That's more appropriate for someone who is non binary. And then there is something called the voice handicap index, which helps to screen for any kind of a voice disorder and something called the reflux sensitivity index, which also can be helpful to screen for, uh, symptoms of reflux. Super important when you're doing this work that you invest in a good quality microphone that you have some sort of, uh, an app or whatever to, to do your recordings. There is a free acoustic analysis software program called Praat P R A  T that I currently use. As again, I said free, but it's clunky, so you have to play with it. And I put a shout out to Christy Knickerbocker who on her website actually has a little tutorial on how to use Praat. And you know, something like a [00:41:00] stopwatch and, and beyond that, you don't really need a whole lot of equipment to do this work. The typical things that we, uh, measure or, uh, is, uh, maximum phonation time. So you'll probably remember that from grad school, uh, as long as you can on a habitual pitch. The S to Z ratio, again, you know, you probably learned that in grad school, but just as a reminder, how long somebody can sustain the skinny S is a guesstimate or, uh, somebody's vital capacity, and then how long they can sustain the Z sound zzzs is, is a guesstimate of of glottal, glottal, sufficiency. So you're looking, you want that estimate and that Z to be, uh, pretty much one-to-one meaning, you know, the same amount of time on the S as the Z. And that's a screening. And if, if it's not one-to-one and the Z is shorter you might want to think about that there could be a vocal pathology that's causing the vocal folds not to completely close. [00:42:00] So we take with our sophisticated software, uh, programs, we're taking the average fundamental frequency, we're recording during conversations, reading tasks, you're going to do some sort of a perceptual, uh, measurement. So if you were, again, you remember from, from, from grad school, something called the Cape V, which is a perceptual tool to use. And I also really like to do some of my own sort of informal judgment on things like intonation and things like resonance. So as you get dive deeper into this sort of work, you get to you, you start to think about somebody's intonation patterns. I think a lot about stereotypes, unfortunately, in this, uh, area of our profession. But a, a stereo it's stereotypically a more feminine presentation is to have more rising and falling of your voice. And with regards to resonance, we talk about, and again, beyond what we can talk about today, but things like chest resonance and [00:43:00] head resonance, which are sort of, again, going back to that sort of qualitative aspects of a voice. So we listen for those sorts of things. And then there are other acoustic measures that you can take. If you, again, going back to grad school, like a jitter and shimmer and that sort of things, not necessarily as important, unless you're suspecting some sort of a voice disorder. And then, you know, finally, sometimes we look at some non-verbal communication. So we may look at things like body language and gestures, and also important to pay attention to nonverbal reflexive, voicings, such as throat clearing and laughing and those types of types of things. So after we gather all of this information, I know you want to know what do you do in a therapy session? So if you go back to that sort of power source and filter that we talked about, so we may do things like working on, and I hate the word diaphragmatic breathing, but I, and I prefer the term lower focused breathing. So making sure that, you know, [00:44:00] people are expanding their upper abdominal muscles when they're breathing. They're not using a lot of chest movement. This is going to be helpful for all of our clients. It's really sort of the, again, it's the foundation of the voice. And then with regards to looking at the source. So this is when we start to talk about things like pitch. So there is normative data with regards to how we gender a voice and how that matches someone's pitch. So again, going back to sort of, you know, grad school and things like fundamental frequency is how many times the vocal folds are vibrating per second, 200 times a second is the typical pitch for someone to be gendered as female, but really it's a range and it's anywhere from about 150 to about 225. So this, this really [00:45:00] huge range that we will going to listen to a voice and say, Hmm, I think that that person might be feminine. They may be female. And then when we're thinking about a more masculine sounding voice, we're talking about a voice that's really anywhere from about a hundred to 110 to about 140, 150, but there's this really huge area. That is what we call sort of the gender neutral area. And that's when all of those other aspects of voice come into play and communication come into play that are, we start to say, Hmm, why do I gender that voice as more masculine or more gender neutral or more feminine? And that's when we start to talk about things like resonance, we start to talk about things like intonation we talk about is the voice [00:46:00] choppier, or is it more blended? And again, a more stereotypical masculine sounding voice is not going to be as blended from one word to another. I was just very blended going from one word to another, which we think about as a more feminine presentation. So these are the types of activities and tasks that we do in our therapy session to help our clients achieve their desired vocal quality. And going back to what AC was saying about the evaluation, that is the time when we really need to listen to our clients. And ask them what they want in their voice. It is not about my perception. It is not about society's perception. It is about their desires for their communication style. And Kate has her hand up. [00:46:58] Kate Grandbois:  I do, I have a question. [00:47:00] We talk a lot about data collection on here. Cause that's very ethical, making sure that what you're doing is, is aligned with perspectives and values of your client. Cause that's evidence-based practice. And I'm wondering if you ever use a recording and have the person listened back to it as like a biofeedback to say, yes, this is what I like. Or I don't like this aspect to give you that feedback about what they would like to change, because I say that because I'm a speech pathologist and the nuance and subtlety and specifics of what you're talking about. It is a lot. I mean, those tiny little subtle things can make a big difference. [00:47:34] Barb Worth:  And Kate, I'm going to ask you a question. Oh no.  Barb Worth: When you hear, and Amy, I'm going to ask you when you listen to your voices back,  Amy Wonkka: I hate it.  [00:47:46] Kate Grandbois:  That it doesn't I've  [00:47:47] AC Goldberg:  I think it's universal. Yeah. Oh my gosh.  [00:47:51] Barb Worth:  That doesn't bother me.  [00:47:54] Kate Grandbois:  Am I, am I weird I can listen to my voice? Cause I edit all these audio files. I've just, I just listen  to it. [00:47:58] Amy Wonkka:  [00:48:00]  [00:48:00] Barb Worth:  You are really in the minority. Most people hate. Why is that? Well, first of all, what did you remember from back in grad school that we hear ourselves through bone conduction, right? So we're actually not even hearing other people right here. And then we have all the limitations of our recording equipment. Right. Right. So, so that's really multifaceted. But the other thing that I do want to bring up is that there is a certain percentage of our clients who have vocal dysphoria. And so for some people listening, it's hard enough for them to practice right. Their voice, but to listen back can be really challenging. And so that is something that I really use discretion and would only do following a, uh, a conversation. You are agree AC? [00:48:56] Kate Grandbois:  you are wise. I never would have thought that  [00:48:59] AC Goldberg:  [00:49:00] when I, when I ask my clients, I say, you know, are you comfortable recording your voice? Are you comfortable recording your voice, sounding in this new pattern? So you can tell me whether you like the way, it sounds, don't think of it as your voice. Think of it as, you know, is that a voice you can, you can listen to because I, a lot of clients really, you know, do experience a tremendous amount of vocal dysphoria and hearing their voice can, can trigger that. And even though your recorded voices and the voice that you hear in your head, it's still can really be like murky territory. And you know, there, I do take recordings of my clients so that I can, you know, measure progress. But I frequently have clients who don't want that shared with them until they feel like they've achieved where they are, or where, where they are, where they want to head with their voice.  [00:49:50] Barb Worth:  I think to answer your question though, Kate, with regards to, so how do we collect data and AC might have a different response to this, but one of the things that I [00:50:00] think is really hard for my graduate students is that we do a lot of Likert scales. And so, because it really is ultimately about the client's perception and their desirability and satisfaction. So we do a lot of like on a zero, zero to five, five, meaning this is, you know, sort of, yes, this, this is, this is it. This is what you want, where are you today? Or where were you in that segment? Right. And, and I think there's probably a little bit different than, than, than other aspects of our field. Do you agree?  [00:50:31] AC Goldberg:  Oh yeah. I mean, I say you know, how did that feel? And I, you know, usually there's a numeric scale. How did that feel? Do you want my feedback? You know, and then I might tell them if they say, you know, that only felt like a seven, how do I, how do I take it to a 10? And I, I talked to tell them something like, you have to over cue you in order to get there and then fall back into where you were trying to get to.  [00:50:55] Barb Worth:  So with regards to sort of like, you know, therapy techniques that we use you know, [00:51:00] we do a lot of the techniques that you learned in voice class or that, that, that people who work with voice, people with voice disorders do use. So things like resonant voice therapy, which is a, which is, uh, a technique to help to get a more forward resonance. We do things like sending occluded vocal tract exercises, meaning [lip trill] and I think AC has a straw. Yeah. So phonating through a straw. We do, you know, laryngeal massage. So, yeah. So one of the things that we teach our clients to do, we may do first and then we may teach our clients only with permission obviously is to, to reduce any tension that they might feel, because you could imagine that, you know, this takes some retraining and I, I like to use sports analogies, you know, that you have to warm up in order to, to do this type of work. You don't go run a marathon without stretching and [00:52:00] in theory, right. And that also that there might be some, some small amount of muscle fatigue asking your, your, your, your muscles to do something different. And so things like laryngeal massage can be super helpful for the clinician to apply to the client and also for the client to learn themselves I think I also, you know, briefly mentioned, we do work on things like word choice or body language we work at on, you know, non-verbal vocal aspects like laughing, sneezing, coughing. We have sessions where we, you know, turn on a funny, uh, comedian and practicing laughing.  [00:52:39] AC Goldberg: , The best. practicing laughing, also practicing loud voice practicing phone voice, practicing polite voice you know, sort of, you never think about all those sets to your voice until you're doing this type of work. And you're like, oh, I have a different voice for, you know, when I'm ordering food at the drive through versus when I'm calling to make a doctor's appointment. Versus when I am talking to a friend or when I'm [00:53:00] raising my hand in class, they're all different sets and people need to, you know, make sure that they're comfortable falling into their new habitual voice in each of those sets. [00:53:09] Barb Worth:  And I think, uh, you know, we start very much, you know, at sort of at the word level and then we sort of move along and I think. It's also really important to remember the cognitive load that it takes in order to be thinking about your voice and formulating language at the same time. So I'll give you an example. I'm so proud of my graduate students, because they have formed this really incredible group of, of actually as a, it's an interesting group because it's actually people working on masculinizing their voice and feminizing their voice. And they work together on work-related tasks and do work presentations. And so these are people who have been in therapy for a while. Let's say like six plus months and they get together and they work on their workf voice. [00:54:00] So, uh, it, it, and, and it takes a huge amount of skill to be able to talk at such a high level. I mean, we have a PhD students who were talking about, I don't even know, like astrophysics, right? I don't even know what they're talking about, but it is incredible at this level using their new voice.  [00:54:24] AC Goldberg:  Imagine me as a speech pathologist, speaking as a speech pathologist, using a new voice, it's a thing. We still have to, I do still have to center myself and call my attention to it. I'll find my resonance creeping all the way up, especially at the end of the day, like I'm right here. And like, I just have to kind of like, be like, okay, you know, get, get yourself back down there.  [00:54:46] Kate Grandbois:  That's a tremendous amount of things to focus on all at once. Not to mention any environmental variable or any, I don't know. Other social cues you're picking. I mean, communication is complex on the best of days. [00:54:57] Amy Wonkka:  So to try and think about [00:55:00] shifting something that's so automatic that we don't, I mean, even just the points that you were making about all of the different vocal registers that you're using in all of these different contexts, I don't, i’ve never thought of that, but then you set it in it completely makes sense. But to be thinking about all of those vocal changes all the time, plus your message I don't even.  [00:55:19] AC Goldberg:  think about just spelling your last name. When you're, when, when you're, uh, you know, over the phone, you know, like, okay, you know, what's your last name? Can you spell that? And then, you know, when you have to spell something over the phone, it's like G O L and you know, if you're spelling something in your new habitual voice and you're like, oh my gosh, I have to make all of these strange sounds and this new voice, I mean, even spelling can be, can be burdensome. When you're, when you're using any voice. We love to empower people to use their new voices across all settings. You know, I, sorry, go ahead, Barb.  [00:55:55] Barb Worth:  I was going to say, I know that we are running out of time and I know that we love to empower [00:56:00] the speech language pathologists who want to do this type of work. [00:56:03] AC Goldberg:  Yes. This type of work, this type of work is re uh, it's. You know, for me as a transgender person, it feels so full circle for me to come back and help people in my community, feel more comfortable with their vocal presentations, as someone who was so uncomfortable with my vocal presentation for so much of my adult life. You know, I feel like there was, I did a lot of work on my voice and I know what's involved in it. And so having the lived experience of modifying my own voice and knowing what goes into it, knowing the feelings behind it, knowing that somebody can come away and feel like, wow, like I can just walk down the street and talk to someone and not have them know. And that was a big thing for me, is that like, I just, I didn't want that to be the focus of my conversation. Like, oh yes, I'm trans. And you know, I would like to order a coffee. I never wanted that to be the focus of my conversation. And I [00:57:00] understand when my clients come to me with the sort of like, I just, I want my voice to go unnoticed. I want it to be aligned with the way that I look. I want to feel good when I use it. I want to be able to laugh in public with my friends. I want to be able to feel comfortable communicating across all settings. And I love nothing more than empowering members of my own community to use their voice, their most powerful instrument to speak up for themselves in all in all settings. And I love SLPs who provide this work and do it competently because they're helping people like me who, you know, may not have had access to this service years ago. You know, it really wasn't something that we, that we had that we offered as a field. So I'm just so grateful to clinicians like Barb, who, who started this work, you know, kind of in our field way before you know, I came along and, and knew that it was even a thing in our field. [00:57:54] Barb Worth:  And I, I feel so privileged to have walked this journey. I know it sounds super cliche, but [00:58:00] I do feel privileged. You know, when, when a client comes to my office and asks me to help them and such an incredibly personal, private, intimate part of their, intimate but yet outward presenting, right, part of themselves and the absolute joy that people feel as they're achieving their goals. And when they say things like, wow, like I am feeling so much more aligned. And I'm not afraid anymore, or I'm, I'm not reluctant anymore to use my voice across all [00:59:00] of these different aspects of my life. And I have to say that it, you know, out of my, as I said, 27 years of, of work in this field, I have to say it's the most personally rewarding for me. And hence why I think that AC and I want to help to educate others on how to do this type of work.  [00:59:27] Kate Grandbois:  Well, I can't say anything after that, that was moving and inspiring. And I think speaks to just your level. You, both of you, your level of knowledge, your level of passion about this topic.And we're so grateful that,  that you agreed to come back and hang out with us because this is just such a wealth of information. So thank you so much for all of this. [00:59:47] Barb Worth:  Well, Kate, it was such a pleasure and, you know, we, we didn't get a chance to talk about, you know, resources. So I know that we're going to put some information up on the website that will have, you [01:00:00] know, books that AC I would call them our Bibles. I mean, they're the Bible, the green Bible. Yeah. These are, these are resources that we use all the time. Various journal articles, uh, websites, and what have you that sort of have helped us along the way.  [01:00:17] Kate Grandbois:  We will put all of that in the show notes. So if you're listening and you're out on a run or drive. Rest assured that a list of resources and links will all be available in the show notes. So, if you, again, for anyone listening who wants to use this for ASHA CEUs, you can go over to our website and purchase access to the quiz. The link to AC’s platform, Transplaining.info with a code for the discount will also be listed in the show notes. Guys, this was awesome. Thank you so much for being here with us today. And we are just very grateful for your time.  [01:00:48] Barb Worth:  Thank you. [01:00:49] AC Goldberg:  Thank you so much for having us.

This is a transcript from our podcast episode published May 9th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:39] Kate Grandbois:  to welcome two guests onto the show today, which we're so excited about. Welcome Jennifer Leighton and Dr. Margaret Bowman. Thank you. Um, so little anecdote, all four of us had, we worked together once upon a time in the days of your many years ago, the four of us worked [00:02:00] together in this really unique outpatient hospital setting. And this hospital setting was unique because half of the office was supported by an outpatient rehab hospital. And the other half of the office was supported by a medical was more of a, not a rehab hospital was I want to say a regular hospital, a medical hospital. None of that makes any sense. But my point is that we all share. Um, an office, we shared a kitchen. Um, we shared interoffice space and half of us were therapeutic professionals on the other half were medical professionals. And it was this really unique, um, work experience because we got to participate in so much collaboration. There was so much collaboration between the therapeutic staff and the medical staff. Um, and because of that collaboration, we learned so much from our medical counterparts. We learned about medications, medication, side effects. Um, we got to have all of these casual discussions about communication and pain and medical needs. Um, [00:03:00] and we are really excited to, um, dive a little bit into that today. And discuss the relationship between complex medical needs and, uh, communication deficits. Um, we chose this topic because as speech and language pathologists, we work so closely with clients and students who do have complex medical profiles. And unfortunately in most speech and language pathology work settings, we don't get the opportunity to work closely with medical professionals and attend grand rounds, grand rounds lectures on, um, different types of medical interventions. So, um, we're super, super excited about this before we get started, though. I wondered if, um, Jen and Dr. B, you guys would tell us a little bit about.  [00:03:45] Jen Leighton:  Hi. So I'm Jen Layton and I am very excited to be here today. I have been a speech and language pathologist for over 30 years. Um, I started my career working with adults with neurological [00:04:00] difficulties on a traumatic brain injury unit. And that. Background gave me tremendous insights into the students I have been working with for the last 20 years. Um, fortunately I had the opportunity to work with Dr. Bowman, um, for six years at the clinic and I am very grateful that I've had that background. I feel like I bring that information to my job every day. And that was one of the reasons we thought this would be a great podcast to share with people. And, um, I currently work in a collaborative with students three to 21 with complex communication needs with a lot of AAC needs. And prior to that, I was a speech therapy consultant to the schools for AAC. [00:04:43] Dr. Bauman:  Great. All right. Hi, I'm Margaret Bowman. I'm a child neurologist by training. Uh, I began my career mostly interested in individual children, uh, who have learning disabilities or learning. Uh, somewhere along the line, I got [00:05:00] a little bored in the clinic and decided I would do some research. Uh, so I camped out and we did some research as it relates to brain function, particularly in individuals on the autism spectrum along the way, though, I've continued to do the multidisciplinary kind of approach that you've already heard about, which I think has been extremely valuable. Um, Jen talks about how valuable it was for her. I think as a neurologist was extremely valuable for me. Uh, we don't in our training have exposure to people with other disciplines. I would at least not outside of the medical field. And so the ability to work with individuals who would come from a therapeutic side of things and to realize that people look at, uh, the same patient from a different angle is really extremely bad. Uh, for those of us who were trying to treat individuals from a medical perspective, we don't always appreciate some of the other aspects of the child [00:06:00] or adolescent development. And so this has been a real experience for me as well, and I have to be here and I hope that we can all contribute and share information together. That'll help everyone. So thank you very much for joining us.  [00:06:16] Kate Grandbois:  Um, we're so excited to have you both. Obviously you both have a tremendous wealth of experience, um, and it's just nice to see your faces. We've both known you for years, so it's so nice to be here altogether and have this, have this really great discussion. Um, I am going to just quickly read through our learning objectives for the episode, as well as our financial and nonfinancial disclosures. Sometimes people write in and ask me to skip this because it's boring. I can't Ash. It makes me read it. So we will try and get through this as quickly as. Learning objective, number one, discuss the importance of considering medical conditions for individuals with complex communication needs learning. Objective number two, discuss ways to identify when individuals with complex [00:07:00] communication needs may be expressing pain learning. Objective number three, identify at least three medical conditions that could be associated with complex communicators disclosures. Jennifer Leighton's financial disclosures. Jen is an employee of a public school system. Jen's nonfinancial disclosures. Jen is a member of Attia and Masha. Dr. Bowman's financial disclosures. Dr. Bowman is employed as a neurologist in various outpatient hospital settings. She's also a researcher through the Boston university school of medicine, Dr. Bowman's nonfinancial disclosures. Dr. B is a member of the American academy of neurology, the American academy of pediatrics, the international society for autism research and the society for neuroscience. She also serves on various advisory. Kate that's me. I'm the owner and founder of groundwater therapy and consulting LLC, and co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of ashes, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for [00:08:00] behavior analysis and therapy, mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis specialists. [00:08:09] Amy Wonkka:  Amy that's me, financial disclosures. 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 Asher, SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children.  [00:08:25] Kate Grandbois:  Okay. Boring stuff is over. Now we get to talk about all the fun things. So I think it might be a good place to start to just address the obvious question. Why is it so important to consider medical conditions? When we are treating individuals who are either non-speaking minimally speaking or have complex communication needs, what is, what's so important about this relationship? [00:08:49] Dr. Bauman:  If you're asking me, I guess you are, uh, I think it's critically important. I think because. Most of us simply know that if we don't feel well, we're not going to do well. Uh, and if [00:09:00] we can't identify a child's discomfort, then how can we expect that child to, uh, give their best or put their best effort into and make the progress that they're capable of making it really is critical. It's not, not obvious about how one does this and it's, it can be challenging to make these kinds of diagnoses. And furthermore, it's also challenging about how you convey your suspicions, uh, to a parent without having to, uh, you know, alarm them so to speak. Uh, but I think that it, it is critical that somebody at least, um, raised the suspicion to some, uh, to a parent that there could be some medical concerns and that, that it should be checked out. And  [00:09:41] Kate Grandbois:  I think, you know, it also, you know, individuals with complex communication needs and individuals who are non-speaking or minimally speaking. They have a hard time communicating. So, you know, being we as speech and language pathologists, we think so often and talk so often about communicating basic wants and needs, but [00:10:00] communicating about pain and communicating about physical wellness is so critically important. Um, and I think for SLPs, you know, in the various, you know, different work settings that we have not only outpatient clinics where we used to work with you, but school settings, or, you know, outpatient clinics that don't have access to medical information, having a look, you know, having that as a lens and really making sure that's a focus is, is critically important for life. It really.  [00:10:29] Dr. Bauman:  Well, I, I, I totally agree. I think that they're probably just to take time here to expand on that topic a little bit. . It's extremely difficult. They have no way to verbalize or communicate to us that they're uncomfortable. Uh, so for example, there have been circumstances and I'll just give a scenario of a young woman. This is a young adult, came into the office, hitting her head repetitively, uh, saying head hurts. Uh, and that was the one thing that she could apparently [00:11:00] say, and her parents came on and they were saying that they thought she had.  I said, well, you know, before we go that route, I think we, she, she should see a gastroenterologist. Okay. Now this is not anybody that's got any kind of gastrointestinal symptoms whatsoever. Okay. Let's just start with that. All she's doing is hitting her head repetitive, long story short, they go to the gastroenterologist, which only they didn't think I was crazy. And they went to that person and it turns out that they did whatever the workup was. And this young woman ended up with gastroesophageal reflux disease in the soft vaginitis. They got treated and no more head hurts or heading her head. Okay. So I think in this circumstances, what you're getting is a woman who's telling you, I don't feel well. And. She's not telling you this is her one way of saying I don't feel well. It doesn't necessarily mean my head hurts. Okay. So I think how you translate what somebody is telling you is another issue, another scenario. And I'd like to tell stories, because I think they, I remember stories better than, [00:12:00] you know, having, uh, is to say that was a child that I saw in California. And this was a four-year-old and I was the third neurologist. And the story here was that this was a child who had seizures and everybody had been treating the seizures. And no matter what they did, he was still having these seizures and what should they do? And so somehow I ended up being the certain neurologist. So I hear the story. And about two thirds of the way through the visit, the mother says, oh, well, by the way, I have a video on my cell phone of one of these episodes. So she turns on her cell phone and I look at it and I. This is not seizure. This is Castro intestinal. This is a kid who's lying on the floor, all crumped over kind of doubled in pain on his stomach. Uh, and clearly looked like he had gastro and some kind of gastrointestinal problems, , a kid goes in the following week, and then DAS copy and the colonoscopy whenever she did. Anyway, I get an email. And now that I'm back on the east coast, uh, basically he says, yeah, Esophogitis good call. Okay. [00:13:00] So this is a kid that's been treated for seizure disorder that he didn't have for a year and a half, because nobody was, it's hard for where the, even the neurologist or the doctor to always understand or envision what a parent is describing, or at least it is for me. So yeah. Coming out of a neurology background when somebody's describing something and they say, well, I think it's seizure Mir your brain automatically slips into what you've been trained to think about. Okay. And I think the message here. I hope throughout this whole, whole presentation is that all of us have to think out of the box. We have to think beyond our own discipline. Uh, and I think that's the real advantage of working in a multidisciplinary environment. But to, to this kid who had been treated for a seizure disorder, he didn't have for a year and a half, and this is why it wasn't getting any better because it was the wrong thing. And I, I frequently say to parents that if, you know, if your child is presenting with some kind of symptoms, [00:14:00] know if it's a behavior problem or whatever it is, please take a video on your cell phone. Everybody's got a video on their cell phone. Please take a video on your cell phone and let me see what it is that you're actually talking about, because I don't want to misinterpret what it is that you're saying. And that's just been an enormous. Quite honestly. So I think it, it's not only that the child or the adolescent or the adult is having trouble communicating it's also, those of us in healthcare are having trouble understanding what the person is trying to communicate. Uh, and it may be that they are, they're giving us symptoms that none of us would predict would be consistent with the diagnosis that they really had. So if it's.  [00:14:43] Kate Grandbois:  You just said so many things that I want to talk like so much about gonna try and I'm gonna try and pick that apart a little bit. I think, um, one of the biggest things that you mentioned that stood out to me was this relationship between, between the behavior that you see [00:15:00] and the possibility of it being caused by physical discomfort or someone not feeling well. Um, and Jen, I know that you, you have a lot to say about this because you and I have had this conversation a lot before, um, in terms of, you know, the ethics around making sure that medical issues are ruled out and you can't just quickly be like, oh, well, that's how they've always been. Or, you know, that's, that's just how they are and dismiss something when you, without considering that layer of, of, of, uh, Possibility that it could be physical discomfort. I don't know if Jenny, you want to say something about that?  [00:15:36] Jen Leighton:  Well, the one thing that has struck me, um, particularly listening to, um, and other people, Dr. B, who worked in our clinic was that what things look like aren't necessarily what they are. So that has been like the greatest lesson I feel. So this young gal, who's saying my head hurts, my head hurts when in fact it's [00:16:00] not anywhere near their head. And I think it's, it's a little bit twofold, right? Like something can look like one thing and it's actually like potentially GI. But the other piece is that, um, I've learned that a lot of my students who have limited verbal means are able to learn something's wrong. Right. They can indicate some things wrong, but the abstract concepts of pain. Become so incredibly difficult. And like you said, localizing pain, like they don't know where it is. Um, recently I've had a couple of students who have been successful saying something's wrong, something hurts. And I feel like that's a really big step and of course, giving them the communication to do so. Um, but then again, then we it's left to us to try to figure out, okay, well, what is that? And what, what could that be? Um,  [00:16:45] Amy Wonkka:  yeah, I think you raised such a good point, Jen, because we're also not inside somebody else's body. So it's very hard as the speech language pathologists, you know, we talk all the time about teachable opportunities and seizing the moment. And if somebody hits, you know, fallen and scratched their [00:17:00] leg and they're crying and you can obviously see what just happened, you can certainly model the relevant vocabulary in that situation. But so many of these more complex medical issues, like what Dr. Bowman is talking about, we, we can't be inside their bodies with them, so we're not even able to have. Attach the language to that, uh, because you know, we don't know how it feels. We don't know where, where the feeling is and it is, it's really challenging. And I think, you know, the idea, I agree with you in terms of teaching sort of a broader catchphrase, like something's wrong. Um, at least as an alerting phrase,  [00:17:40] Dr. Bauman:  I think that's an important statement. I had, uh, one place. I was giving a talk. And after the raising these kinds of questions that you all have discussed and a very bright young woman looked like she was in her twenties, came up to me afterwards and said something like, you know, when I get sick, it takes me three days to figure out what's wrong with [00:18:00] me. I'm thinking to myself, here's a very bright articulate person who cannot figure out what's wrong with her. W what do we expect for a non-verbal into persons I, it really, it really brought home to me. The real struggle. I think it is in terms of, yes, we can teach people to say, okay, I'm uncomfortable, but yeah, identifying where that is or what it is. That's a whole new ballgame. That's really a chance.  [00:18:28] Kate Grandbois:  Um, I think that, you know, there it goes without saying that as SLPs, we have a really unique responsibility here to address these kinds of things. And Jen, I love the point that you made about when we go to teach communicating about pain and health and medical needs, how abstract some of that languages, um, even my own, my own children, you know, the difference between an ache or a dull pain or a sharp pain or a tingling sensation. I mean, there are so, you know, when you really, and [00:19:00] I'm sure Dr. B you have comments on this as a, as a medical professional, you rely so much on. On patient report of describing what, you know, what the physical manifestation is. Um, and so I think that there's a, there is such a responsibility there for us to try and, um, either not use that or not teach that kind of vague and abstract language and use more of a catch all or really consider what might be the most effective way to communicate some of those things. The  [00:19:32] Jen Leighton:  other piece I think about too, is the behaviors that we see, a lot of times when there doesn't appear to be an antecedent, um, it's a question that I guess gets raised in, in our, in my mind, but, um, you know, potentially not in everyone's minds, right. That maybe there is pain that's unseen and an unexpected and you know, is it happening right after a meal? Is it happening when the child's hungry? Is it happening after a bowel movement? Like, you know, where are we seeing it? And. [00:20:00] And even then it's really hard to determine, right? Dr. B I  [00:20:02] Dr. Bauman:  mean, Yeah, it is, uh, I mean, I could go on and on about a number of scenarios, but it's all right. If I keep talking about my little anecdotes, because I think that to me, at least anecdotes help. Uh, another, another anecdote is a young man who was 12 years old at the time. I mean, I would guess I would call him the gentle giant, uh, just as nice. Autistic young man. And, uh, Sunday night, of course, I get a phone call from his mother that she's locked herself in the bathroom that he's having these horrible, aggressive behaviors towards her and, and self-injurious behaviors. And I mean, just totally out of character and she's, what should she do? We, her husband of course, is out of town, which is sort of typical. And so there she is by herself and I said, well, you need to get to an emergency room as soon as you can. I've been, I think, you know, maybe you can call somebody from the school to help you, blah, blah, blah. Anyway, so, uh, so anyway, Long story short, she's able to get to the emergency room and they end [00:21:00] up in the psychiatric emergency room at one of the major hospitals . Good. And typically not to be snarky about this, but most of the time psychiatrists don't do a physical examination. They don't, they, you know, that's not their style so much. However, it happened to be that particular night that somebody did a physical examination in the psychiatric emergency room. And long story short, the kid turned out to have an otitis media, had an ear infection. And so they shot him up with penicillin. He fell asleep in the emergency room and got up the next morning and he was perfectly white walked out the door. So again, I mean, this is a situation where, you know, just an ordinary ear infection this kid was just going through the roof over this pain and discomfort. You're aggressing towards everybody and it turned out it was a otitis media and, you know, just fortunately somebody found it and printed it and got taken care of. So yeah, it's, as Jen said, the behaviors, you see [00:22:00] these odd behaviors, you're sort of like Sherlock Holmes. You're going to have to say, okay, is it, this is it, this is it. This isn't that's because lots of times. There aren't a lot of localized clues, unfortunately. Uh, one other scenario, and then I'll, I'll be quiet. Uh, was another, uh, the other child who was having sleep problems, uh, he couldn't, he'd get not, you know, he's snoring, he's waking up and blah, blah, blah. And I said, you know, maybe he's got big tonsils and adenoids. So I said, I think you need to see an ear nose and throat specialist. So I'd send them to that. They come back the next time. And I said, well, did you see the ear nose and throat specialist? Yes, we did. I said, well, what did he say? He says, he's got a big tonsils and adenoids. And I said, well, is he going to take them out? And then she said, and the mother says no. And I said, well, why not? And the answer was well, because he's autistic. I said, what? I said, I don't care what his diagnosis is. The kid needs to have his tonsils and adenoids so we can breathe so we can sleep. So it [00:23:00] gives, it goes back to this, this, I think something that Jen already alluded to There still that sense that some of these behaviors are just part of, well, you know, after all he's autistic or she's autistic, so that's why they do what they do. No, there, I don't care what the diagnosis is. If there's an odd behavior or there's a new behavior, we it's on us to try to figure out what's going on. [00:23:21] Kate Grandbois:  And I love, I love that you state that because I think, you know, we could just repeat it over and over and over again, to make sure that it hits home, um, that, you know, with when, when you're looking, when you are familiar with a student or client or patient, um, and, and this is something that I learned from you through our, like, even more recent conversations, any new behavior is concerning and should, you know, trigger your question of, is there something medical going on? Is there, um, you know, is there something happening? And I, I think that that is something that often gets ordered not often, but can get lost in [00:24:00] the. Educational model or treatment model when you're starting, when you start talking about modifying behavior. Um, and I think it's critically important. And another thing that I wanted to bring up that is related to something that you said earlier was, you know, this idea of behavior as communication. And if someone doesn't have communication skills or they're have emergent communication skills, or they're minimally speaking non-speaking and they aren't able to communicate about pain, how long are they going to have to go without medical intervention? How long will something go untreated? How long will they go without effective treatment and how, you know, we really need to consider that as a backdrop when we see these changes in behaviors, because they could be not just in a little bit of an earache, but they could be an excruciating pain because it's been there for however long, just thinking about your example with the ear infection. [00:24:56] Dr. Bauman:  Well, I think your point's well taken. And I guess one other example I would [00:25:00] have with that is that, uh, as was mentioned early on, I do research and we are research that relates to looking at post-mortem brain . And one of the cases that we got along the way was a young man who died of a ruptured dependence. And he I'm sure he had terrible abdominal pain. Nobody picked up that he had a pending appendicitis and a rector pending and he died. So, I mean, it's not just only, you know, let's take care of so-and-so's behaviors or whatever, but I mean, is this going to be a disorder that's going to potentially be life-threatening for the patient in question? I mean, that's overly dramatic perhaps, but it's. It w we can't afford to just sort of slide by some of these things. I think that we really do need to take a lot of it. Seriously. I think there's a huge tendency to say, okay, we'll use behavior management and I'm a big proponent of behavior management. I think that's great. Uh, there's a tendency to say, well, we'll put him or her on XYZ medication. Uh, um, not so [00:26:00] enthusiastic about that. Although I know it has its place, but if you're, you want to just cover it up with some medication, pardon me, medical band-aid then that's not going to get you anywhere. It's not going to help the child unless we figure out what the underlying problem is and can treat that problem. Well,  [00:26:17] Amy Wonkka:  not only can it be, it can be a matter of life and death, but it's also, even if it's not a matter of life and death, it's a matter of quality of life and all of our clients should be entitled to the highest, possible quality of life. So, I mean, I think whether it's an ear infection, that's going for an extended period of time without treatment that's causing somebody's pain, like that's also something that we need to be aware of and on the lookout for. Um,  [00:26:45] Kate Grandbois:  so all of those are important. I  [00:26:48] Jen Leighton:  have a question, Dr. B, have you ever, um, like, I dunno if there were children or families who have a little bit more difficulty accessing, you know, this type of [00:27:00] diagnostic, um, that would be required for GI, like. Or if a parent's afraid to have their child put out and they can't do an endoscopy on them or, you know, whatever it would be like, have you ever treated GI issues, prophylactically? Is that ever done or is that not really done in the.  [00:27:18] Dr. Bauman:  I think most of, most of the gastroenterologists that I work with, typically what they typically do is get the story and then they, they start off with some kind of medical management. So, okay. Well, this sounds like it's reflux. So I'm going to try to, um, I'm going to give X medication and we'll try that for a couple of weeks and then we'll have a conversation. And do you think it's any better than sober? So I think most of the time they do try to do something without having to do a procedure, uh, many times, however that doesn't work or they, you know, they try a second medication and that doesn't work so that they end up having to go in and do a procedure in any case, uh, and to try to confirm the diagnosis and then, you know, do something that's a little more specific. So yeah, I think [00:28:00] people do do that. It's not something I would do because I'm not a gastroenterologist. Uh, so, you know, I'm not sure I'd be the right choice, but I think some of my colleagues certainly do that and do it well. Sure. And  [00:28:12] Kate Grandbois:  I wanted to go back to something that. That one of you said earlier about just how sort of jumping off from the sensory processing difference and how some of that I think regardless of diagnosis can also just be respecting that you don't know how someone else's body is experiencing pain. So, you know, I, I think that w that's part of that autonomy of, uh, respect of, um, what's the word I'm looking for? Integrity, like respecting someone else's autonomy and integrity, to be able to, um, you know, experience things that are that's different than the way we experience them. Um, and before we sort of jump into our third learning objective, I wanted to ask you Dr. B about, you know, we've talked a lot about [00:29:00] behavioral, uh, communicating pain through behavioral means. Engaging in aggressive behavior or any other, you know, any change in behavior. And I didn't know if you had any anecdotes about something that was very subtle, um, you know, any sort of, you know, instead of the gentle giant, who was all of a sudden engaging in aggression, um, you know, are there any in your experience, any changes in routine or behavior that also have indicated pain that weren't, you know, huge changes from from day and night? [00:29:32] Dr. Bauman:  Hmm. I have to think about that, I guess. Uh, you know, sometimes I guess kids who have sleep problems, uh, I I've seen some changes in behavior that have come from dental. Uh, so somebody has a dental point pain of some kind. So they're. Eating habits have changed somehow that they got there, they used to eat whatever it is they used to, but now they're not, are they not chewing anymore? Or, uh, they w [00:30:00] they won't take what they used to your favorite food, or what have you ever seen seen something like that? And so one thinks about, you know, when say a cavity is this some kind of dental abscess or something of that sort, and I've seen that happen. So I'm sure that that can happen. I'd have to think a bit of that a little bit more, the more, the more circumstances that seem to stand out in my mind are the ones with the real dramatic. Yeah, sure. I  [00:30:25] Kate Grandbois:  just, I think what I, the point I was trying to make, um, was, or making that connection between, it's not always just a huge swing of a change. Um, you know, it's really taking the time to ask the family or ask the parent, are they having. Has anything else been off? Has anything else been to skew, um, and making sure that considering pain or considering medical issues is sort of a backdrop in your thought process was more my, my  [00:30:49] Dr. Bauman:  thinking, well, I think that, yes, I, one of the other topics I think that you have on your list is, is the issue of mitochondrial disorders. And [00:31:00] I think this is one of those scenarios. Uh, it's it's kids who, kids who, well, first of all, kids who go through regression , they had been talking now they're not talking anymore. And they go through this development aggression, but there are a subset of kids who go through multiple episodes of regression over a period of time. So you have a seven year old who's regressed. I mean, that's, what is that? That's not something that we're used to hearing about and we've discovered that this is one of our clinical flags to start looking at. Yeah, one of the mitochondrial disorders and whether there's something we should be able to do about that, there are kids who have been okay, physically, I guess, um, maybe a little bit low tone, but then start having periods of sort of what I would call low, low endurance or easy fatigability. And so somebody could say, well, that's a behavioral problem, but you know, you have to actually take that seriously again, is this a signal that this is some kind of a mitochondrial problem? You know, although we believe that many of the [00:32:00] mitochondrial disorders have a genetic, some of them having a genetic basis, it's not something that you necessarily see upfront. You may see it years later, or, you know, you can show up at someone unpredictable time. So I think, you know, any, any, I think your point is well taken any kind of changing behavior. That's kind of odd needs, need to investigate. Can you  [00:32:23] Kate Grandbois:  describe what it might look like for people who don't know what a mitochondrial disorder is? I mean, just like giving us a general overview of mitochondrial  [00:32:31] Dr. Bauman:  disorders. Okay. Well, he'll get about three hours in a nutshell,  [00:32:37] Kate Grandbois:  10 sentences or less  [00:32:38] Dr. Bauman:  go. There are a whole host of different mitochondrial disorders. Uh, so, and there, some of which I have to confess that I'm not skilled at that. Basically might've mitochondria are the inner engines for every cell in your body. So it can involve multiple organ systems. Uh, it's not just brain, it's not just behavior. It could [00:33:00] be GI. It could be some of these other things we've already talked about, but that's one of the same was as if somebody has multiple organ systems involved. Some of the other signals are the ones that I've already talked about with the easy fatigability for physical endurance, uh, episodes of regression. Uh, I had one other night, I've just lost it in my brain. But, uh, so th those would be the ones that we'd started thinking about. And yeah, generally speaking, we try to, to work those, those kids up, um, mitochondria are sort of the, uh, well, I guess I said the inner engine, rarely cell in your body, but they're what they call organelles that, that live in, in the cells. And so they are a real entity and they do require a certain substances sort of like gasoline for the engine. And so one of the things that we do is to try to identify, you know, somebody. Falls, it falls on the mitochondrial spectrum, so to speak and that we've tried. It there's really no hardcore [00:34:00] treatment for mitochondrial disorder. However, the, uh, mitochondrial society put out a consensus paper probably in 2014. Uh, and one of the recommendations they make is for what we call a mitochondrial cocktail, which is a group of vitamins that the mitochondria rely on for its guests and the engine. And we have those, those substances compounded, which is preferable, is certainly for kids, because otherwise they're going to be taking a handful of pills twice a day, but have them compound it into something that the child will actually take and take it twice a day. I would tell you that we've got many kids who've responded very nicely to the. I had one young man, for example, who, uh, wasn't speaking, uh, we, we put him on the cocktail. He language began to emerge. Uh, then the insurance company refused to pay for the cocktail. So they was off the cocktail and his language skills regressed. So then we were finally able to do a [00:35:00] medical necessity letter and they are insurance company went back and paid for it again. And fortunately he was able to recover the language that he lost. He uses a device pretty effectively for communicating and does, does use some verbalization, but mostly it says device, but, uh, anyway, he's. Uh, great guy. He's now a young adult. He works in a nursing home where they think he's the best thing since sliced bread and works in the mail room and the cafeteria in the laundry and blah, blah, blah. So, I mean, I th I think it, it gets back to changing somebody's quality of life, too. I mean, it changes.  [00:35:34] Kate Grandbois:  Sure. I mean, and I think we're sort of getting into that third learning objective, reviewing different medical issues that can sometimes overlap with people who have complex communication needs. And another one that we'd sort of touched on earlier a little bit in one of your anecdotes is seizures. Um, and I think that, you know, I, I know speaking personally, I've had several of my students and clients more than several, [00:36:00] many of my students and clients over the years, um, also have, um, a seizure disorder. And I wonder if you could tell us a little bit of what kinds of things as if a speech pathologist listening has a student or client or patient on their caseload and they are assessed, they suspect a seizure disorder. What are some of the things that you would recommend that they look at?  [00:36:23] Dr. Bauman:  Well, first of all, I think mostly what I've gotten from the speech pathologist who I've worked with is basically somebody says, well, he, when, when I'm working with him or her, uh, they often have these staring spells where they look like they're kind of out of it. And I called the name and they're not responding. And then, you know, a few minutes later they come back, uh, occasionally they'll, they'll describe some kind of twitching or unusual behaviors, uh, some little shaking things that the kids do, but most ones that I've heard from other. Maybe just the one that heard I've been this business of staring spells, which are, you know, I, I'm not like we used to see a lot of what we call used to [00:37:00] call Petit mal seizures were just both staring. So I can't remember the last time I saw petty mouse danger. They, most of them are now what we call complex partial seizures. Um, and so, you know, if somebody is reporting that usually the speech pathologist or the occupational therapist, whoever, uh, reports that they're seeing some funny staring spells, and they've raised the question as to whether it might be seizure. And usually they translate that to the mother, you know, transmitted to the mother who then transmits it to the doctor who then decides whether they want to work it up or not. And unfortunately I think most people. Uh, the trick is getting the EEG. Trying to get electrodes to go stick on somebody's head for any length of time is not easy. Um, furthermore, if you get it's it's, it's tricky. Okay. Uh, I don't know if you want to go through the whole scenario here, but, uh, we can get it turns out that you can do an EEG on somebody and they can have a perfectly normal EG and still have seizures. And the reason for that is that EGS are, are picking up [00:38:00] electrodes are picking up electrical activity on the surface of the brain. If they focus of the seizure is down deep, you're going to miss it. Okay. So it's perfectly possible to have still have a seizure disorder and have a perfectly normal EG. It's also perfectly possible to have a funny looking AEG and not have seizures at all. So you're still having to try to figure out how does the clinical piece. That you with what, what we're going to see on the, on the EEG? I think, um, again, it gets back to if, if somebody is reporting funny episodes that they think might be seizure, please, please turn on your cell phone and please give me a video of what it is that you're talking about. Because if I can see it, then I have a better idea of what you're actually talking about. Uh, and I realize that's not always easy to do when you're working with somebody and suddenly they start doing whatever it is. Do you have time to haul out your cell phone then and grasp a little video? Uh, some people are able to do that. Some, sometimes they did the event doesn't last long [00:39:00] enough, but if they, you know, honestly, a picture's worth a thousand words, whatever behavior is being described about, please, if it's ever possible to get a video of what these behaviors are. And I tell the parents the same thing, by the way, not, not just. But if you're a parent, can you just get me a video? So for example, the other day, some mother sent me, she was saying that he, her son has now got tremors in his hands. Uh, and I said, well, you know, what does that really mean to me? I mean, how is it central tremor weather what's going on here? And so I said, can you get a video? And she was, she was able to send me a video. So I had a better idea of what, what this was about. I think it's probably secondary to a medication when we just put him on, as it turns out, but okay. At least now I know what we're talking about here. Uh, so I think it all, it, it, it, any kind of video that anybody can get is really going to be useful, no matter what,  [00:39:52] Jen Leighton:  I think those could be helpful for really anything that we're seeing, right? Like if we think we're seeing something that looks [00:40:00] seizure ish and you might see it and say, gosh, that could be GI or, you know, so if parents are, you know, bringing students, children to medical professionals, videos of what the concerns are. Therapists staff people working with them, as well as what the family seeing. That's actually a really good point,  [00:40:18] Kate Grandbois:  Dr. B and I think, you know, as long as, you know, I think that's a really, really great point. And obviously there's that conversation that you have to have about like permission. And I know, you know, every workplace has their own, has their own, you know, sets of equipment and using personal cell phones to record students and patients and that kind of thing. But, um, I love the idea of, you know, maximizing our modern technology to, to translate more better quality information, because I think it facilitates that collaboration between medical professionals and therapeutic professionals. That's so critically important. Um, I, there are, uh, there's at least one other big disorder that I would love to talk about [00:41:00] called pandas, um, which I know all of us have had a little bit of experience with, but before we get onto that, there was one other question I wanted to ask about. And that's the fatigue. So I know from personal experience, um, in the handful of students and patients that I've worked with who have had seizures after a seizure episode, their level of fatigue is, is so significant. Um, and I, I didn't know if you wanted to talk about that a little bit and how that might obviously impact someone's learning or be a red flag for further referral, et cetera. [00:41:34] Dr. Bauman:  Yeah. Well, I, I think it's just a see to me, it's a signal that this was really a seizure, uh, that the, if in fact they they're that fatigued afterwards that they fall asleep for a few hours afterwards. Yeah. I mean, um, can't think of too many of things that would do that. So, uh, yeah, I think it just helps with that is if the fatigue gonna interfere with their learning. Um, maybe for the immediate future, but probably not, you [00:42:00] know, in between seizures, I wouldn't expect them to have such a degree of fi of fatigue that they were able to participate. But yeah, again, if you have frequent subtle seizures, I suppose that's possible, do you have people who have, you know, they can have 20 little events a day, I guess, and now not that I've actually documented that, but you know, it's, it's in the literature that you could do that. Uh, so I suppose that after that, that yes, we could have some intermittent fatigue and that could interfere. I think that, you know, if they're tuning out though and having so having a seat, I guess if, if in fact somebody is having some subtle seizures, suppose you're in class and this child tunes out because he or she had a seizure, but it's not possibly pretty obvious to anybody. They just blanked out. So to speak that they're not getting the information that the teacher is teaching or whoever's working with them, was working with them. So they can, then you have to say, well, you know, they can look like they've got an attention deficit [00:43:00] disorder because they just tuned out. But it's not an attention deficit disorder. It's because they tuned out because they had a seizure and then whatever was being talked about.  [00:43:08] Kate Grandbois:  Is the neurology behind? And I don't know if this is a stupid question or not. So you can just judge me in private later on after this comes out of my mouth. But if someone, is there a relationship between. Seizure activity or high rates of seizure activity and loss of skill. I know in the past, you know, I've in charts I've seen, um, you know, quote change in medical status, right. So they had a seizure or had a certain level of seizure and have lost some sort of skill. Is that, is that a thing? Is that a real  [00:43:40] Dr. Bauman:  thing? Yeah, I think it is a real thing. It's not common, but I think it is a real thing and it's usually not permanent. It's usually the it'll come it'll come back if you work on it again. Um, but yeah, I think it is a real thing. It certainly has been reported. So in  [00:43:55] Jen Leighton:  students or children or patients who are having difficulty, um, [00:44:00] like retaining or learning new information and they have a history of a seizure disorder, would you like in multiple seizures to like, like multiple small traumatic brain injuries? Like, is that how it's impacting the brain? I'm just curious, neurologically what's happening. I mean, we're seeing  [00:44:18] Dr. Bauman:  that sort of multiple I've had no, I don't think I see that as multiple brain injuries. I think that, that the nerve cells are just overexcited and are not transmitting information the way they should, but I don't see that as brain brain injury, per se. I think it's, um, I wouldn't them to describe it as atypical disordered neural communication, I guess, uh, hyperexcitability of nerve cells and nerve transmission of this causing this, the seizure activity. Uh, but I don't see it as brain injury per se. Thank you.  [00:44:54] Jen Leighton:  Because I do think that's a misunderstanding in some of the circles that I've been [00:45:00] in. So it's helpful to have that clarification. And then, um, I did have a question I wanted to go back about mitochondrial. So does mitochondrial disorder occur in the general population?  [00:45:11] Kate Grandbois:  Where do we see  [00:45:12] Dr. Bauman:  that? Actually it concur in the general population. And again, I have a set of non. twins girls. The mother took her down to Atlanta, which is one of the places that we were at a time using two for diagnosis, and she got a muscle biopsy and this young woman. With turned out to have a complex one mitochondrial disorder. I mean, I mean, I think our mother said that she tended to fatigue a lot, but I mean, other than that, I mean, cognitively find it turns out now she's graduated. She got a master's degree in special education and is teaching. Uh, but she still has a lot of trouble with fatigue. We've got her on a Mito cocktail and she's tasked to kind of pace herself in terms of the kind of things that she does during the day. So she doesn't overextend yourself in this sort of thing, but she's, she's definitely got it. No [00:46:00] question. And there's cognitively nothing, nothing wrong with this lady at all. She was just very nice pleasant, young woman, but she's got this excessive fatigue. Yeah. You're going to do not have to be autistic or have a special need in order to have a mitochondria. Very interesting. Thank you.  [00:46:17] Kate Grandbois:  So in our last 10 minutes, um, I wanted to review pandas. Um, I'm just going to ask you what it is because I have a very vague definition of what it is, but I'm, I would bet my house that my definition is  [00:46:30] Dr. Bauman:  wrong. Probably not. What's your definition. Don't  put  [00:46:34] Kate Grandbois:  me on the spot like that. I'm not going to tell you I'll be  [00:46:36] Dr. Bauman:  wrong. You're telling me you're the doctor. I want to hear what your impression is. Okay. Okay. I'm going to  [00:46:43] Kate Grandbois:  guess. Ready? I'm going to put my vulnerable position here. My understanding is that pandas don't know what it stands for. I believe it's an acronym and it is strep that has  [00:46:57] Dr. Bauman:  gone.[00:47:00]  That's very good. Actually, that's not bad. Okay,  [00:47:04] Kate Grandbois:  good. That's my medical degree that I  [00:47:05] Dr. Bauman:  got into cracker Jack box. Okay. Sounds good. So the right it's an acronym. It, and I wouldn't have to write it down. So, uh, it stands for pediatric autoimmune neuropsychiatric disorder associated with streptococcal. That's what pat does Stanford. So yes, you're absolutely right. It's related to stress and it's generally people who have had one or more strep infections, uh, why some people get it and some of the people don't get it. They have not clear it's an audit, considered an auto immune disorder. Uh, sometimes it can be fairly brief. Uh, usually it presents with, uh, behaviors such as aggression, OCD, behaviors, anxiety, depression, uh, again, uh, frankly probably any change in behavior. We're back to that story. Again, would be something that you would probably want to check it out about. Uh, there are ways of [00:48:00] diagnosing it. Uh, you're trying to diagnose it. Some of which has to do with, um, blood tests. Uh, there are also other, you know, some people would get other studies to try to move. Other possibilities of why this person is kind of falling apart, but usually the blood test will be something like Andy, any step to strep the licensed titers to show who that he or she has had a recent episode of, of strep. Uh, and then they're treated with Amie triple play. The first line of defense is, is antibiotics. And, uh, you know, sort of, it's not a quick 10 day antibiotic story. It's usually can be weeks worth of antibiotics. If that doesn't work, then there are people who go to more extensive treatment. So one of which is what's called IVI G so InterMune as a gamma globulin kind of therapies. Uh, sometimes the, uh, pandas can be. So it can last months. Uh, so that probably had kids. That is why I added as long as a year, uh, just, and you have [00:49:00] to keep trying to treat it and nail it down. So it's, it's, it's pretty variable. Uh, but, um, it's kind of a contract in some ways, in some places it's controversial, there's some places where they don't believe that pandas is real, uh, that they think it's, you know, something that, you know, somebody gets out of bed dream about or something. Uh, but I think I, I'm pretty convinced it's real. And I I've certainly seen kids respond to the antibiotics are seen them treated mostly with amoxicillin, but I think people are treating other ways. Um, I think that there is a lady by the name of Sue Sweden, who was at the NIH and who was really sort of the lead dog in pursuing this particular disorder for many, many years. I think she sort of semi retired at the most. Um, but I think has done some very nice research, which has been pretty convincing that this is a real disorder and it's a it's re is response response to strep infection. And I  [00:49:56] Kate Grandbois:  think it's worth mentioning that it's relevant to the speech and language [00:50:00] pathologists, because I've seen firsthand what it does from a communication standpoint, in terms of very persistent, repetitive communication in an individual who maybe didn't have that intensity of repetitive communication. And, you know, it sort of, again, that change in behavior that, that this is a change in status. And all of a sudden, all you will talk about all you are interested in saying is red truck, red truck, persistent, persistent. Um, and it was in my experience, it was, it was because of pandas. Um, Jen, I know that you've also had some experience. Um, and, and I don't know if you want to take a minute to describe how it can be related to communication.  [00:50:42] Dr. Bauman:  Um,  [00:50:44] Jen Leighton:  You know, I've seen it in two students. Um, and in, I guess, one of my questions related, and then I'll try to answer your question, Katie is what if it's not caught at the time that the strep [00:51:00] infection is active? And what if, you know, you see some of these, you know, these new OCD behaviors and they are going on for a period of time, and then let's say six months, eight months later, people start, you know, a physician or somebody decides to look into this, you know, like at what point is it always treatable? And I'm just  [00:51:19] Kate Grandbois:  kind of curious about that  [00:51:20] Dr. Bauman:  piece. I see. Well, that's a good question. And I don't know that I can answer it. Uh, oftentimes I will recommend. Families seek out a specialist who, uh, works with pandas because that's not, I mean, I'm aware of it. I know, sort of, you know, kind of at the surface superficial view of it, but I think, you know, really it's one of those deals where you really need somebody who's been around the block a few times and has seen a lot of kids with a lot of complicating factors. So, but, um, I, I think that they do get treated long-term I, but I not sure that I can pick them really answer that question. Actually. [00:52:00] It's a good question.  [00:52:00] Jen Leighton:  No, thank you. Um, and then just in terms of how it impacts communication, the two students I had were both AAC users. One had minimal verbal output, but he used his device to repair communication breakdowns. And what happened was the OCD was so intense about things, unrelated to communication, that it was difficult to get both of them in fact, to focus on communication and they weren't able to access. There basic wants and needs, um, what was going on for them. It was just because they, they kind of had these OCD completely unrelated. And in fact, in one case the OCD continued to change. So like one day it would be, you know, something and then the next day it'd be something, you know, a little more concerning and another day. And it had to, like, it had to get completed before then, then the OCD would change again. And, um, to be honest, he never came, you know, came around to being like, I really want to communicate, you know, sadly, um, that was a big  [00:52:59] Dr. Bauman:  issue [00:53:00] and this change of good and bad days, I guess it's pretty typical. I mean, it's not like it's always the same thing. So your.  [00:53:10] Kate Grandbois:  Before we sort of, um, wrap up for, for the day. Well, for this episode, anyway, it's not the, it's not the end of the day. It's the middle it's, it's the thing. Um, I wonder if we could just take a couple of minutes just to emphasize and recap, um, how, you know, we've covered a lot of different major medical issues, you know, this is so relevant to anyone with a complex body. There are so many different, um, intersections between communication disorders and medical issues. Um, and I think it's one of the we've, we've talked about a lot of really intense, uh, medical issues, seizures, pandas, mitochondrial disorders. But you've, we've mentioned that mentioned a couple of very, you know, every day aches and pains too, like ear infections, we mentioned [00:54:00] mentioned dental issues and vision. Vision is another, um, as another issue that I think is, is so important to, you know, to address,  [00:54:11] Amy Wonkka:  I totally want to echo that point. Kate, I think vision and hearing, you know, don't forget that we're  [00:54:18] Kate Grandbois:  looking at the, I mean the  [00:54:21] Amy Wonkka:  auditory system and the visual system are both super important, particularly when we're thinking about maybe somebody who might be using an aided communication system, you know, I mean, being sure that we're mindful, not only of, you know, kind of medical needs related to. Health issues, but just the reality that we need to make sure that everybody's getting the same access to hearing and vision screenings that are meaningful, um, is really important too. I say this is a, is a full glasses wearing person. Um, you know, but it makes a huge difference. It makes a huge [00:55:00] difference. Again, back to that quality of life piece. If you have sensory system, um, sensory systems that aren't working optimally and there's things that we could do to help make sure that you're better able to access auditory and visual information from your environment again, that's, that's really, really powerful. And  [00:55:19] Kate Grandbois:  I, I think, you know, we are this whole episode, we're talking about people who have complex communication needs and are either, you know, minimally speaking or non-speaking. So in these instances you were more likely more often than not probably dealing with some sort of augmentative alternative communication system. Um, and to Amy's point, you know, the hearing and vision systems are critical ax, sensory access points for communication, um, in a variety of different ways. So, um, so I think, you know, these are just really such tremendous points before we wrap up Dr. B and Jen, is there any, do you have any parting words of wisdom for, for our audience? [00:55:58] Dr. Bauman:  Well, can I, [00:56:00] instead of a party word of winter, I like to follow up on, uh, she shoot me down if you want. I would still think about. Because that can cause you vision problems as well. And I can only relate that because, uh, as an eighth grader, I beget, uh, this, uh, personal, uh, I remember failing an algebra test because I couldn't see the board and there's something happened to my vision and I couldn't see the board. And so I remember explaining that to somebody, uh, and I got a vision test and there was nothing wrong with my vision. It wasn't until I was a medical, actually I was a resident in ma kind of left medical school. And I was a resident in neurology at the university of Maryland. I might have one of these episodes and the guy behind me who was one of the faculty, people said, I think you have my Curry. Okay. Well, this has been going on all these years. Nobody just, you know, oh, well, blah, blah, blah. So. I know it's not just people who have disabilities, [00:57:00] you can have these problems. It can be people who, who don't have disabilities are having trouble explaining, or at least having interpreting so that people understand what it is that they have. So again, I think the speech pathology component of this is really important. How do you help people to verbalize what's really going on? I could have helped him. Probably a speech pathologist could have helped me at a time to help explain he described me because obviously he took probably about 10 plus years and more before I finally, I found out what the diagnosis really was. That's  [00:57:30] Jen Leighton:  such a good point though. And it is a little bit of like the chicken, egg phenomenon, you know, is, is someone having headaches because they have vision issues or they're having vision issues because they have headaches. Like, I think a lot of it is, um, like you said, like detective work, trying to figure out what's going on for students. One, one thought I have in terms of just sort of the summary piece is. Just how important it is for us to collaborate on all of the issues. You know, being in a [00:58:00] school, getting input from medical professionals, being medical professional, getting input from the school. I, um, I'm very fortunate to work in a program. Uh, we have a large number of nurses in our program, so we seem to be very medically based. And, but when we have students going for medical appointments, we do a Google doc and we write from every discipline's perspective and share it with the physician and the family prior to a student going. Um, and that just seems to have really taken off in the last couple of years, because, and now the physicians seek out that information from us, those who know us. So, um, you know, just, I do think the collaboration piece is just so key for our students and  [00:58:40] Kate Grandbois:  patients. I totally agree you. This was so great. I learned so much from both of you. Um, I feel like I can speak for Amy. She did too. I did. Thank you so much.  [00:58:51] Dr. Bauman:  Thank you so much. This was fun. It was good to talk to. [00:58:56] Kate Grandbois:  Yeah, thank you. So you guys, I mean, just giving us [00:59:00] your time, this was really awesome. So thank you so much. If anybody has any questions about this episode, uh, you can reach out to us@infoatslpnerdcast.com . Um, as I mentioned, you can earn Ashesi use for listening to this episode, if you would like to earn ashes, to use cruise on over to our website to find the episode, uh, and where you can purchase access to the quiz. We love hearing from our listeners. And we're so glad that you joined us today. And thank you guys for coming. Thank you  [00:59:25] Jen Leighton:  for having. [01:00:00]

This is a transcript from our podcast episode published September 12th, 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. We're excited for today. We get to welcome Jeannette Washington. Welcome Jeannette.  [00:01:46] Jeannette Washington:  Thank you. I feel very welcome upon among you SOP nerds. So I'm glad  [00:01:55] Amy Wonkka:  you're here with us today. You need to discuss dyslexia in schools, but before we get started, can you [00:02:00] please tell us a little bit about yourself?  [00:02:02] Jeannette Washington:  Sure. , so I'd love to take up some times talking about me. , again, as you all stated, my name is Jeannette Washington and I worked as an XLP and a software engineer. , I love working within that intersection. It has inspired me to write the novel technical difficulties. Why dyslexic narrative is matter. I am very fond of working with the language based learning population and really creating different avenues for teachers to assess the students that fall under that purview and for SLPs to learn more about their role as it relates to diagnosing, , those with dyslexia. So I Teeter totter between teachers and SLPs with teachers. I like to help them understand how they can include multi-sensory [00:03:00] activities into their lessons. And with SLPs, I love to help them understand how they are a part of the intervention process diagnosis. And so. So with that all said, , I kind of do a little bit of this, a little bit of that. , that space is generally called, like ed tech. So maybe we can call this the SLP tech space that I'm in.  [00:03:26] Kate Grandbois:  I love that. I love the perspective of, of having this knowledge of language development and dyslexia, and also being a software engineer. And maybe it's just because I'm an a, I know I talked your ear off about this before we hit the record button and maybe it's just because I'm an AAC person, but I, I think that is just so interesting that, that having that two perspectives, that must give you such a unique perspective in your clinical work. [00:03:51] Jeannette Washington:  It certainly does. It provides me with a different lens in which I can, , view different scenarios. And I'll [00:04:00] say that I stumbled upon. Software engineering as a means to, , to find something new. It was an exploratory stage. I was in, I had gotten a divorce and I was like, I want to reinvent myself. So I started really, uh, wanting to, to, to find ways in which I could empower myself as a, you know, as a woman and software engineer kept kind of popping up on my radar. So I was like, well, let me give it a try. And in doing that, it definitely opened up some new doors that I didn't have open for me previously.  [00:04:37] Kate Grandbois:  That's awesome. And you own your own practice now.  [00:04:41] Jeannette Washington:  You do a lot of fancy things. My practice, I own a practice called Bearly Articulating and it is in the Detroit Metro area. So if you are in Michigan, come see me and I hook you up. And right now I'm focusing on creating [00:05:00] assessments and creating resources because I know how important it is to create valuable materials that everyone can use. You know, it's only so much, you can tell people without providing some type of, , resource or material, they can put their hands on. So that's what I'm focusing on. , in this season of my life. That's  [00:05:23] Kate Grandbois:  awesome. Well, in the show notes, everything that we mentioned today, any online resource or any, any article, , will all be listed in the show notes. So people can just have a little library of resources, you know, right in their phone and their podcast player. So, , well, I, I just really want to keep talking to you, but I have to read these disclosures and learning objectives. So I'm going to try and get through that as quickly as possible. , so quickly the learning objectives and our financial and nonfinancial disclosure, sometimes people write in and ask me to skip this part. I can't ASHA makes me read it so I will try and get through it as quickly as possible. Uh, learning objective, number one, define how speech pathologists fit into the [00:06:00] intervention process of dyslexia in the school. Learning objective member to provide a comprehensive list of some of the components of a dyslexia diagnosis and learning. Objective, number three, identify strategies, techniques, and programs that speech pathologists can implement to target phonemic awareness. Then net Washington's financial relationships. Jeannette is the owner of barely articulating and the author of technical difficulties. Why disliked, why dyslexic narratives matter in tech Jeannette's nonfinancial relationships. Jeannette is a member of the international dyslexia association and the Michigan language, the Michigan speech language hearing association, Kate that's me, my financial disclosures. I'm the owner and founder of grand watt therapy and consulting LLC. And co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of Ashesi 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 Massey BA and the association for behavior analysis international and the corresponding speech [00:07:00] pathology and applied behavior analysis specialist. This is Amy.  [00:07:03] Amy Wonkka:  My financial disclosures are that I'm an employee of a public school and a cofounder of SLP nerd cast. And my nonfinancial disclosures are that I am a member of ashes sink 12. That's my dog. And I serve on the AAC advisory group for Massachusetts advocates for  [00:07:18] Kate Grandbois:  children. I'm able, so Jeannette, we're very excited. I want to get back into all the nitty-gritty nerdy nerdiness. Can you kick us off by telling us a little bit about dyslexia, just to make sure everybody is on the same page. And then once we've covered that, maybe a little getting into that first learning objective, , talking a little bit about the SLPs. [00:07:41] Jeannette Washington:  All right. So for those listening, I'm sure you've heard dyslexia being thrown out there in conversations casually, but you may not know what dyslexia is. So I am going to explain it to you in layman's terms, dyslexia is a learning disorder that affects your ability to read, [00:08:00] spell, write, and speak. Essentially it's considered a language-based learning disorder and it's often annotated as S L D specific learning disorder on IEP. So a lot of times you will see SLD and you're, and you're probably wondering what is this? It's likely that it is dyslexia dyslexia falls within the scope of speech language pathology, because it is hallmark with associating letters and sounds with. Just being unable to really associate them together. And, , your common indicators could include spelling, fanatic phone and elect. Oh my gosh, exactly. I want to say fall analogies so bad. I've been doing a lot of work, , within the letters program, if you all are familiar. And so [00:09:00] we're learning about phonology and phonological awareness. So it's, it's really deep on my brain. So what I want to say though, is a common indicator of dyslexia would be, , if a student spells phonetically and inconsistently, , for that student to read and reread with little comprehension, difficulty putting thoughts into words. And trouble with writing and copying. So those things you may see, and those things are some indicators, or as we are familiar with the phrase rich blacks.  [00:09:40] Kate Grandbois:  So I know we talked about this a little bit before we started recording, but I think it's an important point in, in that addressing dyslexia, intervening with dyslexia or other language learning differences is definitely within the scope of practice for a speech pathologist. But again, sort of revisiting that scope of practice as a larger circle, [00:10:00] then their scope of competence within a circle within that larger circle. Right. So just because something's in your scope of practice, doesn't mean it's in your scope of competence. And then within the smallest circle in that little diagram is your role in your workplace. And I, what I think is interesting about dyslexia is that we share. We share that with so many other disciplines. And if you are a speech and language pathologist, and you know that this intervening, you know, dyslexia, interventions are part of your scope of practice, you feel competent in that area. You still may not feel that it's within your scope and based on your work setting, if there are other professionals who have air quotes, nobody can see me. I'm doing air quotes who have been designated as the reading teacher or the person to intervene. , and I wonder if you can talk to us a little bit about that gray area and, and how SLPs sort of navigate those three  [00:10:56] Jeannette Washington:  roles. Okay. I think that [00:11:00] that was a great question and I love how you framed it for me. So I will say this dyslexia is not recognized in every state. , current legislation is happening around making more sense. , inclusive and aware of dyslexia and what it is. , there are some states that just, you know, they don't even utilize that terminology. And with that in mind, you have to be, , very aware when you're going into the school districts and, , practices. With that terminology. So for instance, , in the state of Texas, they have what is called a dyslexia therapist. So that person would be working with the net scope of competency for dyslexic learners, , and, uh, speech language pathologists may not necessarily be the first person that they would go to. If a teacher has a child that is [00:12:00] presenting dyslexia or, you know, have those common indicators, we talked about, , some districts prefer to use reading specialists, , almost exclusively. So they don't bring the speech and language pathologists into that conversation. So again, intervention is going to differ based on the structure of educational setting and the educational stakeholders and more over within nest. So it's a little political when you think about, , yeah, there's only about, , I'm going to say it's somewhere between 40 and 50 states that recognize dyslexia. So it's, again, it's political and I've seen legislation that is impending. So I think changes are around the corner, but, , right now you kinda gotta get here where you fit in. And so I think it's important for SLPs to learn about dyslexia and learn how to [00:13:00] assess and, and really be privy to dyslexia as a whole you're setting. That may not be something that you are working specifically with. So  [00:13:12] Kate Grandbois:  I had no idea that it varied so much by geographic lo I mean, everything in our field varies by geographic location to a certain degree, but I think what's unique is that there are. There are different roles and like designated titles and roles and responsibilities that vary so much depending on where you are. And, you know, thinking about that from the family or client perspective, how confusing is that? So who do you go to and how do you advocate for yourself?  [00:13:43] Jeannette Washington:  Very confusing. I would say the first step would be to look at the international dyslexia association website and find your states. And once you find your state, you can start making some allowances [00:14:00] in and learning more about how dyslexia is perceived within your state. That would be the first step. , but yeah, it's, it's really confusing across the board. I've lived in a couple of different states. That's why for me, it's like, oh my goodness, this is all over the place. Cause when I lived in Mississippi, they were just enacting a law where every child. By the age of five, we'll get a Fest for dyslexia, regardless if they show signs or not. That was something that the governor put in place because he was actually dyslexic. However, when I moved to Michigan, when I mentioned the word dyslexia, people were like going the other way, like, oh no, I don't want to touch that with a 10 foot pole. So, , it is going to definitely be based on where you are and that can help you to determine what roles you can potentially play. But I would still say that it's important to understand it so that if you [00:15:00] have general questions, you know, , how to answer them, where to look and that sort of.  [00:15:05] Amy Wonkka:  Well, and it sounds like there's the bigger umbrella of what the, what the regulation and sort of practices within your state and then even further, you know, zooming in from that is the piece about, okay. And then what is it in your school or in your workplace? Because that still may be different. That may be just a difference from district to district. And that's just one more layer of confusion.  [00:15:31] Jeannette Washington:  I have to agree. , I've seen intervention. That worked with dyslexic students. And I came in and they said, oh, we got it. We don't need, you said, oh, that's great because, uh, my case load is already booming. So if you got it, we'll let you  [00:15:47] Kate Grandbois:  get it. I mean, think about how many other workplace variables have a negative impact on some of that, , collaboration. And we talk about collaboration on the show a lot and how interdisciplinary multidisciplinary trans [00:16:00] disciplinary interventions are so important. , how service delivery models play into that in terms of being able to offer indirect service so that you have time written into your day to go collaborate with the dyslexia, like the licensed dyslexia specialist or the literacy specialist, or whoever has been designated as the point person. , I'm wondering if you have any. Thoughts feelings, words of wisdom, guidance for the speech pathologist. Who's working in a setting who has a student on their caseload, who has this diagnosis, or has this written into their IEP, but feels a little lost in terms of their role on the team, in terms of how to support that student in terms of their language learning difference. Can you talk about that a little bit?  [00:16:52] Jeannette Washington:  That's a great question. , I would say that shows and podcasts like, like these are going to be [00:17:00] super important to that SLP so that they can glean from these opportunities to learn more about dyslexia. I would also say that, , utilizing a screener beforehand could be helpful and that way you get a better understanding of. What it is that you need to be focused solely on because a lot of times we get these IDPs and they're a little confusing. We're not quite sure what we're supposed to be doing. I mean, we see it as it's written for us in plain view, but again, that's not something that we're extremely familiar with. So it's definitely going to consist of some, some time really understanding what dyslexia is. , there are some organizations that have some blueprints to help you all to understand exactly what it is that needs to be happening. But I will [00:18:00] say, , as it relates to a comprehensive, maybe like a list of components for a dyslexia diagnosis, you want to have that paper trail that consists of a family history documentation showing whether, , the mother and father. Experience dyslexia or whether they struggled in that area because as we'll see, dyslexia is hereditary. So there is a large percentage and likelihood that if a mom or a dad may have had dyslexia, then that child is going to prison it as well. You want to also be able to do a language assessment. One of the best assessments that I found out there is going to be, , TEALS. And it's the norm reference test that has been standardized to identify language and literacy disorders. And, , that is going to help kind of guide you as you create or [00:19:00] modify those goals so that they can be attainable for that student. Oh, I'm sorry. It was an  [00:19:05] Kate Grandbois:  acronym. Can you tell us what the acronym name? Oh, Amy's writing me. Bill's T I L L S.  [00:19:14] Jeannette Washington:  So TEALS is T I L L. It is the test of integrated language and literacy skills. Perfect. It's, it's a, , pretty costly tests. Uh, hopefully your district will have it or they'll be able to provide it to you, but, , it is a great way to kind of dive into more of your familiarity with language and a little bit of literacy. And, , I think it is helpful again, when we're keeping that paper term, we're going to that meeting and we're saying, Hey, this is what I saw. And this is the information I gathered. It really keeps you accountable. Yeah, I hope that answered your question. I know I'm kinda like here and there, because I'm a [00:20:00] really thinking about my younger self and what I needed to know when I was going to those meetings and they were telling me like, this is what this child has, and this is what you have to do. And mind you, these are people who were not very privy. So the roles and responsibilities of a speech language pathologist. So that's why I'm kinda like a little here, a little there. So I'm thinking, what would I have benefited from learning?  [00:20:27] Amy Wonkka:  Well, and we talk, we talk a lot on this podcast podcast, just about how having a comprehensive assessment really informs your ability to develop a treatment plan and generate your goals and objectives. So knowing, you know, where is a good starting point, I think is super helpful, whether you are, you know, somebody who's part of a team supporting a student who, you know, is presenting with dyslexia, or whether you're the sole provider or, you know, depending upon your work environment and the state that you're living in.[00:21:00]  , knowing a good starting point for an assessment, I think is really helpful. And I was wondering if you could talk to a little bit kind of just about that, but if you're kind of steering the ship in terms of the intervention, if you're a speech language pathologist who is supporting a student who has these learning needs, you know, what are some. What are some tips in terms of kind of collaborating if somebody else is the person who's kind of driving the  [00:21:28] Jeannette Washington:  intervention? Well, that's a great question too. So I will say that, , we should consider the fact that every, I must say to enable the child to make progress. And, , these IPS must be appropriately ambitious in the light of the child's disability. So when we go into the IEP meetings, , and we are mindful that we're here to provide, , our expertise in any way that's possible and we're open to. [00:22:00] Providing that feedback or, , being that echo, then I think that makes it a little easier. I know at times we are collaborating with different experts, different professionals. It's almost like we're all buddy kids, because everybody wants to really assert themselves as the person that is driving the ship. But I think in this instance, if the ship is already being drove and you've been asked to be a passenger to make sure you are listening and I'm taking notes as to what people's different feelings are the parents, what are the parents being combative? Are they accepting of this diagnosis on the other professionals around you? Are there. Providing support that you think is, , equitable or are they pushing back a little bit? So I think being very observant is going to be important in that driving force, [00:23:00] as you are working alongside other professionals and not making it into an ego thing, you know, you're just listening. And at that point you're creating, and this may be helpful. I can't say that I've done this before, but almost like sketching. A, , like a web, so you can understand, okay, this is what I can bring to the table. And this is what they're currently asking for or requiring. And you, because I know that multi-sensory, , teaching instruction is helpful, even for us, as we're learning as adults. Once I, sensory expression is so important. So consider taking some time and creating a mind map or a graphic organizer, just what a pencil or pen or whatever you have available at that meeting. It may be a craft and understanding how you can connect within those different places or gaps that exist.  [00:23:58] Amy Wonkka:  I love that idea. [00:24:00] I love that idea even more broadly, just in terms of collaborative planning and working together students. I think that that's a great idea.  [00:24:08] Kate Grandbois:  I also think, and we see this is an also a repeat thing. You mentioned the word ego, that is a critical piece, a critical barrier to effective collaboration. I think, especially when you're talking about, , eh, uh, clinical area that is shared by so many disciplines and could be specifically allocated to one discipline in particular, if you're in a different state or school or workplace setting or what have you. , so I, I think just for the sake of saying that again, I think that's a really important piece to consider. Yeah. I mean,  [00:24:41] Jeannette Washington:  it's easy to be egotistical. I think it's harder to just take a back seat or to say, you know what, I'm going to listen, what I've been finding, which is so, uh, monumental as an adult is if you just listen. , and just be observant. There's so [00:25:00] much that you can take in. , I was born in February and, , I'm not really into astrology. My, my family is though they aren't always talking about it. So as a Pisces, I have like very intuitive nature about myself. And that's so important when I'm in these meetings, I'm leading with my intuition and I'm just sitting back and I'm watching body language. , you know, I'm listening. And I think that that is so underrated. You know, we, we go into these meetings and we want to listen. I got my master's from here, or I am a PhD. I am very aware of listen. Take a seat, say out a piece of paper and really start doodling some, some notes to yourself. And you'd be surprised you probably walk out of the meeting more informed than you would have if you went in there, which a cap and gown on some about where  [00:25:57] Kate Grandbois:  no one can see Amy and I dislike aggressively [00:26:00] head-nodding and us being just all the high fives for that statement. I think, I think the power of listening is something that we don't do enough as, as humans. , and I think part of that is maybe cultural, , here in the states and it provides, it creates opportunities across everything. Clinically collaboration, counseling. I mean, where there's, there are so many, we wear so many hats as professionals. , and I think learning to listen, , is, is just so critical. So thank you so much for bringing that up too. I mean, that's so true.  [00:26:38] Jeannette Washington:  Are we listening to respond or are we listening to just, you know, grasp that information  [00:26:44] Kate Grandbois:  kind of listening? Exactly.  [00:26:46] Jeannette Washington:  Yeah.  [00:26:48] Kate Grandbois:  Okay. So I want to, I want to zoom out a little bit and sort of think about, , the role of the SLP and sort of getting into the second learning objective about what some of the [00:27:00] comprehensive co what, what, what what's some of the components of the dyslexia diagnosis are. So you're an SLP and X school. The, , you have a student or students on your caseload with this written into their IEP. You are not. Quote, unquote dyslexia specialist in your workplace setting, you have some of these, I'm just sort of like painting the picture. You have this team environment, you have this collaborative piece, you started talking a little bit about assessment, and I think that's so important because like Amy said, assessment and a thorough and comprehensive assessment will really drive our treatment. , and I th I'm, I'm wondering if you can make that connection there for us in terms of the components of the dyslexia diagnosis and what else and how you might look through that lens to frame a more comprehensive  [00:27:52] Jeannette Washington:  assessment. Okay. So generally there are about eight different things that need to be assessed. And we talked about that [00:28:00] case study, where you're getting that family history and you're understanding the familiar structure of that student. We also talked about, , that TEALS T I L L. Assessment that is going to focus on language and literacy. We also want to do an achievement test than intelligence test and articulation test motor skills, tests, and social skills. Those are all going to be very helpful as we are looking at the whole child and understanding whether that child has dyslexia.  [00:28:36] Kate Grandbois:  That's a lot of tests.  [00:28:38] Jeannette Washington:  It is a lot of tests. That's why it calls for a all hands on deck. I mean, some, some common things that we evaluate could be, you know, word recognition. , we're an autonomous C reading fluency, as you'll see within that Till's assessment. , the coding [00:29:00] phonological awareness, , as I was stumbling over that word earlier, all of those things kind of tie into place and we need to know whether they are existing at a milestone level or benchmark or whether they are very low for that student. So we can make an accurate picture of dyslexia.  [00:29:22] Amy Wonkka:  I, can you talk to us just a little bit more, as we were saying before we started recording Kate and I have like very, very minimal skills in this area. So this might be a silly question. , but. What might you expect to see in going through like a comprehensive battery like that, that would make a dyslexia diagnosis more likely relative to something else, accounting for the difficulties that we're seeing with a student.  [00:29:47] Jeannette Washington:  Okay. So the first thing I think of, , usually those who have a dyslexia diagnosis are students that have a high or an [00:30:00] average IQ. So that's something that sticks out to me, plainly, , and is one of the things that makes dyslexia so unique because people automatically assume it is a disability and that that person has a lower IQ or a lower achievement score. So that in itself is going to be, , a red flag. So to speak. Once you see that there. [00:30:26] Amy Wonkka:  That's helpful. That makes sense. Is there anything else that sort of stands out that you're looking for? I think you mentioned, you know, you want to do on articulation assessment, , just thinking about those other assessments that people are doing, you know, and that pattern that the SLP or, or kind of the comprehensive team, not just the SLP that everybody's really looking for in doing all those different assessments. [00:30:50] Jeannette Washington:  So, , one thing you'll notice is that, , when it comes to potentially articulation that the dyslexic [00:31:00] learner may have a hard time putting sounds together and blending on they're going to have issues. Segmenting and rhyming, those are not going to be skills that come easily to those with dyslexia. So those again are going to be those indicators, red flags. And as you are going through the assessment process, you can kind of take a note of that or put a check by that like, Hmm. This child, , had issues with putting those thoughts that they had into words, or they had issues with, , spelling or writing, , consistently. So, , their writing samples are going to usually be very consistent because they will be, , writing, listening to the words and writing those words. There's a disruption there. So they're hearing different sounds. They're not able to associate those sounds. So those [00:32:00] things will, will help you to make an informed, uh, assessment overall.  [00:32:07] Amy Wonkka:  So I feel like with all of that, it just makes it that much clearer that it really isn't important to have all of these different components. It's, it's not something where if you suspect dyslexia, you do the tills  [00:32:18] Kate Grandbois:  and then you.  [00:32:20] Jeannette Washington:  Again, I think I stated this earlier, but it's important for people to do a potentially like a screener beforehand. , a screener can help you so that you don't waste a ton of time. It's going to work smarter and not harder for you, because if you do like a quick little screener, there are online screeners that are pretty lucrative out there. And if you were to look for one, I would make sure that it had a CEO from the international dyslexia association. So you knew that it was accredited, but you could do a quick screener, maybe 10 minutes, and that'll help you to see whether a further assessment is warranted or, you know, is this [00:33:00] something that the child just is struggling? Or is this something that is, , you know, probably age appropriate or, or that sort of thing. So a Springer is going to help you rule out and it can help you save time as well. Because if you do see those indicators in the screener and you say, okay, we need to get a team together and we need to make sure all eight of these components are assessed. [00:33:27] Kate Grandbois:  So let's say you're a speech pathologist with, you know, a hundred students on your caseload. That's, you know, the reality for a lot of our counterparts originally. And you've identified this student, as you know, having some of his, as you say, red flags, you conduct the screener. It shows you that there is something to be concerned about it that you should move forward with a more comprehensive assessment. And this assessment that you described, this very thorough assessment that touches on all these dignities diagnostic criteria is very thorough. And I have to assume [00:34:00] time consuming. Do you often see. Multiple members of team helping to take on this assessment. Do you, do you usually see speech pathologists referring out for some of these assessments or is this something that's best done maybe in the school, in a team environment? [00:34:18] Jeannette Washington:  I've definitely seen a lot more, , of the referring out, but again, that's going to follow that per view of whether that is, , something that is acceptable at that particular school, because if a referral is not, and then I, okay. So I'm going to pause that for a second. And it just tells you that a dyslexia assessment outside of school is going to be very expensive. One of my good friends just got one in the state of Michigan. She Def definitely paid over a thousand dollars to have her child assessed. Now, when you think about the average family, , you know, there are going to be one or [00:35:00] two children per household that might not be achievable. So that's something you want to make sure you consider. I would say that having someone in-house do it and having an SOP that can connect with her intervention team or with her colleagues and say, Hey, can you assess for this? Because I'm going to be working to assess this of what would be a better and a more feasible option. , because a lot of universities do offer, uh, assessments for dyslexia, but the waiting list can be up to a year. So again, and this is coming from the knowledge I've gained ambition. I don't know whether there are easier ways in which you can do it. In other states, when I lived in Mississippi, their work easier ways to get a full assessment. And you didn't have to really rely on an SOP too much, because again, you had that dyslexia therapist and also the fact that there were laws in place [00:36:00] where all students that assess regardless. So if you're in a state like minds, , you may want to double down and try to see what it is he can do in house, because if you make that referral, , it, the parent may not be able to afford to get their child assessed, and then that's going to cause potentially illiteracy and then illiteracy can cause potential prison pipeline issues. So it just keeps going and going and going. So,  [00:36:30] Kate Grandbois:  , I'm so glad you mentioned that because I, in another episode, We've, you know, we've talked about this before about that, you know, we as SLPs have a responsibility because there are really big impacts. If you have, you know, struggles with literacy, that has a really, it's a ripple effect across, you know, communities sometimes. So, , I think, I think that's a really good point. I'm, I'm really glad that you mentioned it. , and I also want to say, you know, if there are waiting lists and I, I wouldn't be [00:37:00] surprised if that's a systemic, more of a systemic nationwide issue, just given the shortage of at least speech pathologists right now you lose a year of instruction time. So, you know, that's just waiting for an assessment. , so I guess what I'm wondering is if there is an SLP listening, who's really in that pickle and, and would like to do an assessment, but is realistically restraint, you know, restricted by time, the time problem, the, the time problem that we all have. Are there ways to share the, you know, the burden of bringing in other, , obviously advocating with your administration is a really huge piece of this in terms of like altering your workplace setting to better serve your students. But that's a, you know, a mountain to climb for a lot of us. , but are there other people on the school team who might be well-suited to participate in that assessment so that the SLP doesn't need to carry that?  [00:37:52] Jeannette Washington:  Yeah, absolutely. That's a great like followup too. So I would say definitely lean [00:38:00] in with that teacher. Lean in potentially with, , the social worker or the counselor at the school. Cause they can assist with those social skills. , then you want to see who else is usually in a traditional school. You, you usually would have like a social worker, counselor you'd have the teacher of course, and the SOP. So those are the primary, uh, pillars of a school. And I would say just lenient with those individuals also be intentional about the time you set, because if you had a large caseload, , you don't want to, , yields in society around this or you don't want to become, , well, what I like to think of it, it's not really procrastination, but it's almost like. Do you, you know, you have something to do, but you really don't want to do it. So you kind of dragged along, but you don't want to obviously build that into your routine because that's not going to benefit students, nor is it going to [00:39:00] benefit you because you'll have this thing hanging over you that you have to do. So I would say, be intentional about your time. , even if that is setting aside 45 minutes every day to focus on that, uh, I don't know, 45 minutes things like. Uh, cause time that's, that's the issue, but just being intentional, because I think if you set aside, I'll say at the lowest 20 minutes per school day to kind of focus your energy into that assessment, then you'd likely be able to cover more ground and also do not be afraid to ask colleagues for assistance. You know, ask that teacher say, Hey, I know you have a lot on your plate, but we really got to get Johnny squared away so that he can, , have the tools he needs to succeed overall.  [00:39:49] Kate Grandbois:  And if the SLP, this fictitious person, who's in my mind, listening to them. So listening to this, and we're describing this issue in terms of where there probably is a real prison [00:40:00] in terms of advocacy, hating wit to create workplace change or advocating with the administration. Are there resources out there that you can point someone to, to, you know, a sat you've already mentioned? , I think the international association, the international dyslexia association website, and how that might have some information about state law and state requirements, but are there other things that you would recommend an SLP bring to the table in terms of advocating for structural change? [00:40:31] Jeannette Washington:  So, , yeah, it's very thoughtful.  How  [00:40:33] Kate Grandbois:  do you fix the world, Jeannette? How do you fix all the problems? [00:40:41] Jeannette Washington:  One step at a time, one step at a time. So, , what I would say we do have the most powerful tools in the whole wide world at our fingertips, and that is our cell phones. So we want to make sure that we are using them in a deliberate way. And that may mean [00:41:00] Googling decoding dyslexia or Googling, you know, international dyslexia association, or even Googling at the academy of, in Gillingham to see what's out there because knowledge is power. And that I've got to really help you move that dial. Once you understand the state, like, , the, the state's scope of things, then you can really move some mountains there. So I would say to Google and see what you can really bring to the table. It would take five minutes to look at, , an article on decoding dyslexia or to be able to pull up some information about. How, , the advocacy process works as a whole, right? So you want to definitely make sure you are looking up some grassroots organizations that are, , really pivotal in that community. One that [00:42:00] is nationwide is caught decoding dyslexia, and that was created by us. The mom. Who found that their children were not being supportive, like they felt they should. So they created it, this outreach arm. And, , I would say looking at some of the work that they done would be helpful because as we know, advocacy is not a one size fits all. It's not a cookie cutter situation where we can copy it and paste it here. So understanding the scope of this Lexia from your state standpoint, I think that's going to give you, , a lot of ammunition as you're moving forward, because you want to know what the state has in place. And so you can start, , calling out those different laws and, and letting people know.  [00:42:51] Kate Grandbois:  And sound very important quoting laws.[00:43:00]  [00:43:07] Jeannette Washington:  exactly,  [00:43:07] Kate Grandbois:  exactly. No, you're right. Power. I think that that's such a good, you know, something that we already know, , you know, knowledge is  [00:43:14] Jeannette Washington:  power, but I was going to say, we don't want to give you all too much homework, but you kind of got to do a little homework when it comes to this. Just a little  [00:43:22] Kate Grandbois:  it's a little, but if you're listening, presumably you're seeking out this information anyway, and now yes, you're you're now you have kudos to you. Yes. Dropping the breadcrumbs. This is where you can learn more. , and in the time that we have left, we need to get to our third learning objective. And I, I have to ask you a little bit about assistive technology because I'm just dying to, but I'm going to save that for the end, in terms of. , strategies and techniques that an SLP can implement to target phonemic awareness. So again, painting that picture, you're, you know, Jane SLP in the schools, you've got, you have a time [00:44:00] problem. You've done the screener. You pulled in all the resources at school to complete this fabulous, comprehensive assessment that took no time. And you've lost no instructional time because this is a fictitious scenario. What that we're just moving through it. And now it's time to start writing your IEP goals or writing your, you know, writing up your treatment plans and really thinking about how to move forward. What are some of your like best recommendations for, for when you are in that place?  [00:44:29] Jeannette Washington:  Okay. So first I would say, , as we know, phonemic awareness is the ability to identify and manipulate individual sounds in spoken words. So we want to be conscious of activity. That will heighten their, , or our students' ability to identify and manipulate those sounds. , first one I can think of is tapping syllables or clapping syllables. You know, you can start a [00:45:00] therapy session with just doing that with their name. Hey is so nice to see you and, you know, maybe create a routine where he taps those syllables of his first and last name with you, just in the intro of you and the student getting together. , you can do syllable tallies, uh, just, I think it's important to really be creative. , we can do a syllable search in your speech room where you go around and sort words by syllables, just from what the child sees around them. , I think using our nursery rhymes and songs like Hickey Pickety are often fun. , but when I look at. Ways in which we can notate that on an IEP, we can do, , goals like this student will be able to recognize and generate rhyming words, various structured activities with 80% accuracy. , maybe another goal could [00:46:00] be the student will be able to identify initial medial and final phonemes in, uh, uh, high frequency words, or grade appropriate words. So those are going to be good goals and achievable goals for that student. Because again, we want to make sure is that, , the IEP. Main aim, which is enabled to chop the child to make progress and it must be appropriately ambitious. So I think that those would be some very ambitious goals and those would also help you to utilize, uh, Hickory Pickety. And like I said, the syllable surge or tapping those syllables  [00:46:42] Amy Wonkka:  well, and it, and it makes me kind of think back to those examples, make me think back to what we were talking about at the very beginning of this podcast where, okay. You might not be driving the ship, but there are a number of people on the ship. Right. So if those are your goals and objectives in your speech and language session, I mean, it's, it's not a huge jump to think about [00:47:00] how ideally you're coordinating with other providers in the child's school environment to work on those same things. If you're using a clapping, tapping strategy, you're going to at least want to share that information with the teacher. , And I think that some of these, I know that our third learning objective is about speech and language, but I also know that you work with educators. , and I didn't know if you wanted to talk a little bit about when you've seen effective use of some of those strategies and techniques across environments. [00:47:30] Jeannette Washington:  Yes. Please talk. Well, yeah, so I think that that's those, , those aha moments that make what we do so much more when, uh, the child can do that, carry over and. And, , really just seeing the teacher, implementing things and strategies that you suggested, and you utilizing some of those same resources, uh, with the student when you're in their therapy [00:48:00] session. That is just amazing. And it's also important to, to have that parent or a board. So everybody is targeting those same areas of interest and that child will be seeing progress a lot sooner because there'll be using it across the board. So, , I would say working with the classroom teacher is going to be one of the most important, if not the important, , the most important thing as you are building that carry over, , even coming into the teacher's class. What I've done on a lot of occasions is coming into the class and doing almost like a coaching session. Like I'm showing her what I did. And she's like, oh, well, I could do this too. If she's implementing it. And it's really just the best. I love to see it love to see her.  [00:48:48] Kate Grandbois:  And I, I, I know I repeat myself every single episode that we recorded, Amy's laughing. Cause she knows that I, you know what I'm going to say. Do you want to say it now? You can say, you want me to say it, [00:49:00] the importance of indirect service, the indirect service delivery model and having it written into your IEP so that you have time. You have time, you are doing a service to the student by even just by consulting, by observing, by teaching the teacher, by being a learner of watching the student in the classroom. I mean, all of those things are critical components to us being effective team members. And for some reason in our field, We get really stuck on. And I think this is just a field issue, not like a clinician issue, but we have this, you know, culturally, uh, uh, uh, I don't know, preference for this direct service and thinking that that's the best way to service our clients and direct service doesn't necessarily mean pull out. It could mean push in, but the indirect service delivery model allows you for so much more flexibility. And I'm really on a soapbox here. I'm sorry. I just, I literally say it every single time. I needed to make a t-shirt or [00:50:00] something that I don't have to keep saying it. The aha moment that you just said, how can you make that happen if you don't have indirect service written into your grid? [00:50:12] Jeannette Washington:  Yeah, that's, that's a good point. You make, , I will say that gender, you said. Laughing at you say it all the time, but Hey, sometimes I think hearing it more and more and repetition helps us to really acknowledge how important it is. And then we take that with us as we're in our schools and our classrooms, so, or our therapy rooms, so to speak. [00:50:37] Kate Grandbois:  So in the time that we have left, you've done you've, you've given us a really nice rundown of, , what SLPs can do to target phonemic awareness. I loved some of the suggestions that you just gave. I have to ask you how assistive technology fits into all of this. You know, that I have to ask that question. Hi.  [00:50:56] Jeannette Washington:  So this, the technology is definitely going to be [00:51:00] your friend. , I will say that text to speech and speech to text software is some of them. Like okay. Dyslexic adults and dyslexic high school students I work with, they absolutely can not get enough of audibles or, , speech to text devices that helps them to still be able to communicate their thoughts around certain topics and habits, , written out for them like a dictation or for them to be able to listen to information and have it. We come into their form front and they're comprehending it in a way. So some tools that I have seen that, uh, they love when it comes to the text to speech are going to be into words, natural readers. Uh, re-ask. And then when it comes to speech to text, you can [00:52:00] look at dragon naturally speaking and talk typer. Those are some of that I have seen been used often. Now, when I travel internationally and work with individuals with dyslexia, I find that the smart pen. Is really important to them. And that's something that I wasn't really exposed to here. But when I went to Nigeria, I saw that they were using a lot of smart pens and basically it's like a ballpoint pen and you use it as you're reading and it dictates that information to you or speaks it to you. And I was like, oh, that's really cool. So I want to, yeah. I want to actually get more of those. I saw one in action and I was like, oh my God. So I have to get some so I can, , you know, share them with all my SLP friends. , other ones I would say, uh, color overlays have been helpful with reading. , let's [00:53:00] see timers and metronomes. Aren't sent to be really, really helpful. , I know for me, I use the Pomodoro technique and that's helpful for me. And I also think of those with ADHD that could potentially benefit from a timer and metronome. And if you all didn't know, okay, well, let me say, if you all didn't know dyslexia and ADHD, co-occur about 60% of it. What did you want? My  [00:53:32] Kate Grandbois:  question was what's the Pomodoro technique.  [00:53:36] Jeannette Washington:  Oh, fun. Okay. So I learned that when I learned to code it was so, uh, helpful for me. So you worked hard for like 25 minutes and you get that task done and then no, no. Is it 20 minute? I think it's 20 minutes. You work for about 20 minutes on a task and then you take a five minute break and then you work for 20 minutes and you take a five minute break. So that's the Pomodoro technique and it's really [00:54:00] helpful because it helps you to stay anchored and laser focus for those 20 years. And then we, that five minutes you can say, who take your break rules, and then you jump back in for the 20 minutes. And so it really keeps the momentum with the project that you have going, , whether it is studying for school, , or just working now that we're all working from home. I can, you can see how that's helpful. I have to take many, many breaks, but to be able to focus on something for that 20 minutes that, uh, you can get a lot done. I  [00:54:33] Kate Grandbois:  love that. I see. Now when you mentioned, you know, using timers and metronomes how that can sort of be a support using that technique. That makes a lot of sense. So if you're the SLP and you're listening to this and your hygiene, SOP, who's listening and you have this situation, and you're really interested in assistive technology, just again, bringing it back to the school environment, [00:55:00] at what point. Would you start recommending an assistive technology of Val or start trying to, I mean, just again, thinking about that, their learning objective in terms of supporting our students, , with phonemic awareness, at what point do you sort of start to bring in some of that assistive technology? [00:55:18] Jeannette Washington:  Honestly, , I really do it early on because we are working with digital natives. These students have in these children have never lived in a time where technology was not easily available to them. You know? So with that in mind, they are using this on a regular basis, regardless. So you just adding on a layer of support by saying, Hey, when your son is using his tablets and now. Why don't you all look at this particular app or, you know, this software and this'll help you do this and this'll help to achieve that. I think I, I pretty [00:56:00] much re , you know, put that out there within that first couple of weeks, because they're already using the technology. It's easy for them such as implement whatever new strategy you have using that M 80 device. So, I mean, again, these are digital natives we're talking about and a lot of the assistive technology, especially if it's on that level. Or medium strand. It doesn't require training for now. If we're talking about something on that high tech end, then we would need to have a actual training done so that parents, and everybody knows how to utilize that. But, , if it's at that low to medium strand of technology, then yeah, I usually tell them the door. I think  also  [00:56:50] Amy Wonkka:  just how much technology has evolved in a relatively short period of time. I mean, and you know, this much more intimately than I do just kind of as a [00:57:00] consumer. , but just thinking about things like. You know, I recently found out my public library lets me get free audio books and I can just check out free audio books. And this is my new favorite thing. [00:57:13] Jeannette Washington:  Yes. I've been using it for over a year.  [00:57:17] Amy Wonkka:  I love it up with it. And I'm like told everybody about like, did you, you could get free books in the library.  [00:57:24] Jeannette Washington:  So I am obsessed with that  [00:57:28] Amy Wonkka:  big magic, the library sense of book to your phone and you can just listen to it. So I think some of these things you are just, if you happen to be dealing with people like me, who didn't even know that was a thing, just giving people exposure. This is technology that, like you said, you know, folks like us who are maybe a little bit older, we're not maybe digital natives, but the kids are. And so just giving us all awareness that this is just sort of accessibility for our culture now. And it's amazing. And yeah.  [00:57:57] Jeannette Washington:  The library center. Really amazing. I'm [00:58:00] sorry. I was just, I'm so excited with you right now. This is my favorite thing. Like I can, we could do a podcast for the entire title. We talk about this. That's how my son, he's eight years old. We listened to audibles all the time like this. This is,  [00:58:23] Kate Grandbois:  I need to, I  need  [00:58:24] Jeannette Washington:  to get on this train.  [00:58:27] Amy Wonkka:  And it is magic and it comes to your phone. And that's, I, I  [00:58:32] Kate Grandbois:  love, I love that. I love it, but I, I do think that you make it not to bring us back to the boring stuff, but I think you make a really good point about eating to the consumer, meeting people, where they are in terms of how they're consuming it. Because if they're already, if it's already a part of their daily life, then extending that into an educational learning environment is really not. It's really not that big of a deal. We're all using technology all the time. Anyway. , I, I have learned so much from this. I [00:59:00] am so grateful for your time before we wrap up, do you have any additional gyms or words of wisdom that you want to leave our  [00:59:08] Jeannette Washington:  audience? Oh, gee, you put me on the spot with that one. Well, if  [00:59:13] Kate Grandbois:  you, if you had a message for the SLP out there in this position that we are discussing.  [00:59:21] Jeannette Washington:  What are your words? I would, I would say you are not alone. You simply need to just lean in a little harder. Other people are asking the same questions. Other people are in the same position. , so I hope that this isn't an isolating experience for you. , you can certainly reach out to me. I have tons of resources. I am sending people resources all day long. And, and I don't mind it because that's, that's what we're here for. We're here to be resourceful to one another. So there you have it. [00:59:57] Kate Grandbois:  That was excellent. Thank you so much for joining [01:00:00] us. 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 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 September 5th, 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.  [00:01:34] Kate Grandbois:  So once upon a time, when we first started recording, we recorded an episode on partner training and augmentative, alternative communication we did. And during that episode, we maybe fan girls a little bit over authors of some literature, which was very exciting. And then for some very, very lucky reason that author contacted us and agreed to come onto the show with us today, which is awesome. And what's even better is that she had a really wonderful idea for a new topic and brought along a colleague who we have met and had so many great discussions with. And so today we are so excited to welcome Dr. Cathy Bingerand Dr. Natalie Douglas welcome Cathy and Natalie.  [00:02:15] Natalie Douglas:  Hey, thanks so much.  [00:02:16] Cathy Binger:  Thank you. [00:02:17] Amy Wonkka:  So you guys are here to discuss implementation science, which I have to say. It's something that we did not know was a thing until you emailed us about it. So we're very excited. Before we get started with that topic, could you please both just tell us a littlebit about yourselves [00:02:33] Cathy Binger:  Sure. I mean, so I'm Cathy banger. I have to tell you the reason why I actually did find you and contact you has directly to do with the topic that we're talking about today. , I was working on a paper with Natalie and my colleague close colleague, Jennifer Kent-Walsh on implementation science and was looking to see for purposes of the paper,you if, when and how people have been using our partner training or communication partner training program, and that's where I discovered your podcast. And then I've been listening like a mad woman ever since. Cause it's so great. So, anyway, so I am a professor at the university of New Mexico. I've been here for about 16 years now and I specialize in doing research into child language and specifically child language interventions for children who requireAAC. Natalie? [00:03:26] Natalie Douglas:  Yes. So I am at central Michigan university. I've been here since 2013, but before that I was a clinician in longterm care hospital, outpatient environments. And that really drove me back to the academic world, those clinical problems that I couldn't solve. So it was there that I kind of fell in love with implementation science around 2009. So I've basically been thinking about it non-stop ever since.  [00:03:55] Kate Grandbois:  And what I love so much about the collaboration between the two of you is that you come from very different clinical worlds and I'm so excited to discuss implementation science and how it's really a common - it seems like a common denominator across all of speech pathology. And we talk about this a lot on our podcast - our scope of practice is so wide.. When I talk to someone who works in a sniff, I can't believe that I have the same degree as them, because I don't know anything about anything that they do. So what I think is really interesting about this topic is that it's something that we can all relate to and really transcends so many different workplaces and clinical areas of expertise. , if I need to say I'm excited about it one more time, it will just be redundant. So instead I'll just say I'm excited about it. So before we get into it I'm going to quickly read through our learning objectives and disclosures. Sometimes people write in and ask us to not read this part. I can't not read it. I have to read it ASHA makes me read it. So please bear with me. I will try to make it fast learning objective number one: describe a brief history of implementation science and its recent intersection with speech and language pathology learning objective number two, distinguished between the traditional research pipeline and alternative research designs focused on implementation and learning. Objective number three, list barriers and facilitators to SLPs engaging in clinical research disclosures. Dr. Natalie Douglas, his financial disclosures. Dr. Douglas 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. Dr. Douglas has no non-financial relationships to disclose Dr. Cathy banger financial relationships. Dr. Banger is employed by the university of New Mexico. Dr. Banger is nonfinancial relationships. Dr. Binger is a member of Attia and special interest group 12. Kate that's me financial disclosures. I'm the owner and founder of groundwater 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 therapy, MASS ABA and the associate and the association for behavior analysis, international and corresponding speech pathology and applied behavior analysis, special interest group. [00:06:09] Amy Wonkka:  Well done. That was really fast.  My financial disclosures. I'm an employee of a public school system and co-founder of SLP nerd cast. And my nonfinancial 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. We did it. The boring bits are done. All right. [00:06:28] Cathy Binger:   I actually, I love that you guys do the learning objectives. It's the only place where I feel like. You actually put them to good use because you revisit them during the podcast and you tie them back in which I need to start doing. So thank you for doing that. It's actually really helpful. [00:06:49] Kate Grandbois:  You're welcome. We like them. We try, I think it's mostly because we're not necessarily auditory learners ourselves, so, so, and we realized that people are listening to this while they're jogging and biking. Maybe not biking, but, or maybe biking. I don't know. People be people. So it was trying to repeat information is, you know, some of the best way to really get it in there. Anyway, moving on, , implementation science, tell us everything. What is it? Maybe that's where we start.  [00:07:14] Cathy Binger:  Take it away, Natalie. [00:07:17] Natalie Douglas: Okay. So there are so many definitions of implementation science, but a major one. And I think a major way to frame it is implementation. Science is the study of what research gets into typical everyday contexts as delivered by the typical clinician. So we're not necessarily talking about a research assistant that's like in a school delivering an intervention. We're talking about like the provider that would be there anyway is delivering the intervention to a child who should receive it. Right. So it's the study of what strategies might be better than other strategies. So implementation strategies, you know, there are implementation outcomes that you could study that would be maybe different than the outcomes of the intervention, right? So it's like, if you think very broadly of. You know, and, and like Kate was saying earlier, you know, no matter which kind of section of speech path you're in, you either want your client to communicate better or swallow better. Right. So that's, that would be the ultimate intervention outcome. Whereas an implementation outcome might be something a little bit different. Like how did, what was it like administering that intervention as a clinician? Tell me your perceptions about that. Did, what was the cost involved? What are your, what is your leadership or your administrators think at the level of the organization? Is this intervention sustainable? Like after the research team leaves, like, will you keep doing it or will you be like, oh, thank God. I'm so glad they left my school. My day is. Easier now. , so those were kind of some of the basic things that I think about with implementation. [00:09:25] Kate Grandbois: Would it be fair to say that based on that definition, implementation science is really more about the clinicians perceptions perspectives, behaviors than it is about the client outcomes. [00:09:37] Natalie Douglas:  I think that the clinician's perspective and perceptions is one thing that you could measure of many. So I think implementation science is still ultimately most concerned about the client and patient outcome. , but then you also have different layers  to get to that. Patient client outcome, where you're going to look at things at the level of the clinician at the level of the healthcare system, perhaps of the school system and of the organization. Cathy I don’t know if you would agree with that. [00:10:11] Cathy Binger:  Yeah, absolutely. I actually just pulled up one of the frameworks to help me, so yeah, I mean, uh, you have your intervention itself and that intervention, as you said, like you have your typical intervention outcomes, you're expanding like the veterans or whatever, but it's really, it's really, you're you're you can do both of those things, basically the same time in the same study. And you're looking at things that Natalie talked about. So for example, in a, , what we're working on right now in the initial stages for our own partner instruction program, like two of the, , implementation outcomes that we're planning to look at are the appropriateness of that. Intervention. Right. How appropriate do clinicians think that our impact program is? , as an example, how appropriate, what about the educational assistants who are implementing it in the schools? Like what are their perceptions of it? If we're working with families, what are their perceptions of it? , are there ways in which this isn't appropriate? So it's, you know, like we present that to them. We present them with the the intervention and we talk to them about it and they tell us, you know, oh yeah there's no way we can do this because of this, you know, because of these organizational level factors, like, or my case load is way too big. Like there's no way, you know, like all that kind of stuff, but it can also be what's the school principal have to say about that. , you know, like having the SLPs be the ones who are providing all of this instruction to the teachers in the classroom, , there's maybe there's some real barriers to that, right? Like, you know, we've got to meet caseload, workload standards, this isn't part of the, like, how do you tie this into IEP? And like all those kinds of things that get in the way of, in our case with, you know, the intervention I'm telling you that right now, with our impact program, what are all the ways, things that get in the way of good implementation of, , a partner is communication partner instruction program. And then, and then there's the actual doing of it. Like, you know, you're okay, you're running your intervention program. Like you got some feedback, he changed up your program a little bit, , to try to address those concerns. And then while you're doing the intervention. You're still talking to those people. Like you're doing focus groups, you're doing in-depth interviews, you're doing like some kind of usually qualitative research approach. That's your implementation arm of this project that you're working on. And so while you're doing the intervention, you're continuing to talk to the SLPs who are delivering the intervention, right? The SLPs in the schools let's stick with the school example. , and also, you know, doing, doing the same thing with the educational assistants or the special ed teachers, or whoever's doing the actual, like face-to-face with the kid, , you know, that sort and getting feedback from them and they're telling you, what's working and what's not working. So that's, you know, you're measuring the feasibility in that case of your program by talking with the key stakeholders. So they can be very close to the intervention, right? Like in our case, it could be the, again, those educational assistants who are delivering the intervention, it can be the SLP who's teaching. The end of the educational assistant writes, you'd get your SLP, who knows how to do the program. And they're working with a EA and EA is working with the kid. So like what's going on at those different layers. And then above that, what's going on at the organizational level, how, like, you know, what are the things that are good and that are getting, you know, all that kind of stuff. So, yeah.  [00:13:41] Kate Grandbois:  So to sort of recap, implementation science is sort of the intersection between evidence-based research oriented interventions and real world problems or real, real time, real life interventions, barriers in a work setting, how it's being implemented, but the stakeholders feel about it. It's the intersection of those two things. [00:14:03] Cathy Binger:  Perfect. Oh, good. I'm so glad I didn't screw that up. And is it,  [00:14:07] Amy Wonkka:  is it always taking place in a, in a real life environment?  [00:14:12] Natalie Douglas:  I think for the most part, yes. You know, and so one thing that I'm sure there could be exceptions to this, but. It makes me think about principles of neuroplasticity in a way, like you want to train what it is that you want in the context that you want it, you don't want to like hope and pray that it's going to generalize to other settings. Right? So if you want it in the nursing home, do it in the nursing home. If you want it on the acute care unit, do it there just like how you would train a communication strategy, you know, or anything else. Right.  [00:14:49] Kate Grandbois:  This makes so much sense. It's sort of like, duh. I mean, if you want, if you know that, that I, I love that there's now a research focus on, on what we, as clinicians working in, in, you know, working with our students, particularly individuals who might have a harder time generalizing, or might have a communication impairment for a specific cognitive re you know, have some sort of overlap with a cognitive issue. , I think that makes so much sense. I'm wondering where it came from. Like where did this come from? Why am I just hearing about it now in my old age, [00:15:20] Cathy Binger:  my medium. Go ahead, Cathy. Yeah. So this sort of gets to the question, but at a point you're making a little bit earlier to Kate that, , w if I flip that question around, the question is why haven't we been doing this all along, right. Like, that seems like the, yeah, like what's going on here. So why we haven't been doing this all along, and I'm not saying this is a great answer, but, , as researchers, you know, Natalie and I P we're trained as researchers, you know, first we were trained as clinicians. We're both SLPs, but then we were trained as researchers. And when you're trained as researchers in the end of the typical medical model, or even a typical, you know, education. Training programs as well. Like when you're doing research, one of the main tenants of doing a good research project is to control your variables. How, how easy is that to do in the natural environment? Well, good luck with that. It's just it's so it's messy. Like research is so messy. And so, you know, for example, , like back way back when I was doing my dissertation, we really wanted to look at, , this, you know, aided modeling, right? So everybody's been doing the aided modeling. They did modeling as a part of any AAC intervention programs since AC intervention programs began. And everyone's been assuming that it's a really important component and you know, me as well. , but I wanted to isolate. Aided modeling to see, is it, is it really necessary, right? Is it just one of many things that's, you know, a good thing to do, or is this an essential component of our interventions? If you want to answer a research question like that, you have to control your variables. Like you've got to, you know, do everything the same. You got to do like everything in baseline that you would normally do in intervention, except for the modeling. And then add the modeling in and see what happens. Like that's one way to look at that and answer that question. So there's a lot of control that's going on there. , I could give you lots of other examples, but you know, like we get in trouble in our own research for the kinds of approaches that we take because people think it's really narrow, but what, you know, it's what a clinician might have a hard time understanding because they don't have a training. Is that there are really good researchy kinds of reasons for doing that to keep things under control. So that by the time we're done with the study, we have actually learned something new, not like, oh, we tried a bunch of stuff and the kids made progress. Like, yeah, we do. That's great. We do that in clinical work all the time. And we need to document that, but research is a different thing. , so when you're, when you're in the business of trying to really answer very specific questions, you can't always do that in this real world kind of setting. And there are important questions to be answered that, that, , that can't be done in the real-world setting. , I think where, so, so that's kind of like the background of why, like there's so much resistance to all of this is a lot of, you know, well-trained researchers kind of freak out. I think about this because. Oh, my God. Like if you're just doing stuff in the real world all the time, you lose all that control that you have in your lab. [00:18:38] Amy Wonkka:  I think that's such a good point. , and when we think about, for me not knowing very much about this, but having spoken with you guys a little bit about it, feeling very excited feelings. , I almost wonder if it's, if it's like, you know, I don't think it has to be one or the other because there is that piece. I mean, I've, I've wondered that in aided modeling is a really good example, is somebody who's, who's also been working in AAC, you know, I I've questioned are there certain client characteristics that make. Make it a much more effective inter prevention for some people compared to other people. And I do, you know, I mean, I, I do go back to the research and I want those studies to be controlled so that I can, you know, read what somebody else teased out. I think, you know, what's really exciting to me about the idea of implementation science is that you could apply sort of a similar structured way of looking at kind of the next step beyond that. Like, okay. So, you know, Cathy did this research and found this interesting stuff about, about how you could manipulate different things for students. What does that mean for me? Cause I can't replicate that. So it's, you know, it's, it's like an intermediate step. I feel like that would help  [00:19:52] Cathy Binger:  clinicians. So,  [00:19:55] Kate Grandbois:  yeah. Sorry, go ahead Kate. Oh, I was just going to say so, so here we are sort of thinking about implementation science as the common denominator across all speech pathology and this, you know, start contrast between what you need in the research world to conduct actual research and what we need in the trenches of speech pathology to actually do our jobs and get things done and have those good outcomes for our clients research practice gap. We've heard this a thousand times and here you are, like laying it out. So sort of back to my original question, why haven't we been doing this all along and where did, where did implementation science come from?  [00:20:33] Natalie Douglas:  Yeah. So I think there have been some, and I would have to go back and look for you, , to get the exact information. But there's a couple of stories in terms of growing corn and citrus use, like we're talking like way back, right? Where there, like, there were like food shortages and like one person had this like, amazing thing that they did to their corn and they grew all this corn. Right. And then there were other people who were like trying to grow corn and I'm like, why can't I grow corn? And then it took like 300 years to like, get like this secret corn recipe, like to I'm  [00:21:13] Kate Grandbois:  laughing because like, that's the last thing I expected to come out of your mouth. I  [00:21:17] Amy Wonkka:  was expecting  [00:21:18] Kate Grandbois:  like, oh, it came from the medical path. Something, no corn.  [00:21:25] Natalie Douglas:  Well, and citrus is the other one. There was like these people on a ship. And like, all of these people died of like curvy. Yes. oh my God. These people who ate the lemons and the oranges, like, why are they still here with us? But then it took so long to like, get that message of like, oh, it's the  [00:21:45] Kate Grandbois:  vitamin C. That seems well, I'm sorry. I just I'm so laughing. I just never thought I would scream the word scurvy on our speech pathology podcast. But before  [00:21:53] Amy Wonkka:  we, before we deviate too far from the  [00:21:56] Kate Grandbois:  learning objectives, , I just, I guess when did it come into the world of speech and language pathology? Because I've never, again, in my medium old age I have, this is like, like, this is huge. This is so.  [00:22:10] Natalie Douglas:  Right. So Jackie Hinckley, who was my PhD mentor, gave me a monograph back in 2009. , Dean fixing and colleagues there, I'm at the UNC chapel hill now. And they have a really renowned implementation science Institute. Well, they published what is now I consider to be like a Seminole monograph of implementation science research first in 2005. , but you will find examples within that monograph kind of moving, you know, way far back. , but that's kinda when I first, , came across this and when I was going through and reading that monograph, I just, it was like a million aha light bulb moments because it really, I could see mechanisms for the first time as to why I couldn't. Implement what I wanted to do in my speech path, job. Like I would like be in the nursing home and I would know something about an intervention that I wanted to implement, but I couldn't do it not because I had, I needed continuing education on the topic. Like I knew what it was I was supposed to do or wanted to do for my client, but I couldn't do tell us the marker story. Yes, the marker story is when, so my, a lot of my work is in Y , hopefully helping the uptake of communication supports for people with dementia in nursing homes. , based off of Dr. Michelle work in external memory aids and for people with dementia. And so when I did my dissertation, so this is work that she did for. 30 years of research on the efficacy of external memory aids for people with dementia. And when I did my dissertation, it was like, Nope, like less than half of the people. , I was in Florida at the time were using external memory aids. And I know why, like, so I went to try to do make an extra, I was working PRN in a nursing home at the time. And I wanted to, you make an external memory from one of my clients with the dry erase board. And I couldn't find it. My stinkin marker. And so I was like, went around and I asked everybody and I'm like, I asked the nurse and they were like super busy. And I was like, hi, do you have a dry erase marker? And I was like, really a little bit afraid, you know, to talk to them. And they're like, no. And, , cause obviously there's more important things to do, right? Like someone's bleeding or like pukey. I mean like clearly no one cared about my marker. So I just ended up walking across the street to, , CVS and just buying a marker and then like coming back and then doing it, , making the memory. But I felt so like, man, like there is such a gap between what I'm supposed to be doing and like, I can't even find a dry erase marker in this building to write on the board. Like, this is just, what, what are, what are we going to do here? Like how do we fix it?  [00:25:15] Kate Grandbois:  And I think everybody listening can probably relate to that. To some degree, they have their, a marker story of their own a day where they couldn't take a break or their caseload was crazy, or they were spent, you know, extra time dealing with a grieving parent who was crying. And, you know, I think that the, and this is what I love about this implementation science idea is that common denominator, all disciplines. Thank you for telling your  [00:25:39] Natalie Douglas:  story anecdote.  [00:25:43] Cathy Binger:  Yeah. So that is a great show. In terms of, you know, modern day, Natalie, you stopped me where I'm wrong. But, you know, as Natalie said, it's only been a couple of decades that implementation science has really been a part of the research conversation period in the medical world. , so this is, uh, this is a new conversation that we're having and it's really a rapidly growing rapidly expanding discipline. So there are a couple pockets that were early adopters of this, like in cancer and in mental health. , but what in our own discipline back in 2014, , the. Foundation arm of Attia, the American speech language hearing foundation sponsored the implementation science summit and, , really have to take our hats off to Leslie Olswang. Leslie Olswang and Nancy min Getty were really key in putting that whole science at the summit together. So they invited researchers who did intervention research from across the disciplines of speech pathology and audiology to come learn about implementation science in 2014. And it was the introduction. To that for, I think, you know, most of the people, if not all of the people who were there. , and so Jennifer Kent Walsh and I were invited fortunately to go to that summit and we left there like this, oh my God. Oh my God. Oh my God. Like, we have to do this. This is what we got into this gig for, you know, in the first place. Like, this is why, like, we were both clinicians. I worked for eight years, , doing various things before I went back to school and was so frustrated by, you know, being in my own head, you know, just feeling like I was never good enough. I could never do what was in the journals. I, I, I just felt like such a failure, especially very early on. I mean, really, you know, throughout that time of, , not being able to do what, what I was reading about and thought I was supposed to do in reading a journal article and being like, oh my God, okay. I just spent all that. I did what I was supposed to do. I just spent all that time reading that article. I don't know how to apply any of this. I have no clue, but you know, and again, it's that research to practice gap where, , W w you know, the great, I think the, one of the great, uh, secrets that's out there that for some reason, no professor wants to tell their students is that, , the research journal articles that they're reading were not written for clinicians, right. Were written for researchers. They're, you know, they're in research journal articles and they have to meet research standards. And I'm not saying like, you know, there are some more clinically oriented journals than others and some work, you know, all that stuff, but they are not written for clinicians. Clinical newsletters are written for clinicians. Research journal articles are written for researchers and they have to meet all kinds of research standards. , and, , You know, like, oh, I just stepped to Kate. When you, when, when I listened to the podcast that you guys did on our communication partner instruction program, and Kate was like, oh my God, that one article, I could do that article. [00:28:40] Kate Grandbois:  Honestly, the fact that you listened to that, and now I'm looking at your face and you, you heard me say that I couldn't read your article. Like I'm just bearing my soul and the most humble moment to our entire audience.  [00:28:53] Cathy Binger:  But I was still glad that you did because it's true. Like, and we know that when we write this stuff, because it's not Kate, it's fine. Cause it wasn't actually written for hearing. And yet we tell our students and our clinicians that they're supposed to Amy looks like she's going  [00:29:13] Natalie Douglas:  to  [00:29:13] Kate Grandbois:  because I'm like, it was a really good article. I'm sorry.  [00:29:16] Cathy Binger:  I told the world. I know it's so funny. I was laughing so hard listening with you and not somebody  [00:29:22] Kate Grandbois:  else who just now has any feelings  [00:29:23] Cathy Binger:  about me. But it's directly applicable to this conversation because that stuff is not written for you. And yet we expect clinicians be able to take that stuff and adapt it. And we wonder why, like, why isn't everybody doing all this evidence-based practice? And we pointed the clinicians. You're not doing your job. And it's total and utter nonsense and implementation science is there to fill in the gaps. And so, you know, that implementation science summit, that Jennifer Kent Walsh and I went to back in 2014, like we left saying, that's a, again, that like this, this is gonna change our lives. , and it's taken us all these, like, we're still, we're not there yet. Where that finally planning, implementation, true implementation projects. , you know, it's a long road.  [00:30:06] Kate Grandbois:  I have a question about, , the intersection between implementation science and single subject design. So we've talked a lot on our podcast about ASHA's evidence-based practice triangle, just for anybody who's listening, who needs a refresher. It's, multi-pronged our, our approach to evidence-based practices. Multi-pronged you have your client and family values and perspectives and stakeholder perspectives. You have clinical judgment, and then you have evidence, but evidence is external evidence as well as internal evidence. And that's, you know, the data that you collect on your client's student patient to make sure that your intervention is working. And that's really where we start getting into single subject design research. And I'm wondering if there is a big overlap between these two things  [00:30:53] Cathy Binger:  between single case design research and implementation this based practice or implant and implementation. , I don't Natalie, let me take a quick stab at this and then you follow up. Sure. You know, I don't know that doing single case design research is necessarily inherently that much closer in getting us from here to there then doing big group designs, because you still have the same issue where you haven't necessarily consulted your stakeholders in order to develop and test your intervention. Right. You can still do it in your lab. You can still do it in a nice clean setting with controlled materials and blood, like all the same stuff. So I don't think that methodology necessarily, , is inherently closer in some ways. I kind of think maybe it is because you're looking at client behaviors, every single session, which you're not doing with your larger group designs, which are just, okay, how are they doing at the beginning? And how are they doing at the end? You know, it's a much. Fine tuned kind of approach. , so you're learning more about what's going on with the client, but you know, it's still like, there's nothing you have implementation outcomes when you're doing civil cases  [00:32:07] Kate Grandbois:  and research. Now, Natalie, before you jump in and pepper, your brilliance onto that, I would love to circle back at some point and talk about the role and importance of the communication partners and stakeholders. , I just wanted to say that so that I didn't forget. Go on.  [00:32:23] Natalie Douglas:  Yeah. So here's what I think about that because when I was working as a clinician, , and even though I took research methods classes, I, I did not know. And I still, probably only in the last like bit of time did I realize what is single subject design? So if I was a clinic I could not administer. For clinical payment purposes, a single subject design, because that would mean I would have to choose to not treat certain items of the disorder because I'm having to hold those in control while I'm only treating one aspect. Right. And that's kind of an ethical issue as a clinician. Like if I have a client with aphasia who has naming and reading difficulties, and I want to see this treatment X have an impact on reading and naming, right. I'm going to, I'm going to kind of hold, I'm going to try to hold naming and control. Right. , so I'm wondering if, what we're thinking of when we're thinking about clinician data is something that we refer to as like practice-based evidence. So like. I am not holding these things in control. I put a document for you. This is everything that I'm doing, and these are the outcomes that I had. Right. So it's like, I had this person come to my session. We worked on this, this and this. , and these are the outcomes, right? And so that makes me. I think that that might be more of the intersection is like practice-based evidence. So one thing that we really haven't talked about yet is in all of the models that we've talked about so far, it's still very top down from the researchers perspective. So the researcher says, okay, I studied this intervention in the lab. I got this with ideal conditions and now we're ready to go. So let's like pop it into a school and let's okay, we'll talk to stakeholders. You know, we'll talk to the principal, we'll do this. That's still a pretty top-down approach. There is room in implementation science for something known as co-construction where I, you tell me like, this is the clinical problem that I'm having as a researcher. And I'm like, huh. And then like from the ground up, right. The researcher and the clinician, and potentially even the client's family, right. Or the client themselves from the ground up, you're working that intervention and developing that intervention to be studied kind of from the beginning. Right. So it's like less of, I have this intervention now, how am I going to like, tweak it and get that in? Like we have to be doing that. Absolutely. Like there's room for all of this, but there's kind of another approach where you can kind of co-construct what that intervention. And I just wonder from Cathy's perspective and we'll probably never know this, you know, what would your intervention look like if you started. From the very beginning. Right. And more of that code, maybe you don't want to talk about that. I'm happy to talk  [00:35:48] Cathy Binger:  about it. It might look different. It probably would look different and we'd be much further along with it in terms of being able to get it widely implemented, right? Like it's also more efficient to develop interventions using implementation science because you don't waste 2, 5, 10, 15 years, , doing stuff that's just not going to work in the real world. , so it's, it's just, you know, if I were to start my career over right now, , we would have done all those things very differently. , we would have been doing implementation science as we built that intervention from the beginning and our other interventions that we're working on as well.  [00:36:28] Natalie Douglas:  I  [00:36:28] Kate Grandbois:  would love to talk a little bit about. I know I mentioned, I wanted to hear about the role of the communication partner, but I think in thinking more broadly about that, the role of the environment and implementation science and the role of, I guess, the role of the, just acknowledging the role of the environment and communication partners in implementation of intervention in general, , and you know, sort of also thinking about our third learning objective with barriers and facilitation and facilitators for, , you know, how to get to some of that ground up or co-construction co-constructed literature or research, I guess that was a lot of questions at once. We can start, we can start with the, with the, , with the environment and, and role of the communication partners.  [00:37:13] Natalie Douglas:  Yeah. I can give an example about the environment. So there was one study that I did a few years ago that looked at kind of practice patterns of speech pathologists in skilled nursing facilities and speech pathologists, , who had. If a higher productivity pressure and felt, , more negative aspects of organized organizational culture actually provided less, , language and communication services when compared to dysphagia services. So again, you know, this was a correlational study, so we can't say that, you know, it was the absolute cause of it, but there really appeared to be some type of association between perceived productivity, pressure and aspects of the organizational culture and the type of services that were provided. Almost like, you know, in my mind, I just think about, well with these swallowing referrals, I have to put these fires out and make sure like nobody gets readmitted to the hospital and everybody, and of course that you know, needs to be done, but then there's maybe less time. For language and communication services in that type of environment,  [00:38:28] Cathy Binger:  potentially. So Kate to circle back around to your question about partner instruction and how that all fits in. So with implementation science, we're looking at things like, , you know, how can we implement an intervention in a real world? And if we are going to implement it with teachers, with educational assistance, with whoever, , can, what are the, what are the things that lend themselves well to an intervention? And what are the things that keep that intervention from being something that you can, you know, tackle? So there may be caseload issues. There may be, , you know, everybody's only being seen in group settings and it's an intervention designed for individuals. It can, you know, there, there are all those things that come into play that are just real life stuff that you have to face when you're a clinician and you face that stuff every day. , so implementation science, when you bring that in, you're involving your stakeholders and figuring out, oh, like in the case, again, it's easy for me to talk about our own program, the impact program that, , the, is it, are there things that are part of that program that are just not implementable in the school setting? , we tried to make it as flexible as possible. For example, you know, you don't have to spend 60 minutes doing X in one shot, you can break it up, but there are probably any number of other things that are not ideal in a real-world setting. So, , how do you do that? I'll give you, oh, I'll give you a really tangible example of a paper that, , just got accepted into the AAC journal. We did a, a hybrid telepractice. , and face to face version of the impact program. , and it was just a first shot, just three kids. , oh, there's this one component of it is telepractice, but, , one of the things that we found was that, , oh, this was with parents. So, you know, the program was implemented three days a week. And the feedback we got from parents was no can do, like that's too much. This needs to only be two days a week because this was just more than we could handle. Right. So like getting, getting that kind of feedback from them. , and then how we parsed it. Oh, I know what a big thing was that that Erica Tempe was in charge of this study. , she was Jennifer Kent, Walsh's doctoral student. And, , she came in from a strong clinical background and she said, I love the impact program, but I can't bill for the impact program because you got all these role plays in here and, you know, like, uh, I can't bill for that time. So I can't do this this way. [00:41:00] Kate Grandbois:  Indirect service, every episode we mentioned indirect service.  [00:41:06] Cathy Binger:  Yeah. So we, , you know, Jennifer and I were both kind of like, you know, especially me, I think, you know, fighting around the role-plays are so important and blah, blah, blah. And Eric was like, yeah, well, I can't bill for it. So what, what are we going to do? So she really talked us into doing a version of the program with no role-plays and the kids there for every session so that you can bill for it. So like, that's an example of what happens when you get good steak. You know, she came in as an SLP with that stakeholder feedback and we have to Bob and weave like, you know, we had to change, make changes to the program. So I think that's a really good example. Like what can happen when you're really getting that stakeholder input.  [00:41:45] Amy Wonkka:  I love that example. And Kate and I, I mean, we have, we do have our soap box about indirect service broken record. Yeah. We feel like I'd love to see more advocacy around that because it's such an essential service to be able to provide to our teams and our families. , but you know, we also talk a lot about the set framework and just the different barriers and facilitators that are unique to every environment. And so I think that's something that is really exciting to me about the idea of implementation science, because it's also that you could potentially be flexible within different types of environments and with different stakeholders. , I had a question kind of back to that learning objective, number two, just to help wrap my mind a little bit better around implementation science. Like how, how is that different from sort of traditional research that I'm used to reading? Like are the dependent variables different? Do they change. If, if they do kind of, how do they change? , is it more, you're looking more at sort of a treatment package, then you are able to kind of isolate those little, very bulls that you might do in more of a clinical setting. How, how are those differences? How does that play out with implementation science, with speech and language?  [00:42:59] Cathy Binger:  Yeah,  [00:43:01] Natalie Douglas:  those are such fantastic questions. , wow. Amy, you  [00:43:06] Cathy Binger:  might be an implementer.  [00:43:09] Natalie Douglas:  I mean, wow. I  [00:43:11] Kate Grandbois:  am lettuces SLP. Nerd cats [00:43:13] Cathy Binger:  slammed on, I'm wearing my out of my hair and  [00:43:18] Natalie Douglas:  like stand up. I mean, this is like, okay, so here's here. Here's the thing I think. And Cathy had touched on this earlier. Traditional research was not designed for a clinician. And I think that is the even clinical research, right? Because we take our model for behavioral clinical research from a pharmacological research model. Right. And this is really relevant now because of the COVID vaccine. Right. And so when all of these scientists are working on the COVID vaccine, like, I don't want them to Bob and weave. I want them to get it right. All the variables, all the variables  [00:44:04] Kate Grandbois:  that is such a good analogy.  [00:44:07] Natalie Douglas:  I don't want you to, I don't care about the stakeholders fricking get that thing in my arm. Like, we don't care about that. Right. But that's not what we're doing. We're not giving a pill. We're not giving a vaccine. We're looking at levels of behaviors. In the traditional research pipeline. Right? The first thing that you do is look at treatment efficacy, right? So you're trying to figure out is my treatment safe? Is it going to kill anybody? Not many things that we do. Well, I might not say that I was going to say that not many things that we do cause harm because I think that's not true. I think sometimes we really can cause harm. Right. So I think that's kind of the first step is to think like, does my research cause harm? , so if your research is determined, your intervention is determined to be safe, then it would move to more of like an advanced efficacy stage where you, like, you increase the number of participants, but you're still kind of in the lab, you're still controlling for all the variables. Right. And then you would move to. Effectiveness where now you're maybe in a real-world setting and instead of your research assistant, giving the intervention in the lab, maybe the research assistant is giving the intervention in the school. Right. , you know, and  [00:45:24] Cathy Binger:  that pipeline, it  [00:45:28] Natalie Douglas:  doesn't support clinical practice for behavioral interventions, I think in most cases. Right. , and Cathy, I know you wanted to add something to that.  [00:45:40] Cathy Binger:  Yeah. To just, , so the piece I wanted to add was that. Really what we are talking about with implementation science is the intervention package. Right? So I think you were also asking about what about these narrow or questions like aided modeling and isolating that that's, that's still the same stuff. Like I would do that same study the same way if I, you know, like to answer that question, but what implementation science is really getting at is this bigger question of the intervention. It's an intervention that you have that, you know, that you think is a complete intervention that you're trying to walk down the research pipeline to get it to the point where it's ready for mass dissemination. And that's where you guys come in. Like the podcast is on the dissemination end of things. Once you have good information. , so we really are talking primarily about, you know, some kind of cohesive intervention in our discipline, you know, currently the intervention package that we're, that we're looking at. Yeah,  [00:46:40] Natalie Douglas:  we're working on a scoping review right now, , with where we are trying to look at, like all of the implementation science studies in communication, sciences, and disorders, like in all of time, basically. , and we're still working on it and we'll have to submit it, blah, blah, blah. But one of the things that we ended up doing is we called it a practice of interest. Right. Because I think sometimes it's an intervention. Sometimes it's like an assessment package that you're trying to get in. Sometimes it's education, you know, I think like all of those are potentially part of the intervention, but it's this idea that you have some type of thing, right. That you're trying to move in to every day kind of practice practice. Yeah.  [00:47:26] Cathy Binger:  Does that  [00:47:26] Natalie Douglas:  help any? Yeah.  [00:47:27] Amy Wonkka:  Yeah. Thank you. You guys answered my question really well. I feel like I have a much better, like, because I think that, you know, we're not saying. I mean, I'm obviously real excited about this, but not to the point that we're saying, throw everything else away. All right. We're not saying, we're saying these are doing different tasks and it's exciting because this implementation science component is something that, I mean, I didn't even know it was a thing before evidently there are enough published studies out there that you can do a scoping review. So that's exciting.  [00:48:00] Cathy Binger:  , but I think, sorry, but no, Yeah, Natalie would be happy to tell you, trying to figure out which of those studies even belonged in her scoping review was a monumental task because people were not really doing implementation science. They were calling it. You're not seeing it for good reason, Amy. It's not that there's a ton of stuff out there and you've missed it. It's not out there, right? Like, you know, people do things like qualitative studies to interview stakeholders and learn more about whatever, but what they're not doing yet. And as a whole in the discipline is putting that within an implementation science framework and saying, here's my implementation science framework model that I'm working with. I have X that I'm, you know, X intervention and. Move this through the pipeline, and I'm going to make sure that it's, you know, good for stakeholders like that. People are really gonna use it and then it's functional and it's useful. And then we have good outcomes and blah, blah, blah, blah, blah, blah. And so that you have a pathway that you've mapped out for yourself as a researcher and know all the pieces that you need to look at, to put together, to get from here to there. And that is not happening in the literature by and large right now. That's right.  [00:49:11] Amy Wonkka:  Well, and I like just connected with that. It makes, it does make me wonder about like, if we started doing it more than there hopefully would be room to replicate it. And so then even though it's not highly controlled, like your clinical work in the lab, if people are able to replicate it, every replication gives more strength or, or, you know, raises new questions, I guess, about whatever that treatment package is. , but it is, it's really exciting to think that that's a direction that we're moving as a field. , It's really exciting to think, Hey, in 10 years from now, will we be able to say, oh, this was replicated in all of these different types of places and here were, you know, trends we noticed or, you know, I think as a clinician, I would be very excited to read, to read that. [00:49:54] Cathy Binger:  Yeah. And that's the hope and you know, the reason Jennifer and I left that implementation and some of it's so exciting was because we really saw this as the giant missing hole in our discipline, like in our research, like we've been on and on and on about evidence-based practice forever. Now it's time to be on and on and on about implementation science. Because what we have is just like every we're not, we're not special. Our discipline is like every other discipline in that a very tiny percentage of interventions make their way through the whole pipeline and into mass use. And even those that do take, you know, 15 to 20 years to get there. And we've got folks who are needy, who are out there who need this. So, you know, all that, think about all the research that you read when you were in grad school and, and you know, all the things that you were told to go out and do, and how often you have not seen those things being done right. More often than not those things aren't being done. And it's for good reason. It's because we have not done the work of implementation science to really look at real world stuff. And make sure our interventions are good fits for those settings. Right.  [00:51:03] Amy Wonkka:  Well, and I think it's going to help with the dissemination piece too, because Kate and I have already mentioned we're medium old and you know, we, like, I went to school before all of this social media,  [00:51:14] Cathy Binger:  I'm just kidding, but I had to go to a  [00:51:17] Amy Wonkka:  special room to use it. So, , but you know, I do feel like that's also confusing for the new clinician. We've touched on this a little bit, you know, or, or the seasoned clinician, who's trying to do their best, but also trying to have some work life balance, and also recognizes they can't fix the whole world and also recognizes they have too many tasks on their plate every single day. And I think there's also this piece of, and you can go on, you know, and, and here we are, we're, we're on Facebook and we're on Instagram, but it's also hard to. Look through all of those things and you have a critical eye as far as what's the best application for your clinical situation. And I think, you know, implementation science is really exciting in that way too, because it can help connect us as practitioners. So the things that people are looking for, people are looking for that information online. That's why there is so much information like that online because people want to do a good job.  [00:52:14] Kate Grandbois:  ,  yes, yes. And I want to take that one step further and sort of looping back to that time that I asked you like seven questions in a row, , and sort of thinking about that last learning objective of, of, you know, that connection between how speech pathologists. We, we do want to read the literature. We do want to do a good job where in this field, because we're passionate about it. , That in how is that related to the research practice gap and how can speech pathologists become more involved? Like if there's a listener out there listening to this and says, oh, this is so cool. Like, I would love to do research, but I don't really want to go get my PhD. Like what, what is the bottom up way that, that we can sort of solve  [00:52:56] Cathy Binger:  that problem? Like, what are the barriers  [00:52:58] Amy Wonkka:  and facilitators to SLPs and KJ clinical  [00:53:01] Cathy Binger:  research? Are you  [00:53:03] Natalie Douglas:  reading our  [00:53:04] Kate Grandbois:  third learning objective? Yes. That question.  [00:53:06] Natalie Douglas:  What are they? I love it. I love this question and I, okay. I think I did right. That's why I wrote it. Okay. Here's the, this is my, a lot of this is like my opinions. So just F this is my opinions. And all of you feel free to check me on this. I think a couple of things, one, we have a major. Hierarchy here between researchers and clinicians where clinicians do not feel. Cause like I would say to a clinician  [00:53:42] Cathy Binger:  truly, if, uh, and  [00:53:43] Natalie Douglas:  this does, this has happened maybe like once since 2013 where a clinician has emailed me about a research article that they have read. And they're like, I really like this research article, you know, could you talk to me, like, could I get involved in something as an author? I would just freak out. I would be like, oh my gosh, they read that. They found it useful. Like it would make me so happy, but I think most clinicians do not feel comfortable contacting the first author of a paper and being  [00:54:14] Kate Grandbois:  like, Hey, just fan girl, about you on a podcast. They don't ever like actually email you. We just talk about you behind your backs  [00:54:22] Cathy Binger:  in public,  [00:54:25] Natalie Douglas:  but privately. So I think we got to get rid of that hierarchy and I think there is a. And another kind of unspoken situation where the academic community at large has tried to shame clinicians into evidence-based practice. And that's a terrible  [00:54:46] Cathy Binger:  strategy. Amen to that. Yes, yes, yes, yes, yes, yes. And it's  [00:54:52] Natalie Douglas:  like, that is, that is just not, so how, why, why would you want to get involved in something where you're constantly either implicitly or explicitly being told that you're not good enough or that you're doing it wrong or that all of these efforts that you put in are, you know, like nobody, like nobody wants, nobody wants to do that. So I think, , you know, I think contacting researchers directly, you know, is one way, , and I think cultivating community with other clinicians, like what you're doing is another way, , I'm so like hopeful with all of these, you know, with Instagram and social media. And I mean, I did the disclosure, I work at the informed SLP. Part-time like, people are really trying to disseminate information and get  [00:55:45] Cathy Binger:  it out there. Yeah. Another barrier in the past has been like we've, we've had, , we've been really fortunate to have a number of people contact us about the partner instruction work that we do and our other work as well. But you know, the work that we've done to date has all been in person. So if they don't live in Albuquerque or New Mexico or Orlando, Florida, we really haven't been able to, you know, really include them in our current projects. But now with that silver lining of COVID and opening us more of us up me in particular and Jennifer too, Jennifer can also do to, to the promise of, , telepractice, , man that starts to open up the whole. Right. Like we have a huge project. We want to do a whole series of projects that are, we convert the  [00:56:29] Natalie Douglas:  whole  [00:56:30] Cathy Binger:  partner instruction program that we have into telepractice program, for example. Cool. And, , then yeah, our research participants can come from anywhere. , which is just an amazing, amazing thing to think about, which is, you know, the way that leads to the question then is if we can get clinicians interested, clinicians in contact with us, then we can see, and we're doing implementation science. And real-world said like, that's the other thing too, is not only is it limited where we are, but then we're doing it in our way. Well, we're going to still do some things in our lab, but we're also gonna be doing projects in the future that are not in the lab. And if it's partner training, you know, I work with Amy and teach her how to do our program. And then Amy goes and implements it and records everything, and I get it back and I can be there for the telepractice sessions, blah, blah, blah. Well, like that changes everything in terms of clinicians, , being able to be very directly involved in literal research projects.  [00:57:27] Natalie Douglas:  That's right.  [00:57:28] Kate Grandbois:  That's such a good point. That's very cool to think about. And also I love your point. I loved your opinions. They were great opinions and I fully support them. , and if anybody is listening to this and feeling, I hope that people who are listening to this feel empowered to  [00:57:46] Natalie Douglas:  reach across  [00:57:46] Kate Grandbois:  the aisle or cold call a researcher, or, you know, speak up and get involved. I do feel that. You know, I, I agree that academia sort of seems like this. You had called it in our, in our previous discussions before we recorded the ivory tower, you know, it's like wrapped up in a bow and it's very elite and it's, you know, there are people who have studied for years with postdocs and, you know, devoted their lives to this research. And, and I totally respect that, but I don't think that it needs to be so substantially separate from, you know, being so stressed out at work that you just need to find a marker and one marker would make your whole day that much better so that you could actually implement what the people in the ivory tower have, have been researching. So I, I loved your opinions. I think they're great. , I think you're great if you couldn't tell,  [00:58:36] Cathy Binger:  is there  [00:58:38] Natalie Douglas:  big box before  [00:58:40] Kate Grandbois:  we wrap up, are there any like parting words of wisdom that you would like to  [00:58:45] Cathy Binger:  leave our listeners? Is that really a wrap.  [00:58:49] Natalie Douglas:  I can talk about curvy some more scurvy  [00:58:54] Kate Grandbois:  each vitamin C everyone. And that's a wrap. , okay. Are there any other words of wisdom that you would like to impart upon our listeners besides each, each lemons?  [00:59:08] Cathy Binger:  I think words might be a little bit of a strong statement, but, , I'll take a shot at part of that. So Natalie's point in everyone's point about shame, I think is just such an important one to, , reiterate. So, you know, just a very quick story about my own experience. When I left, when I left grad school, I had all the hope in the world. And then by the end of my first year of practice, I felt like an utter and complete failure. Like I was trying to be an upbeat, I just felt like there's no way I could keep up with all the literature, even though I tried, I was not, I mean, I had filing cabinets full of papers that I printed out and, you know, blah, blah, blah, blah, blah. And, but feeling like everywhere I turned, I was getting it wrong and I wasn't able to live up to the expectations of my professors and just, I mean, I almost left the field. I had one foot out the door for multiple years during that time, , after, after year one and I, you know, anyway, so like that was, uh, that was not a good, healthy experience. And so I really also love implementation science because it changes the story, right. That fundamental story of, Hey clinicians, go out there and read the literature and eat your Wheaties. And, you know, you'll, you'll be the world's best clinician and you should be able to do all of this. And, , you know, it's, it's a, it's a false narrative. , and we have to, we meaning researchers, you know, academics, we need to be doing things differently. We work in service to all of you. That's why we exist. That's why we do the work that we do. And even more. So we work in service to the clients that all of us serve. And, , when we're not doing a good job of serving clinicians, we're not doing a good job of serving the clients either. So it's very easy to set up here and say, oh, why isn't anybody using my stuff? Well, that means I didn't do my job. That's what that means. That's exactly what that means. So, , we all, we need to really think differently about how we go about this task of conducting research that is at the end of the day, designed to help individuals who have communication disorders  [01:01:16] Natalie Douglas:  here, here. [01:01:19] Kate Grandbois:  Wow. That was beautiful. I don't think any of us can say anything after that. , well, thank you both so much for, for being here. Maybe we can convince you to come back someday, cause this was just so fun and I'm really hoping that everyone feels so empowered and knows about implementation science now and can sort of take action to, you know, help bridge that gap between th that research practice gap, , as much as they can. Thank you again so much for joining us guys. [01:01:45] Cathy Binger:  You back here again. Awesome. Thanks so much. We really appreciate it.   [01:01:51] Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ashes CE use. 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 . Closing [01:02:14] Kate Grandbois:  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@infoatslpnarcos.com . Thank you so much for joining us and we hope to welcome you back here again. Yeah.

This is a transcript from our podcast episode published September 5th, 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. [00:01:40] Ali Arena: Kate Grandbois:  We are so excited to welcome Dr. Ali Arena and Nicole Moore. Welcome guys. um, before we get started in today's topic, do you guys want to tell us a little bit about yourselves?  [00:01:55] Nicole Moore:  Sure. You want to sure. I'm Nicole Moore. I am a licensed marriage [00:02:00] and family therapist. I specialize in the treatment of trauma and trauma related disorders. I'm also the founder of the center method. It's a wellness center in Santa Monica.  [00:02:10] Ali Arena:  And I am Ali Arena. I'm a speech language pathologist, and a BCBA. And I specialize in working with neurodiverse and neurodiverse couples. And I really specialize in social interaction.  Kate Grandbois:  And you also have your PhD in special education. I just learned about you.  Ali Arena: I do. I in my imposter syndrome is real  Kate Grandbois: You wear many hats. Um, we are, you guys are going to talk to us today about trauma and communication, which is a topic that. So, so, so excited to dive into, because I think it's so much more relevant to our jobs as clinicians than we realize. And the two of you as a pair bring such a unique perspective to this topic. And so, you know, we love collaboration. We talk about collaboration a lot. Um, [00:03:00] so the collaboration between the two of you and your different disciplines and all of your degrees is really, really exciting. Um, let's get into our learning objectives for the day. So there are three of them. I try to read this as quickly as possible also, and I will do my best, um, learning objective number one, define both big T and little T trauma. Learning objective number two, identify signs and symptoms of trauma when working with both kids and adults. And learning objective number three, identify how trauma impacts social interaction and social contracts. Our financial and nonfinancial disclosures. Another very boring thing that I have to read and I will get through it as quickly as humanly possible. Um, Dr. Ali Arena’s, financial disclosures: Ali is the owner of Ali Arena Communications, Ali Arena’s, non-financial disclosures. Um, Ali is a member of ASHA and is a licensed speech and language pathologist and board certified behavior analyst, Nicole Moore's financial disclosures. Nicole is the owner of The Center Method. [00:04:00] Nicole's nonfinancial disclosures. She is a psychotherapist and licensed marriage and family therapist, trauma specialist, and trauma related disorders. Um, Kate that's me, my financial disclosures. I'm the owner and founder of Grandbois 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, Mass ABA, the association for behavior analysis, international and the corresponding speech pathology and applied behavioral health specialist.  [00:04:32] Amy Wonkka:  Amy, that's me, financial disclosures. I am an employee of a public school system and co-founder of SLP nerdcast. And my nonfinancial disclosures are that I am a member of ASHA's SIG 12, and I also serve on the AAC advisory group for Massachusetts advocates for children. [00:04:45] Nicole Moore:  All right.  [00:04:47] Ali Arena:  We've gotten the,  [00:04:50] Amy Wonkka:  the, the, the required components now onto the fun staff. Um, why should we care about learning more about trauma? How, how is trauma related to the [00:05:00] field of speech language pathology?  [00:05:02] Ali Arena:  Yeah, I mean, really fair question. It's not like it was talked about in grad school or anything. Um, but I mean, as humans, most of us have gone through a form of trauma. And it's, to not look at someone with that lens can feel a little unfair. Um, and we'll get into this more, but one of the things that trauma can really impact is your executive functioning and your ability to regulate. And if we're working with our kids, I mean, those are two primary areas that we tend to be looking at. Right. So I think it's important to think about how these things can be intermingled. Um, and for me personally, the more I've learned about my own trauma and just that journey it's, it's pervasive. And I don't mean that in a scary way. I just need, it's very hard to separate again, a person from their past and where that can be showing up in their life. [00:05:56] Amy Wonkka:  And we don't always know these things, but we do know that we're [00:06:00] all human people, [00:06:00] Ali Arena:  exactly  [00:06:02] Amy Wonkka:  who have a diverse range of life experience.  [00:06:05] Nicole Moore:  We are all human and we can expect in our lifetime to all have experienced trauma, especially right now with COVID. That is a collective trauma. Whether we're recognizing it right now or feeling it right now or not, it's something that will be affecting us for years to come. [00:06:23] Ali Arena:  Even us as clinicians. We had a stretch this year to do things that we probably never thought we'd be doing. Um, and although we may not label it as traumatic necessarily, it affected us and we're not really going to realize it until we get to slow down and process what our past year was like working with all of our students, adults, whatever. Right. I mean, it was different. We stretched  Kate Grandbois: and I think, you know, one thing I want to, I guess this is a question and it's maybe leading into our first learning objective. But my impression as someone who knows zero about this [00:07:00] is that the, you know, the lay person may think of trauma as a significant, your house burning down and you're losing a family member or, uh, an extreme moment of physical or emotional abuse. And you think you hear trauma and you think of this significant moments of, of horror, you know, but I I'm, I'm guessing or I'm inferring that that is not necessarily the case. Is that an accurate assumption.  Ali Arena: Yeah, we are going into my first learning objective, Nicole do you want to define big T and little T? [00:07:38] Nicole Moore:  We'll break it down into big T little T. What you just described as house burning down or being in an accident or war. Yes. Um, childhood abuse, sexual trauma, right? These are considered big Ts. They are pervasive. As [00:08:00] Ali said, a moment ago, they affect every area of our life. Um, and they usually cause PTSD post traumatic stress disorder, small ts are usually the ones that sort of get brushed under the rug. don't get much attention and that could be the death of a pet. It could be switching jobs, it could be moving homes. So these things that still majorly affect our lives. But people sort of minimize the effect that they might have on us overall on our functioning. [00:08:30] Kate Grandbois:  And is that because society sort of expects us to like, oh, it's, you know, your dog died, you can get a new one or you move no big deal or you switch jobs, like get over it. I mean, you know, is that, is that, is there some interaction there between what's expected of us and that being in direct conflict with what we're emotionally experiencing because of that little t.  [00:08:54] Nicole Moore:  Perhaps. Yes, I do actually believe that our society and our [00:09:00] culture puts pressure on us to just move forward to power through it, to pull ourselves up by our bootstraps. Right. And doesn't give us enough time to stop and process what's happening and what we're experiencing, and it's all relative. Right? So something that's not a big deal to one person might actually affect another person in a major way.  [00:09:22] Ali Arena:  Yeah. And I think, you know, one of, one of the big things when I was learning about trauma more is, you know, um, maybe not getting invited to every birthday party when you were little, because maybe you were neuro-diverse and things were difficult for you, right. Or you had a little bit of bullying. I don't know if you have, I don't know if I have a little bit, but not like, you know, insane amounts. All those little things still count as little t trauma. And if you already have difficulty communicating, which a lot of the people we work with, do, you could see how that can compound because these things are happening to you. You're really feeling them. You don't have the vocabulary to access, [00:10:00] to talk about what you're feeling. Um, and I think there is a little bit of minimization, like, yeah, everyone gets picked on or maybe not bullied, but like picked on sometimes or like you won't always get invited. Um, I've heard that before from older adults that were saying like, when they were little, people would, um, say like, they're like, yeah, I'm not invited to this birthday party. And their parents would be like, yeah, don't worry. That happens to everyone. But because they're autistic, they were able to remember, no, I wasn't invited to 15 birthday parties. Like I remember every single one. So think about how heartbreaking that is. Right. Um, and if we don't see that as like, oh, they could be having a real response to that, or that could be really affecting them. It's hard. It's hard to not have that lens on. If you're going to talk about, um, social skills. Right. And not think about, well, maybe there's another part happening here. They have this like history in their head of why they shouldn't do certain things. Yeah. Yeah.  Kate Grandbois: I'm [00:11:00] going to throw out another vocabulary word here. Is this related to microaggressions? Something about what you just said, tt felt like, you know, having a lot of, uh, a lot of small, that's what I think of when I hear the word microaggression. And maybe that's just me not knowing what I'm saying.  Ali Arena:  Do you mean small instances? Um, like against you in some way  Kate Grandbois: yeah. And having them build up over time and having to carry that emotional burden as like a, a little trauma.  Ali Arena:  Yeah. I mean, I think that's the definitely pretty accurate. Um, and you just, you know, you think about the diversity of clients we see and they're seeing us because something is difficult for them. Right. So there's some impairment of some kind and that's why they're coming to us. I mean, little stuff, like, I, you know, I can't say my ‘r’, but now kids are making fun of me at school. Like that hurts. But like as speech therapists, we normally don't talk about that part. We're just like, okay, we're going to fix your ‘r’[00:12:00] sound. Yeah, but there's another component there that can become emotional. Like, you know, the 12 year old that's coming for their ‘r’ still on. They're like, I hate this so much. And it's like, yeah, I got it. Like I can I'm you're still coming through me and it's not getting better. And that's really frustrating. Yeah. [00:12:19] Nicole Moore:  I think with ABA therapy that's what's missing. Oh yeah. Right. It's the consideration that trauma is behind a lot of this behavior. So to try and fix a behavior without taking into consideration the emotions and the events that happened to cause those emotions I think, uh, is, is what is the word  I'm looking for?I'm not doing service to the client.  [00:12:50] Ali Arena:  And I think Kate, you and I, both being BCBAs are always in conversation about how ABA is evolving. Um, and I think [00:13:00] I took a CEU recently. It was like kindness and ABA and it was pretty cool. They were talking about trauma and just sort of how every person has a history. So it's just something to think about. Like, you know, we're expressing something in those moments. So trying to maybe navigate what that is a little bit more.  [00:13:22] Amy Wonkka:  When you think about big T and little T trauma, or is it important as a clinician to kind of know the difference? Like, oh, this is a big T trauma. Um, I guess that's question number one. Like, do I need to be able to sort out the difference between those two as, as a speech pathologist, who's just trying to be more informed and provide better quality service. And I guess the other question along with that is, Does sometimes, is that dependent on the individual person? Like,  is it less  about the actual event and more about how the person reacts and responds to that?  [00:13:58] Nicole Moore:  Yes, I would say it [00:14:00] is more about how the person. Uh, how the person receives the event and how they, how it affects them emotionally. Right. And everybody is different. Like I said before, it's all relative. So when I'm shooting people, I'm not, I'm not thinking like big T little T I'm just saying, how is this affecting you in your life? Um, but I think the little ts, again, to emphasize they can be overlooked. So to not underestimate the power of a little t.  Ali Arena:  And I think also what came up for you when you asked that Amy is, you know, I'll work with kiddos. Sometimes I was saying this to Nicole, like we're speech therapists, so they're not going to come to us and be like, Hey, all these other emotional, right I'm using quotation marks, uh, issues are happening. But if you're going through a divorce, something that's actually traumatic in the home. It'd be nice to know that because I remember working with a kid one time, he was just so shut down. And I, you know, I could've done cartwheels [00:15:00] and he would have been like, all right, whatever Ali, I don't care. You know, but I think if I had known some of that information, we might've done a different type of session. I might not have tried to drill so much. I might've been like, should we just color? Should we just bond for a second? Like, so just knowing that is helpful,  [00:15:18] Nicole Moore:  You bring up a really good point that to have a home that's supportive and safe really enhances the efficacy. So to know if someone is going to a home where they don't feel safe is really, really important information.  [00:15:35] Ali Arena:  Right.  [00:15:36] Amy Wonkka:  They asked that at the doctor now.  Kate Grandbois: I know it makes me so happy that they do, [00:15:37] Ali Arena:  what are they asking.  [00:15:44] Amy Wonkka:  Oh, do you feel safe at home? And I'm always like, yes, but thank you for asking. Kate Grandbois: I know every doctor's appointment I've been to, maybe it's a Massachusetts law.I don't know, but they doctoral questions related to physical and physical and emotional safety in the home. [00:16:00] Um, but it's slightly tangential. We're really glad that medicine is moving in, moving in the direction of creating, monitoring for home safe environments. A couple of the things that you guys were saying earlier. I just want to emphasize a point of how sort of bringing it back to the, how this is relevant to speech pathology. If you have a communication disorder, or like you said, Ali, you're coming to a speech pathologist because there is something that you are seeking help for. You are there for a reason, right. And that would imply that in some capacity you have a communication, you are seeking assistance to improve your communication skills, right. Which is a key component of human connectedness in some way, shape or form. So I am just sort of dropping the breadcrumbs here and seeing how this all relates to potential trauma in so many ways. Um, I know I threw the word microaggression in there earlier, which is maybe not the [00:17:00] right word, but just, you know, it comes up a lot in the autistic community that, you know, in the fluency community, uh, you know, and, and how those things, you know, in other words, to reframe it ,communication is, or trauma is incredibly relevant to communication disorders. As, as I'm, as I'm learning, as I'm sitting here talking to you, how do we not talk about this as part of our field, as part of these critical components of counseling? Because, oh my goodness. That's so they're so related  Ali Arena: and I think especially for speechies it's important because we're, for whatever reason, I'm going to say it because we're great. But we're typically the first member of a lot of teams, right? Like they tend to refer to speech pretty early because the speech problem, quotation marks, right. It's pretty obvious to people. So we might be the first people realizing like a larger umbrella, like, oh, actually there's a huge anxiety component [00:18:00] going on here. We should be referring to a therapist. Right. But if we only look at this isolated, like I'm just looking at this speech thing. That kind of does a disservice to the environment and the autistic community is really why I am my own trauma, but why I got so passionate about trauma because yeah, it's inseparable. I mean, they all have experienced trauma and it's literally, you can't pull it apart at this point. Um, and then it compounds, right? So it’s like, Are you actually having difficulty communicating socially because you don't have the language or are you so anxious because you've gotten rejected so much, right? Like it just sort of keeps compounding and then you're trying to pull those layers apart. Um, and so if you don't have someone like Nicole also on a team with you, it can get difficult.  Kate Grandbois: Um, I'm making very aggressive gestures with my hands, for people who can't stand, because, because Nicole, we need you everywhere. I mean, the fact that we don't have a, you know, as a [00:19:00] field, the component of counseling and social work and, you know, people with your credentials being consistently involved on our teams is it's an oversight. Ali Arena:  Yeah. And I think. We're in LA where I feel like I'm pretty into what they're feeling. But when I was back on the east coast, like you would not say a child had anxiety. That was like, if I was going to say that I really had to feel extremely informed, but I feel like just having conversations around. Yeah, I have noticed, um, that this kid really tenses up when we talk about a certain topic. And I just wanted you to know that, like, just giving that parents that feedback. I think sometimes we think we shouldn't, or like, that's not our lane, but again, you're with these kids for an hour at a time, you know? And, and they tend to get pretty close with us. We play awesome games, like we're fun. So they tend to show us more of themselves than maybe worrying about. Kate Grandbois: Yeah. And as you were saying that I was, you know, and this is the [00:20:00] last thing I'll say about it. And then, and then I have more questions about how do I identify it. Um, what you said resonated with me in terms of, you know, discussing trauma or, you know, referring for anxiety because a lot of times. As this as a speech pathologist, making those referrals or bringing those things up, I might get a little bit of pushback, particularly from a behaviorally oriented professional about how that can't be measured or you can't see it. And I just want to say for anybody who is listening. That that is not true. And there are private internal events that we all talk. You know, we all have thoughts. We all have feelings and the behavioral community does acknowledge that. And it's, you know, cognitive behavioral therapy and all these other kinds of things that is a whole. Other topic that we are not going to talk about, but if anybody's listening and they've had that experience, there is a little bit of ammo to throw into the conversation. So I'm off my soap box. I can stay focused. Now.  Ali Arena:  I also [00:21:00] love doing commitment therapy. That's fun too.  Kate Grandbois: Yes. So acceptance commitment therapy is a thing that is embraced by the behavioral community that is related to internal, private thoughts and events that are related to in a lot of ways, anxiety and all the other thoughts and feelings that we have. Okay. Really now the soapbox, soapbox is over. I'm thinking more now about, you know, the clinicians out there. Who are thinking about other students thinking about their clients with, you know, who, you know, are part of the, um, autistic community or fluency community, or can't say their ‘r’s and they're 15. I mean, whatever it is, whatever communication issue they're having and now thinking, oh my gosh, are they experiencing trauma? What are some of the signs and symptoms? How can a therapist really engage more deeply with their clients if they are concerned about.  [00:21:56] Nicole Moore:  So as Ali just mentioned about the [00:22:00] kid who tenses up when they touch a certain topic, right? So you might see a shift in their body language. They might be really relaxed and laughing one second and then they might freeze. Um, you might notice their breath changing. They might have more rapid inhales and exhalations, right? It'll be more shallow. Um, they might, all of a sudden have an outburst and behavior.They might start acting out. Um, they might want to curl up into a little ball and hide and disappear. [00:22:34] Ali Arena:  Um, one of the things I was going to say is, you know, you're in your speech room and you have your investigative hat on. You're like maybe there is stuff. I think one of the easiest ways to even start to have a more safe place for your adults and kiddos is to normalize a lot. So like we, I started a lot of my sessions with improv, which I know we're going to talk about in another CEU, but [00:23:00] I am so awkward during it. And like, I own it. You know what I mean? Like I'm like, yeah, I mess up too. And I'm awkward at this. Or. You know, I, I talk a lot with dating with clients and I'm super open. I'm like I met my fiance online and let me tell you, there were a lot of other things that were really hard and we're not going to do that with kids, but just that normalization and the lack of judgment. And it just being an open place. Makes a big difference. Um, and you can do that little ways, right? So like you can mess up coloring and not make it a big -. So, um, sometimes when another assignment be like intense perfectionism, like just getting so frustrated, if something goes wrong, that could be another sign. I'm trying to think of more. Yeah.  [00:23:43] Nicole Moore:  To your point, I think what you're describing is shame. There's a lot of shame involved in trauma it's, um, shame, meaning that individuals allowing themselves to the shame informs who they are. So they might think in their minds, like I'm a bad kid, [00:24:00] nobody loves me. So there's a lot of shame that goes along with it. I have to hide what happened to me because nobody loves me because I'm bad because I deserve this.  [00:24:08] Ali Arena:  So breaking my heart. I love hearing these. I know.  [00:24:12] Nicole Moore:  Yeah. It's, it's sad. [00:24:14] Ali Arena:  You know, like we were saying, and you can, you can do all the neurology with this. Cause you're still gonna have, but like trauma really affects executive functioning. That's where it's going to like latch on kind of. You, if you start to notice certain executive functioning difficulties that maybe don't correspond with the diagnosis, you would've thought, right. Someone's coming for fluency. And you're like, oh wow. This is really, this seems odd that this, this is feeling like an issue. That's another thing to think about as well. Like why is there difficulties with like planning and organizing your thoughts if we're just kinda talking about the weekend and it's not the fluency part, you know, it's the, um, organizing of the thoughts. Go ahead Amy.  [00:24:56] Amy Wonkka:  If, if you're, if you're working with a client [00:25:00] and you notice that and you notice, okay, I'm seeing this, this thing that would be unexpected. I'm seeing some unexpected challenges with executive functioning. How would your treatment change or would your treatment change if you suspect that that might be connected to some type of trauma compared with somebody who kind of just has baseline challenges with executive functioning, does it look different? Should it look different? [00:25:26] Nicole Moore:  Okay. It actually looks very similar. Um, and, and that's okay. I'll, I'll explain why. So the neurology behind it is the same, um, Dr. Stephen Porges. Created something called the polyvagal theory. And are you familiar with that? Because,  Amy Wonkka: you know, I just like brain stuff.  Nicole Moore:  Okay. Um, I'm going to simplify this so much so that it, anyway, I'm going to simplify it. [00:25:54] Ali Arena:  Please do. Okay.  [00:25:59] Nicole Moore:  is [00:26:00] There is a nerve called the vagus nerve and it goes from our brainstem down our spine and it connects to all of our organs. So we also have, uh, a mechanism within us, uh, that triggers the fight flight freeze response. It's within our limbic system, in our brain and the amygdala within the limbic system, you can think of it as a smoke detector. So some smoke detectors are really, really sensitive. Like if you're taking a shower and the steam goes out and it sets off the smoke detector and you're like, that's not smoke. It's steam stopped going off. But you can think of that as, as trauma really sensitizes our system. So when that's activated it, then sends the direct signal from the brain to our body to get into that fight flight freeze response. And that's when you'll start seeing the behavior changes. Right. And so that's, that's your cue to. And change what you're doing because that person is, it cuts off our, [00:27:00] our access to the prefrontal cortex, which is the executive functioning part of the brain. So with individuals who have autism, they're often caught in that fight flight freeze response, maybe because they don't understand they're, they're interpreting things differently and they just don't understand. And also same thing with somebody who has had trauma. Like I said, that that faulty smoke detector. So they're constantly in that state, that hypervigilant state and a very, one of the very basic, uh, strategies of trauma treatment is emotion, regulation and stress tolerance. So you want to help the person calm their system down. And eventually be able to have a greater stress tolerance to sort of train that smoke detector that they don't need to go off. It's just. That makes sense.  [00:27:55] Kate Grandbois: Now it makes so much sense just to normalize this a little bit. I need that. Can I get, [00:28:00] can I get, I mean, I think, you know, I, I, I am a lot of us have some history or something that's happened to us where we realize, oh God, I really have a hard time handling X. And for me. Conflict. No, thanks. I'm just going to like sit here and be quiet, smile and then freeze. And then my heart's pacing and I'm sweating. I have had conflicts with parents on the job and I'm like sweating, pitting through all my clothes and I look like, you know, it's a disaster. And so it's okay. I think it's important to just acknowledge that this is something that we all experience and as you were talking, I was like, yes, all of those things. Yes.  [00:28:37] Nicole Moore:  Everybody could benefit from understanding this. [00:28:39] Ali Arena:  And that's kind of, Amy to your point. I don't think we're saying like, let's go around speechies and like diagnose trauma, but if we see it and we can recognize it in the moment we can bring in mindfulness, right? We can, we can have them get up. We can maybe switch the activity. I think that's the big piece here is to [00:29:00] just look at the individual more holisticly. And just be like, okay, maybe there's something else going on. That's not, it's not just because they don't feel like doing speech today. You know, go ahead Amy.  [00:29:12] Amy Wonkka:  I wonder sort of to Kate's point, and this is where I'll, I'll pretend to be a BCBA, but I'm not one, but like don't you guys talk a lot about antecedent strategies? Like, is that something that we could just be doing in general kind of for everybody? Is that like, could we, could we all just work a little bit on.  [00:29:33] Ali Arena:  Yeah. I mean, yes. Like I, I fully know that if I'm like, you know, whatever, just being a crazy person, my energy has been crazy and all of my clients feel my crazy energy. So like just me being self-regulated helps. And then when Nicole and I run groups, we always, mindfulness is just in there. So they don't even, you know, it's not like, oh, I'm taking out my mindfulness cards. Like it's just in the [00:30:00] program. That's just what we’re doing.  [00:30:02] Nicole Moore:  Also, I just want to say Amy, that I think one of the tricky things about trauma is that the antecedent is not always clear. It's sometimes it's seemingly disconnected. And so I use the analogy, I say, imagine there's, um, you throw some dots on the wall and it's like a connect the dots without any numbers and you have to figure out how it makes a picture. So it's not always clear and the person doesn't always know why,  [00:30:32] Amy Wonkka:  and if they don't know, how on earth do you have any chance of knowing you're not going to know? Not that we necessarily need to know, I guess is that, is that part of the point is that we don't need to know the specific. To be of help to our clients.  [00:30:44] Nicole Moore:  Exactly. But just to understand that they're going through something to have some empathy for whatever it is. And even if it's seemingly it's, it's small, if you think, well, that was nothing. I just dropped a pencil. You know, it may have been a really big impact on them for whatever reason. [00:30:55] Kate Grandbois:  [00:31:00] I just want to review really quickly something that you said earlier. So it's fight and flight, which we're, I think most of us are familiar with. So run from the bear. Fight the bear, right. Or freeze and pretend that you're a tree so that the bear doesn't see you. Right. These are the analogies that I've come up with in my head. I've recently heard another one, which was fawn.  Nicole Moore: Interesting. I have not heard of that.  Ali Arena: I've been told I fawn so I can give you a little bit, um, yeah. Kate Grandbois:  It's basically like a pleaser, right?  Ali Arena: Yeah, yeah. Yeah. Like inherent people just constantly. Pleasing. I also can check out though. So that was something, um, oh, this is actually so important and I think it's so, so I do have ADHD, so I'm sure this is in here too. When I was little teachers used to always be like, Ali does not listen. She's not paying attention, but I actually now as a grownup, I'm like, I was just checked out. Like I did really well in school. Obviously I was listening enough. [00:32:00] Right. But because I went to a Catholic school, they were like pay attention to me. Um, but I think that's really important too, to just be aware of what kids are like, if they're responding to you, but they're just checked out for a second. Let them just check out for a second. Like, I don't think it always has to be this perfect. I love whole body listening on a Disney, whole body listening, but like, I need to be whole body listening in every moment, like, I think it's just knowing that. Maybe, maybe stuff is going on at home. They need to check out for a second. And I think it's also, um, like I worked with one client. I took out a red pen not to be punitive, but because I have a million colors, I have those jelly pens that we had, you know, in grade school. Um, and he was really like, he liked tensed up like that. Hey, what's going on. He's in his thirties. And I was like, Hey, what's going on? And he was like, I just lost so much red that like, I know you're going to tell me I'm doing things wrong. And I was like, whoa. So something that little, and that wasn't where I was going at all. I think I was writing myself a note to like, make an appointment. I haven't read, but like, so it's just something that little, and he had the words to tell him, [00:33:00] Right, right. Kate Grandbois: That's that's another, like, it's such a huge point. If you're working with someone, I mean, this is a podcast for speech pathologists. Again, working with people who presumably have a communication disorder who may not be able to articulate or communicate what they're experiencing and that that's where you see a lot of commun- , nonverbal communication. So changes in behavior, you know, changes in physical, you know, appearance or, you know, the tensing that you've described. I'm wondering if from a counseling perspective, what can a speech pathologists do in that moment? I mean, what did, what would you recommend? You know, so you see the tensing or you see something that cues you into, okay, something's happening. There's a, they've been triggered. What, what is it that the speech pathologists do? I mean, obviously the answer is don't go forward with the rest of your ‘r’ drills, but what, what else can you do?  Ali Arena: Go ahead Nicole.   And then I'll say, when I [00:34:00] attempt to do,  [00:34:01] Nicole Moore:  as Ali mentioned, mindfulness is really, really helpful, but there are some specific tools to use when you noticed that your client is true? Right. Um, there are three things that I use. One that I use right off the bat is I call it present moment. So bringing the person back into the present moment, because when they're triggered, their brain is somewhere else. They're right back to where they were, whenever that event happened. So they're not in the present moment. You can turn it into a game with kids. So what I do is I say name five things as fast as you can in the room. I quickly. Um, microphone, glass mug thump, right? Or you can say something like I spy something blue, what is it? So you can make it into a game and make it fun, but just make sure that they're, um, engaged with you. So get them to be engaged. Another thing that I do, so breathing actually deeper than calms the heart [00:35:00] rate and then sends a direct signal to our brain that we are safe and turns off  the activation.  They're right back to where they were, whenever that event happened. So they're not in the present moment. You can turn it into a game with kids. So what I do is I say name five things as fast as you can in the room. I quickly. Um, microphone, glass mug thump, right? Or you can say something like I spy something blue, what is it? So it seems simple, but it's a really, really powerful tool. And with kids, you can sing a song. So a lot of them might have a favorite song. And, um, one of my kids likes to sing, “It's raining tacos” Amy Wonkka:  that is awesome. It's so cute. Nicole Moore: So yeah, you can make up a song or sing a song we might know, but just. Taking big breaths and you can do it in super slow motion. So make it kind of fun and silly. And the third tool that's really helpful is I call it sacred place. But as we discussed before, sometimes people don't have a safe place to go to. So we offer them one in their imagination. And with kids, you can have them draw it out. And be really [00:36:00] specific with it. So, and I call it sacred place because safe might be a trigger for them. So sacred place means it's a space where that person has total control. They can invite their cat in or dog and whatever they like and anything they don't want in, stays out and they use their imagination. So, for example, my place is a garden and it has a fountain in the middle of my dog and cat are there. Right. And once, once they're calm, you can actually have them do something called the butterfly, cross the thumbs over and place the hands over the chest and slowly tap one hand. And then the other, that sort of solidifies in the body, the calm. [00:36:47] Ali Arena:  That was really helpful watching you dothat. So I know she has a very calming presence for sure. I try to [00:37:00] bring that with me and just say.  Kate Grandbois: So, so you're the SLP, you've paused your ‘r’ drills you've acknowledged and noticed the trauma or the trigger. And you've gone through these exercises of, you know, deep breathing, you know, tailoring them to the age and preferences of the client, obviously. And then, and then what, so you've, you've brought them back. You, you know, obviously want to finish your session. Maybe you, you know, pare back some of your demands. Are there. if you're working with a younger student, would you talk to the family? Would you make a referral? Like what, what else? You can't just leave that poor little human being going out into the world, knowing that they're suffering because you brought out a red pen. I mean, you know, what are you going to do? Ali Arena:  Yeah. So I think for me, what I've done is always. Like kind of looked at like how large of a reaction was this. Right. Like if it was like, I brought out a red pen and they're like freezing and shaking, I'm like, okay, parents, I mean, parents have to know that. I think [00:38:00] though, if it's smaller, like I see a little bit of a shutdown and then I can sort of redirect through the activities Nicole mentioned, I might wait and see if that's like a pattern that's occurring a lot because the thing I, I think, um, I. I don't want to make it seem like is that we're supposed to be like trauma police, like out there labeling and, and telling. And that's really important too. Like if a kid is in trauma, you don't need to like, tell them they're in trauma. Right? Like you just into the breathing. And like,  Kate Grandbois: it sounds like it would be a bad thing to do [00:38:32] Ali Arena:  and you're not supposed to be like, oh, I'm seeing, it looks really tense and it's probably because you're having such a bad memory, like you don't want it. So I just think, um, I'm joking about that because I think actually that's the opposite of what we're told. Not always, we're told to label the crap out of things because we want the kids to learn the language. Right. So that's why I'm sort of making it such a joke, but it's not actually, you don't actually want to highlight it because I actually feel more triggering like, oh wow. Now they see even [00:39:00] more than I'm having a reaction. Um, and to Nicole's point, traumas sneaky. So like they might not even know they're having a reaction like Kate, when you were giving your example of, um,  Kate Grandbois: when I sweat through my clothes  Ali Arena: you might have been sweating for good tenants where you noticed your sweat, and I'm not trying to say that to scare you, but like your body might be showing something before you even cognitively are like, oh, this is happening. So by highlighting it, you might make it a little weirder for the person. Um, so again, I think just using those strategies, if it's a very large reaction, I mean, I think we all know we have to tell parents, right. Their kid is having a really difficult time. Um, and if it's, uh, an adult like, so that, that, um, man with the red pen, I really clarified, like that pen was a random choice. Like I, I will now take out a green pen. Um, but I was like, There's going to be red pens at the office. So we got to talk like this needs to be addressed in some way. So in that instance, I think you can honor, like [00:40:00] I just saw what happened, you labeled it, this needs to be addressed. I don't think it's me. That's addressing it. And he gets your therapist or whatever, because what I find what happens a lot with, again, with, um, I work the most with the autistic community. So I swear I'm not trying to make it, like, I'm not saying that it only happens in them. Um, because they're autistic, there tends to be a lot of black and white thinking. So I am seeing Ali for social stuff. I would not talk to Ali about anything else, but like I was saying all these things layer. So if I see a moment where I'm like, Hey, I don't think that's just because you have autism. I think there's something else happening here. I'll definitely help to identify and refer. Kate Grandbois: That all makes a lot of sense and is incredibly helpful. And it's making me think of, again, this is a very natural segue into our third learning objective. Just to how, how trauma does impact these social interactions. So you're having a social interaction with your client, right? I [00:41:00] mean, and you've, you know, there is a huge impact there. So just to refresh our listeners' memory, the third learning objective was identify how trauma impacts social interactions and social contracts. Um, I think we've already illustrated a lot of ways that trauma can impact social interaction, but what is a social contract? Just for, I think I might have like a very loose definition. That's probably wrong. So I'm going to let, I'm going to let you tell everybody  [00:41:27] Nicole Moore:  Examples of a social contract might be, you know, Ali and I are sitting next to each other right now, but a year ago we couldn't do this. Right. So the way we interact out in public, do we hug? Do we shake hands? Can we even touch? Right. So, so, so social contracts in the way we behave has been significantly altered with COVID   [00:41:50] Ali Arena:  and I think like a precursor to this point is we all experienced trauma. Maybe it was big T [00:42:00] maybe it was a little T, but COVID was not normal. And we all went through something pretty intense. And I I've been talking to a lot of clinician friends that just ended like their school years or stuff is starting to lighten up and they're like, I'm so burnt out. But I didn't know it because I was just trying to get through this year. And I think we were all doing the thing of like, okay, this will end by October. This will be over by the holidays. No way this is still happening in March. So our bodies were just being like, we're good. We're good. This is all good. And now we're kind of good. I don't want to say we're, you know, whatever. I didn't want to get into it, that politics, but like it's a little bit safer, let's say. And I think now that people have that moment. Okay, I'm safe, but like, do I keep my mask on? Like I joke, I feel like I'm always wearing like a chin diaper. Ali Arena: Like I just have the mask on because  Kate Grandbois: you don't know whether or not to take it off or put it on Ali Arena: near me at all times. Kate Grandbois:  I think that's a good example of a social [00:43:00] contract, right. Because it's the social expectation of how you're going to behave with another person. Is that right? I mean, I know we've used a lot of examples with like COVID and, and greeting people and hugging and all those kinds of things. But in general, a social contract is the ex - is the social expectation from that interaction. Is that right?  Ali Arena: And now imagine, you know, you are young kid and you have had some significant trauma, it might alter the social contracts that you think you're supposed to have. With other people. So I think that's really interesting to just think about, I think our field is moving away from just teaching like blanket social skills. Right. We're really just trying to look like in the moment, what works and looking at kids, different communication styles, but to also consider. Do they have a contract that they aren't verbalizing because something had happened at some point or, um, do I have a contract I'm putting on like, just to really [00:44:00] examine that. And I think, you know, the social interaction piece, like you said, you could go into a fight, right? Oh my goodness. Fight flight freeze or fawn, I guess the four F's. Um, obviously that Kate Grandbois: What kind of Freudian slip was that there's something interesting, just kidding. Ali Arena: Um, but that could be happening and that person's being perceived as. Or inattentive or whatever. Right. And I think we even could do that to ourselves a little bit, like clinician on clinician, shame on the little like, well that person didn't speak up or this person didn't do this. Right. And like, I think the whole point of this conversation is to just give people grace, like have a little empathy, realize that like, just because I'm standing here today doesn't mean that [00:45:00] there's not like a, history there, or like we talk about this a lot. It doesn't mean that like I hit a ton of traffic coming over here, so I could come in with that energy and it has nothing to do with Nicole. Right. So I just think. Keeping that perspective, always of just giving people grace is like our big, our big message.  Kate Grandbois: I love that. And I want to expand on it for like one hot second. This is only the second soap box and I'm going to get, I'm wondering if Amy knows what I'm going to say? Cause I talked about this a lot, but this is also related to competition, ego and collaboration. Oh gosh. So, you know, giving people grace, when you, you know, we're talking about social interaction and how trauma may, may impact that, but you also have to really make sure that you're monitoring yourself for any competitive feelings, especially when we're talking about other decision-makers and other professionals on a team or other [00:46:00] collab, people that we're collaborating with and not get into the well I'm right. You're wrong. Um, and, and give each other a little bit of space and empathy to, you know, help the student with trauma or. You know, now I'm talking about like five different things, but I just think it's really important unrelated. No one, I mean, starting to fall at one point,  Ali Arena: I think again, what we keep talking about it, to really just be looking at a kid holistically. Right. So, and, and another, I love OTs. I probably should have been in an OT like, I just think it's so cool.  Kate Grandbois: add it to one of your other degrees.  Ali Arena: I'll just keep going.  So I like there, you know, there is a certain point I'm like, okay, wait, you're having a lot of difficulty just like integrating an OT should be on this team. And I should listen to what they're saying, like an OT and trauma you're certified in safe and sound protocol. Right. OTs can also be certified in that because it's, it's an integration of the [00:47:00] systems and your vestibular system. I butchered that a little. that a little, but yeah, I mean, so also just recruiting, I'm listening to other people on the team and think of a kid holistically, not just as they can't say ‘r’, or maybe they really can't just say ‘r’, but you know, I'm just saying always think of them holistically.  [00:47:17] Nicole Moore:  I was calling to comment, Kate, that you brought up a good point about, um, people with their conflicting views. And I think a lot of the small t’s and big Ts, but often small teas challenge a person's ego, How they feel about themselves, then it goes back to the shame. Right? So shame is a huge driver for a lot of our behaviors and our social interactions.  [00:47:38] Ali Arena:  Well, yeah. And I'll be, I'll be super vulnerable. I think I have so many stupid letters after me because I was probably trying to prove worth in a lot of ways. Like I had a lot of shame around stuff, but I didn't know, you know, so just again, like just let people be people and just be kind like, I don't, [00:48:00] I just, there is, there's a lot of clinician bullying and competition and I don't know, it's just, it's not, you know, our, our field. And like I was saying, I think anyone who was in a helping profession during the pandemic has experienced little t because we just had a do things that we never thought we'd do doing.  Kate Grandbois: Hmm. So in terms of our clients and our students, And their social interactions. And you know, this connectedness is so we've already just as like a, to reframe this. So I'm on, is coming to see you, presumably because they have a communication issue or they're looking for some support in some area. Um, communication is a fundamental component of social connectedness and social interaction. If they have experienced trauma, I have to, I have to assume that there is a double impact there that this is like a, you've used the word compounded, you know, it [00:49:00] compounds itself, which is I think a really great word. Can you talk a little bit about that.  Ali Arena: Yeah. I mean, like I was saying, it's kind of like the chicken before the egg, and again, I'm going to use the autistic community again, just because I know it the best, not that this doesn't apply to other communities, but yeah, like, like I was saying this thing, it was difficult for me to access my words for whatever reason, or it was difficult for me to enter the group because I didn't get the dynamics of how to enter it. Or, um, you know, a lot of autistics talk about how they, they genuinely communicate differently. And they probably tried to communicate with a neuro-typical person who just didn't it didn't jive. So then you try to keep doing that over and over, and it's still not working and you, you get strategies and it kind of works. And then you, but think about how you're going to feel after years of being like, okay, I'm just not going to do what feels natural to me. Cause that doesn't work. So I'm going to try to cover that up. I mean, That can really add to some trauma. Like if the, world's saying to you, the way you [00:50:00] do things, don't really, that doesn't work. So you should put on a mask and try to make sure that you're, you know, I'm using quotation marks, like okay in the world, that's gonna affect someone. So I think again, It would be naive to think that these individuals haven't experienced some form of trauma and also naive to think that they necessarily have the vocabulary to tell you that. Like, I think just, we sometimes think if someone's not talking about it, that like, it's not a big deal to them, but I wonder for a lot of them, and I've spoken with a lot of autistics, that's so murky. Like that just feels like, well, this is who I am at this point. I am asking. I am constantly scanning the environment for what's socially appropriate again, using quotation marks so that you can under, you can see how that could feel traumatic. Like, I don't know for, for me, one of my CFs was so dramatic. My supervisor hated me, so I like faked it entire six months, you know, [00:51:00] like I tried to go, Kate Grandbois:  it's exhausting. That's emotional. That is emotional work. That is a drain. That is, unless you have experienced it. It is real. Yeah. Not the CF, the emotional masking, no hangover. Ali Arena: Yeah. I mean, well, just us. It's not that I'm ever faking it with my clients, but we all put on a mask when we're like hanging out with client. Right? Like I'm not sitting there drinking wine, like lounging you can't just be me. So imagine doing that all the time. Like it's gonna affect your system. You're it's, you know, I just think   it's exhausting. That's emotional. That is emotional work. your neurology it's going to affect your, I mean, that's another really big takeaway here is that this is a physiological thing that people are experiencing. It is not, it is not like a, it's not something to be shoved under the rug. This is a physical change.  [00:51:52] Amy Wonkka:  So I've got a question for you guys. Um, just thinking about how this is something that is kind of pervasive in our society. [00:52:00] It's a lot of people have had these traumatic experiences. This is something that's challenging, probably a lot of our clients. Um, there's the linguistic impact of, you know, you may not have the vocabulary. So I, so I don't even know what's happening with that in terms of neurologically or just does that make it even that much more challenging to process these experiences? Um, but  if that is a piece of the profiling. Does it make sense to kind of incorporate some of those examples that Nicole gave us into just you're like, this is just part of how we start our session. This is part of how we get ready to be part of this group and kind of set the stage for this to hopefully feel like a better space for everybody to be like us included. I get, you know, as the clinician, what are your thoughts on that?  [00:52:52] Ali Arena:  I mean, yeah, like definitely. To your point everyone's [00:53:00] experiencing something. So just integrating that into your sessions is just really being a, it's being a trauma informed clinician. Right. And just being kind and thinking about the people that you work with.  [00:53:12] Nicole Moore:  I agree with that wholly. And, um, we use it in our groups. We use it and it seems to work really well. We get a good response from it. [00:53:24] Amy Wonkka:  We're worrying about who gets asked the last point, um, when you're, when you're running it in your group, just, just for me. So I can get a picture in my mind of what that looks like. Like, are you like, is that an activity in your group? Like, is that how you start maybe? Or is that a part where, okay, now we're going to play the, you know, be in, be in the moment game, or now we're all going to, you know, take deep breaths to get like, is it, is it something that you kind of call attention to it. It is a recurring event. Like how does, how does that look?  [00:53:56] Nicole Moore:  Yes. Our groups are very structured. So the first part of the [00:54:00] group, we do a check in and then we immediately go into mindfulness. We do breathing and a little bit of a meditation and then continue on with. [00:54:07] Amy Wonkka:  Thank you that helped me like picture it.  [00:54:10] Kate Grandbois: And just for the sake of saying it, if anyone isn't familiar with mindfulness strategies, we can list a couple of links in the show notes. Um, one of my favorite books is related to acceptance commitment therapy called the Happiness Trap. They make an illustrated version. I made Amy read it. Yeah. You, she loved it. It's so good. You can read it in like a half an hour, 45 minutes. Well, if you're Amy, you can read it in like three minutes, but I'm just teasing you just for the sake of it. But it's, it's, it's, there's a lot of really great information out there about mindfulness and there is literature and research that it physically changes you. So it's not, it's not wishy-washy. Also rooted in behavior analysis and accepted by the behavioral community. So another good thing to bring up if you're ever in a difficult conversation with someone, um, but we'll, [00:55:00] we'll list a bunch of those mindfulness resources in our show notes, in case anyone listening would like to do a little bit of a deeper dive or learn a little bit more. Um, in our last couple of minutes, do you have any parting words of wisdom or anything that you would like to share that we have not covered? [00:55:17] Nicole Moore:  Good question.  Kate Grandbois: No pressure [00:55:18] Ali Arena: . I mean, I think I'm bizarre speech therapist in a lot of ways, because I feel like I'm so into drama and all these other modalities and stuff, but I just think to remember like you, yes, you're a speechie, a speech therapist, but you're working with humans again. So just always think about. Um, and, and you're working with not just the little human, the family, like just the always think again holistically. Um, and one of the best things that you can do for the people you work with is listen, you know, like I, I feel like when I first started as a clinician, oh my God, it was so planned and I probably overtalked so much. [00:56:00] Um, but that's, you know, you don't really have, you don't always have to be that way. You can just kind of hold space, be calm. And bring in more and more calming activity as to what you're doing  [00:56:11] Nicole Moore:  and to play off of that as well. Um, with trauma connection and attachment can be really difficult. So just to notice that, so sometimes simply just the connection between you and the student or you and the client can be so helpful. [00:56:30] Kate Grandbois:  Here here. Like, I wanna, I want to put that on a loop. That was, yes. All of, all of that. And, and I, I want to add one more thing to it is that, you know, if you, as a clinician have these really wonderful goals of making connection and holding space and being calm to create a welcoming, and I guess the word safe environment for your client, you also need to do some self care. Oh, I also need [00:57:00] to practice self care, make space for yourself because you cannot pour from an empty cup. And that is something that I think in a helping profession, we don't talk enough about it is not selfish to engage in self-care. It is a gift to other people around you. It's an act of altruism and you do it. You take care of yourself so that you can better serve your clients. And that as the third and final soap box that I will get on to close out our episode. Right. Um, you guys, this was so informative. It was, this was really just really, really wonderful. Thank you so much for joining us. Um, to anyone who was listening, who wants to learn more, we will list a bunch of resources. And links, um, in the episode, in the show notes, um, if you'd like to use this episode for ASHA CEUS, you can do so by cruising on over to our website, www.slpnerdcast.com . You can email us anytime info@slpnerdcast.com . If you have any questions and yeah, [00:58:00] thanks again so much for joining us and hope everybody learned something. [00:58:03] Nicole Moore:  This was so fun. Thank you so much.

This is a transcript from our podcast episode published January 24th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:39] Kate Grandbois:  So today's episode, we're very excited for it's a little bit different than a lot of the episodes that we have published so far because we had a chance to interview an SLP household name. Nancy Kaufman came into the, the zoom room, the SLP nerd cast studio, if you will, and had such a lovely conversation with us today, and we're so excited to share it with everybody. [00:02:38] Amy Wonkka:  Yeah, we really are. And on top of that, we were able to pick the brain of one of our board members who knows more about all things, motor speech than we do. [00:02:47] Kate Grandbois:  Yeah. So if anybody listening is a regular listener, they know that I, Kate knows zero about motor speech disorders. Amy knows more than zero, you know, [00:03:02] Kate Grandbois:  You know, a lot more than zero. Um, but this is not really our area of specialty. So as we were preparing for this interview, um, we were lucky enough to recruit the help of one of our advisory board members, Mike Bright. Um, for those of you who are regular listeners, Mike has joined us on the podcast a handful of times before, and he's so knowledgeable and this is his area of specialty and he really helped us to craft good questions and think about our, you know, how we think about how we think about some of the larger picture, big picture things that we wanted to get into with Nancy. So Mike, if you’re listening, thank you so much for helping us.  [00:03:41] Amy Wonkka:  Thank you. [00:03:46] Kate Grandbois:  Another really interesting perspective about this episode was related to some bigger picture questions that we weren't really expecting to add.  [00:03:58] Amy Wonkka:  Yeah. I mean, I feel like this [00:04:00] season in particular, we've done a lot of listening, learning, and kind of just thinking more deeply about what informs evidence-based practice. And at least my perception historically has always been like evidence equals published research. Right? You read the article and that makes it real. Um, but when you zoom out  and you think about the evidence-based practice guidance from Ash, and we think about that diagram, we really need to remember that. I need to remember that the research, the published research is really just one part of what we should all be considering as clinicians when we're making evidence-based decisions .  [00:04:45] Kate Grandbois:  and not to go too deep on a tangent before, cause I know this is really about motor speech, but when we were talking to Nancy and the, the treatment model that she's developed, um, it really made us think about, we had this great conversation after we wrapped up about [00:05:00] what constitutes evidence-based practice and how this model fits into our evidence-based practice. And remembering that evidence-based practice in speech pathology is comprised of four components. So we have the research articles that we all know are evidence-based practice. And I think a lot of us, that's what we focus on when we think about. But there's also internal data collection. There's internal progress monitoring. What are you seeing in your treatment room? What data collect? What data are you collecting in your treatment room that provides evidence that your treatment is working? It's also clinical judgment. So based on your knowledge and the data and best available information in front of you, what is your judgment about whether or not your treatment is rooted in evidence and client and family values is what you're doing in your treatment room aligned with not only your client's family values, but your client's values. And yes, children [00:06:00] can have values too. That's another really important soapbox for another time, but the reason that this relates to motor speech and this interview is that a lot of the things we do in our treatment room aren't necessarily clearly laid out in literature. Um, and Nancy Kaufman has developed this treatment approach this treatment package, um, that is, is really effective and rooted in a lot of principles of science. And we think it's really important for our listeners to have that as a backdrop, as  we go into the interview.  [00:06:37] Amy Wonkka:  Well, I think just like everything else in every other guest we've had on. It's it's a reminder for all of us as clinicians to take on that responsibility of, you know, collecting the data and having our own internal evidence help be an equivalently important piece of our evidence-based practice. [00:07:00] Um, so just because you read it in a peer reviewed study, doesn't mean it's going to be the best approach for your clients. Um, And likewise, there may be things that either haven't been researched yet, um, or are part of a broader treatment package that makes it more challenging to isolate independent and dependent variables and all of those components. Um, so when you're thinking about things like that, the burden on the clinician burden is a strong word, but the responsibility for the clinician to be sure that they're really doing their best effort in terms of doing your best effort, um, in terms of collecting that internal data and making sure that you're picking something that's effective, uh, for your client is really important. [00:07:42] Kate Grandbois:  Agreed. So let's, before we get into the interview, we do have to read our learning objectives and our financial and nonfinancial disclosures, because it is all part of what ASHA makes us do to offer this episode for ASHA CEUs. So sometimes people will write in and ask me to skip it. We [00:08:00] can't ASHA makes us read it. So hold on to your hats. We'll get through this as quickly as possible. Learning  objective number one, describe components involved in the Kaufman speech to language protocol. Learning objective number two, define compensatory placement and when this approach might be appropriate and learning objective number three, describe how the K SLP approach might be used as part of evidence-based practice. Disclosures Nancy Kaufman financial disclosures. Nancy is the author of materials and e-courses relative to the K SLP methods and are sold through Northern speech services. She receives royalties on the sales of these products. Nancy Kuafman, nonfinancial disclosures. Nancy is the author of two webinars produced for apraxia kids that are carried in their online library. Kate's financial disclosures. That's me. I'm the owner and founder of Grandbois 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 from Massachusetts advocates for children. I'm [00:09:00] 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. [00:09:11] Amy Wonkka:  Amy 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 am a member of ASHA's SIG 12, and I also serve in the AAC advisory group for Massachusetts advocates for children.  [00:09:26] Kate Grandbois:  So without further ado, if you've made it this far into the episode, through our ramblings and our intros and all the things we bring you an interview with Nancy Kaufman [00:09:40] Kate Grandbois:  we're so excited today, we have sort of a speech celebrity joining us an SLP household name, uh, today on the show we get to welcome Nancy Kaufman. Welcome Nancy.  [00:09:50] Nancy Kaufman:  Thank you. I'm so happy that you called upon me to do this podcast. I love the name SLP nerd cast, and I would fit right in [00:10:00] there.  [00:10:01] Kate Grandbois:  Well,welcome fellow nerd. That's very exciting. Um, do you want to start us off by telling us a little bit about yourself? [00:10:05] Nancy Kaufman:  Sure. So, um, I'm Nancy Kaufman, I'm born and raised in Michigan and, um, I'm the owner and director of my own, um, facility Kaufman children's center. And it's located in West Bloomfield, Michigan. Um, I have been practicing for over 40 years. I don't know if I should say that or not.  [00:10:30] Kate Grandbois:  That's something to be proud of. You should say that with pride.  [00:10:32] Nancy Kaufman:  Yeah. I look forward to going into work every day. I love it. I love all the people that I work with. We have grown, I started out all by myself with a answering machine, if you know what that is. And um, and now we've grown to 75, um, staff and we just have hundreds of families and it's just been just an amazing opportunity [00:11:00] for an occupation. I just have been loving it. [00:11:03] Kate Grandbois:  well as a fellow business owner, I, that is incredibly impressive. So hats off to you. That's a lot of hard work and dedication over the years. Um, you know, I started out by saying you're a household name you've done, or an SLP household name, rather you've been speaking for years. You've, you know, produced so many materials that so many of us are familiar with and you've been really involved with the Northern speech services with Northern speech services and apraxia kids. And I wonder if you could tell us a little bit about those resources so that our listeners know where they can go as they listen to do a little bit more learning and dive a little deeper.  [00:11:43] Nancy Kaufman:  Sure. You know, Northern speech services and I have been working together for at least 30 years and they are, um, located in Michigan as well. Um, and Tom Slominsky is the owner and director of, of, um, that program. And they put on conferences all over the [00:12:00] country. Um, and so they have been the host for many of my conferences and, you know, over the last almost a couple of years, we haven't been traveling and I don't know if I miss it. I mean, I, I miss the live audiences and the feedback and the interactions and the questions. It's, it's been such a wonderful time, but, um, now we're going to be having to do more zoom conferences and all day conferences on zoom. I mean, I feel sorry for the audience to tell you the truth. Um, I love to have fun while speaking and, and it's really just been a blast. Um, and then Apraxia kids, my goodness. Yeah. Clearinghouse. Like, if you, anything that you want to know about childhood apraxia of speech, definitely, uh, go through, uh, uh, apraxia-kids.org and everything should be there for you. [00:12:48] Kate Grandbois:  Well, that's good to know. We will put all of those links in the show. For anyone, um, who is interested in learning more, um, and to sort of start diving into some of [00:13:00] this clinical staff, as our listeners know, I don't know very much about motor speech. Amy knows a lot more than I do, and that's okay. I'm comfortable with my place on the learning continuum. Um, but I wonder if you could maybe start us off by laying the, giving us some background information about, uh, for those who are not as familiar in your work. So what is the K SLP approach? Could you give us a little bit of an overview or some guiding principles of what that is?  [00:13:28] Nancy Kaufman:  Absolutely. So it's the Kauffman speech to language protocol, KSL P um, and I actually was influenced by many different people putting, uh, this method together when I was a student and this was in the late seventies. Um, I had a brilliant, uh, supervisor Carol Goff. And she came up with this concept called word shells. And so for children who struggled to speak, instead of trying to teach them full adult forms of [00:14:00] words, which they would not have success with, she would teach them the shell of the word, really this just the gestalt, and then fill in the details of those words, both motorically and acoustically as the child progressed in therapy. And I just loved that and she taught me all about it. And then as a graduate student, um, we had a guest speaker on phonology. I know I'm dating myself, but it was the first time I ever learned about phonology. And what, and this was Dr. Frederick Weiner. What he was talking about was a phonological processes. And what he said was that this is the way that children's simplify their speech motor output when they cannot handle the adult forms of words. And the way that they simplify them is they employ actual rules, like final consonant deletion, and deaffrication, and cluster reduction and stopping and fronting and gliding. And all of those words that most SLPs have learned about. And when I was listening to [00:15:00] him, I was thinking, wow, that's the way to give ourselves rules to implement for children who struggled to speak, who aren't simplifying their speech motor output in a very specific way. They're really struggling. And so if we're going to shape the success of approximations toward target words, we can rely on our, um, understanding of phonological processes to do that. So for a child to be successful producing certain words, we may need to, um, leave off a final consonant. We may need to glide a liquid. We may need to, um, implement stopping or fronting because these are natural phonological processes that even children who are neuro-typical and just beginning to speak, all of them implement those rules as well. So it gave me an idea and I said, Hey, in this word shells techniques, now we can technique. Now we can put in phonological processes as the way to [00:16:00] help children to simplify their output until they can manage the full target adult words. So that was another piece of the KSLP. Another huge influence was applied verbal behavior or applied behavioral analysis. And back in my day, ABA was completely rejected by speech and language pathologists. And that's a shame because so much of what we learn about behavior is going to be very important to us. We're teachers, we're teachers of a behavior, and this case for childhood apraxia speech, we're teachers of behavior of speech, motor skills, and moving that into functional expressive language. Well, how do you teach? We have so much research about behaviors, how to, um, establish a behavior that doesn't exist. So kids that are minimally vocal, uh, [00:17:00] improving upon a behavior that is there, but it's not really age appropriate, or it's not in this case, uh, intelligible speech or eliminating behaviors that interfere with that process. And we know about those types of things where children can really interfere with their own best progress by some of the behaviors that are interfering with that. Um, and, and those kinds of, um, behavioral principles have also been a huge aspect of the KSLP and I actually didn't know that the KSLP followed best principles of behavior learning until I started, I got introduced to applied verbal behavior. Um, and that was only recently, maybe 10, 15 years ago. And the KSLP has always followed best principles of behavior learning. Um, and it was just exciting to know that and to, to find that out and I can go on and on, but if you don't mind, I'll tell you a little bit more. So I met Tamara love ,[00:18:00] Tamara Casper I'm thinking of someone else, Tamara Casper is an SLP BCBA, and she's the first SLP BCBA I've ever met. And she had come to several of my conferences, um, and then came up to speak with me. And she said, you know, I work with a lot of kids with autism. And at the time I did not work with a lot of kids with autism. And she said, you know, there hasn't really been a very good approach for teaching kids with autism who are minimally vocal, how to speak. And the KSLP follows all of the principles that we would be implementing anyway for receptive language, for expressive language, for behavior management, um, that the KSLP fits right in. And so she brought that information to a mentor of hers, Dr. Vincent Carbone, who's a behavior analyst and an excellent, uh, teacher and, um, he did a research, a little research on the KSLP methods as they [00:19:00] related to what they were doing with kids with autism and what they were doing to teach kids with autism was basically bombarding them with full words and just hoping that because of that bombardment, they would then try to speak them. So he looked at that as opposed to teaching successive approximations toward target words. And he learned that there were fewer trials to criterion when taught the approximations instead of the full echoic or the full production of words that are just bombarded. So that was really an exciting piece of research. And then from there, and just really continue to put all of this together. And when new research comes out about childhood apraxia of speech, which, you know, we're such a young field and especially in CAS, there isn't a lot of research out there, but the research that has come out, the KSLP has already been meeting those criteria. And that's always made me feel even better about all of the successes that have been accomplished with the KSLP [00:20:00]  [00:20:00] Kate Grandbois:  well, as a, as a, I'm also an SLP BCBA. And I am I, this is I'm shocked. I mean, it makes perfect sense, but this is the last thing I was expecting you to tell me or to tell us. Um, and I, as you're saying it, I think it makes a lot of sense. And I just, I had no idea there was an overlap there.  [00:20:20] Amy Wonkka:  Well, I, oh, sorry. I have to say I had a similar experience to yours in that, as I learned more about ABA, I did the coursework for the BCPA. Um, I've had a lot of those same feelings where, oh, geez. I didn't realize that this shaping of successive approximations was actually a thing from another field. Um, but I, I definitely have had that same experience where you kind of find out that what you're doing has, has all of this research behind it. I would like to jump in with a question about successive approximations.  [00:20:56] Nancy Kaufman:  Okay.  [00:20:57] Amy Wonkka:  All right. So many people [00:21:00] myself included know about your Kaufman card sets for successive approximations. And I know that you've said, you know, you don't have to buy your materials. You can use the approach with a lot of different things. I have to say, as someone who has used your materials, I find them very helpful. Um, and it's nice to at least see those successive approximations on there and get a feeling for how you apply those rules of simplification to come up with those successive approximations. Um, can you talk to us a little bit about kind of how that approach works and who are the clients that it's most likely to work the best for? Are there characteristics in somebody that would make you not want to use successive approximations?  [00:21:43] Nancy Kaufman:  Yeah. Good questions. I mean, first of all, I started to put together the KSLP in the early eighties. And I did not have any materials until the mid nineties. So there was a lot of time where I didn't have a produced [00:22:00] materials and like everyone else, I was grabbing pictures and trying to put them together in terms of simple to complex speech, motor skills and, um, trying to have just the right, um, you know, pictures to show so that we can then fade our cues off of that and move children from, you know, uh, imitation to the ability to label, but eventually to functional use the words, um, in the natural environment. Um, so. Anyone can do this approach without materials, but I was getting frustrated. And so I put, um, first of all, I had a test. Um, I was frustrated with the tests that were out there. They didn't give me the information that I wanted. I wanted to know what vowels, what consonants and what syllable shapes was, were within a child's repertoire. And then where were they breaking down as you moved through those in a test so that we can decide where to start in our therapy methods. Um, so air go, the [00:23:00] Kaufman Speech Praxis tests for children and Wayne state university press, um, was the ones that publish it and pup were the ones that published it and it is still being published by them today. And then I had no materials. And so I started with kit one. Kit one was really trying to look at the very simple consonant vowel combinations. And you know, when you look at speech, it's a motor skill. And so you can divide it into fine and gross motor really, or I should say gross and fine motor. And the grosser motor consonants are the, are also of course the easiest consonants to produce. So I wanted pictures that contain the gross motor consonants like Mo and ha and maybe what, and then combinations of those from simple to complex syllable shapes. And, um, and then we would have a visual referent [00:24:00] for the syllable shapes that we want to work on. I tried to make them all real words. There isn't any reason to work on nonsense syllables in my opinion, at this level, uh, because you can easily say, um, just to get bilabial to an alveolar but why not bunny bunny bunny? Because it's a real word. Well, that was my thinking anyway. Um, and so kit one was established and then we needed more on, uh, the more complex consonants. And I feel like once you get through kit one, you really have broken through speech motor coordination. And then kit two is kinda more like articulation really, or it's trying to get complex consonants, not only produced accurately, but in apraxia of speech. A lot of the times all, all the consonants and vowels can be produced accurately in isolation, but then they collapse or they're changed in connected speech. So that kit two is more about what I would say, the [00:25:00] word synthesizing those complex consonants in, in really initial medial final positions. Um, so that was why that was produced. And then the fun stuff came along. Um, so, uh, uh, producing the workout book and the workout book was, was prepared to help with getting children to combine those simple words, shapes that they've learned to, um, produce functional, expressive language beyond single word utterances, but just staying with the simple and more gross motor MOBA and why I'm adding a hwab, but we really shouldn't, but it's easier to say those consonants that way when I'm just talking about them. Um, and then the Mudd family got produced. So the reason for the mud family was in my clinical experience, simple by syllabics, like happy Bonnie, [00:26:00] Tommy tuba. Were a very important. To be able to put two different, simple syllables together. And so the Mudd family of dogs, I had their names kind of follow simple bisyllabic names with the exception of a few. So Paddy and Mona and Toby, um, Heidi, and then some of them have just the vowel change, like nanny, poppy, Bobby, but then they could use those as subjects and then move into the three word combinations and move into progressive's and, and, and so forth and to sequence story narratives.  [00:26:32] Amy Wonkka:  Well, and I feel like one thing that's been helpful to me as a clinician with a successive approximation approach is that you move pretty, pretty quickly, especially in that kit one to the target word shape. So you might not have the target sounds in there, all the target sounds, but the target word she is a pretty quick jump. If we're thinking about, you know, uh, CBC V word, [00:27:00] right? You're you have your students or clients marketing those two syllables pretty early on. Um, and I feel like that in itself can make such a big difference in intelligibility for the listener. [00:27:14] Nancy Kaufman:  Well, what we want is for what we've practiced in something like kit one, there are other things that we use besides kit one, by the way, there's a lot of other things we use besides the KSLP materials in a session. But what we want is for those words, to transfer to the ability, to name the item without any cues, and then eventually to use those words for requesting and commenting in the natural environment, especially if you're just at that single word level, but we want a group of nouns that also have lots of different, simple syllable shapes for the children to move from imitation with all sorts of queuing, to fitting those cues out to spontaneous naming, and then to requesting and [00:28:00] commenting. And also we want a list of favorites. Even on those early learners, we want to know what are their favorite foods, drinks, toys, activities, people and pets, names, places they love. And we're going to look at those words and find out what is their best approximation of those, and then help them to produce their best approximation while in therapy. We're continuing to push in all of the details of those words toward that target adult form. So  [00:28:27] Amy Wonkka:  So the people who are listening, can't see like my enthusiastic head nodding and thumbs ups. But I think that that is such an important point. I don't know if you could talk to our listeners a little bit more about that because some times. As clinicians, we might get a little stock in the like drill work and forget about the fun and the application to real life and real world situations.  [00:28:55] Nancy Kaufman:  Yes. So many people think that the KSL [00:29:00P are flashcards and they should just be drilling with them and it's just not true. And I wish that people would at least take my course if they're going to be using the materials so that they really understand how to implement them. But they're just one simple way of having a visual reference for the simple syllable shapes, because we can't always contrive opportunities to produce those specific syllable shapes in the natural environment. Um, but yes, of course the whole idea is for them to then use words and use them functionally and naturally. Um, but also my, I do see children at a table. I do, I cannot in no matter if they're two years old or 10 years old, some people think that if they're two, you should just follow their lead and play and you're on the floor. And I feel like that's not going to get me or them where I want them to go. And so, yes, I'll seat them, but [00:30:00] lots of toys and lots of interesting materials, a to keep their motivation and attention and interest and cooperation, but B to then use the toys so that we can maybe contrive some words that have to do with the toy to then be producing what we've practiced. [00:30:20] Kate Grandbois:  I have a question from the perspective of someone who knows very little about this, you've talked a lot about the use of successive approximations. Are there characteristics of a speech profile that would lend itself better to that approach? Or are there presentations, um, client or student presentations where you would say that, that the successive approximation approach is not appropriate? [00:30:42] Nancy Kaufman:  Um, if the, so we're gonna, if there, if the child has an issue with articulation, that would mean that they have trouble producing isolated vowels and consonants. [00:31:00] And so we have to work on perfection of those isolated sounds. And sometimes if this is actually something that you had asked me in the past, but, um, if a child has articulation challenges, as well as has difficulty combining consonants, vowels, and syllables to form words, and to maintain their motor plans. Um, we might have to provide a compensatory placement for a vowel or consonant that they don't have, or they are not stimulable to produce accurately. We can't wait till a child has, uh, let's say the word cookie. We can't wait till they have a “k”, in their repertoire to teach them the word cookie. They may not be stimulable for it. And no matter what wonderful techniques we have implemented, they still are not able to produce that. But what we know is. Children who are just developing their speech may front, [00:32:00] those sounds to k and g to t and da and we can teach. We're not going to just wait and see what the child enters we could, but, and, and we probably should see what they try to say, but I would take them to or duty for cookie, but I would model correctly. So I would say, oh, did you want a cookie? Tell me T oh, here's your cookie. Always modeling correctly, always working on the cup. And if we gain the cut and the child is now stimulus for it, we can't just then change it up and go, okay, now you can say cookie because that's co articulation. But what we know about co-articulation is that we could reconfigure that word cookie into something that's already assimilated and then push on the latently. And then we're going to extinguish their, their, uh, production of and teach it as cook E because moving from a cup to a calm [00:33:00] movement is much easier than co articulating key, which is very difficult to do. And that's another influence on the KSLP method way back when, I don't know if you remember McDonald deep, it was a test, the McDonald Deep Test, but it was a test to look at coarticulation. We always need to think about co articulation when we're choosing target words, when we're implementing therapy, what, you know, once we get a new continent, what would be the easiest way to co articulate it without too much challenge? And then, you know, they would then have, um, re it would result in failure. [00:33:41] Kate Grandbois:  I've never heard of that test, which doesn't mean anything, but I wasn't, I wasn't aware that that's a thing. I wonder, um, as, again, as someone who doesn't know much about this, when you say compensatory placement, what exactly do you mean by that? [00:33:57] Nancy Kaufman:  [00:34:00] Um, let's say that the child is unable to produce L right with their tongue at the ridge behind the teeth, which is called the alveolar ridge. Um, and they're not stimulable for it. Yeah. Um, they like to say the word look all the time and that as they should, young children want our adult attention. And so we'd want to teach the word look. Now they might be replacing that L with an N nook. They may be replacing that L with a Y like yike you or I, or you yook at me or what get me a w um, but now they're at the, at the level where we need to teach L and it would be appropriate for their age or their ability. And they're still not stimulable. I would let them protrude their tongue, just slightly, not all the way out, but a slight dentalizing and do a luh. And I would do [00:35:00] that with all initial L. So the question is, well, if I'm teaching it that way, are they going to maintain it that way? And the answer is no, in my experience. And we have just established that it's vast and it's lengthy. The children pull their tongue in because it's actually harder to protrude it a tiny little bit. Um, anytime I've ever used compensatory placements, that children then are gain it appropriately. It's same thing like with a T sometimes I'll let them bite their tongue a tiny little bit and spit, and then we're going to put that sound in the final position of a word, because then it's kind of still isolated and it doesn't have to be coarticulated. And this is all about, you know, just, um, technique, but we would do both and I'd still let them dentalize and spit. I know the word spits, not very attractive, but that's what we told the children. Um, and they like it. Then they try it and then they don't keep talking like that. They don't [00:36:00] spit their t’s as they mature and as they gain more appropriate skills. [00:36:07] Kate Grandbois:  So you think about whatever the new realizes on its own and you don't need to follow up with specific. Shaping procedures or teaching procedures to get them to move from the compensatory placement to the more accurate placement  [00:36:20] Nancy Kaufman:  I have to say. I've never had to do that. However, let's say they don't have an /r/ in their repertoire, which many children don't. And even though the norm say that they're not even supposed to have a really good quality /r/ until the age of eight. And I would never let anyone go that long with a, with a poor production of /r/, because it makes the child look very immature and they could be teased and whatever we have to gain that placement as early as we can get stimulability for it. But, um, they might be dropping it out. They might be producing it very much in a distorted manner. I would actually replace it with a [00:37:00] w um, I would rather them say I, I won. I re I wan the race. I wan the way, rather than I am the ace or whatever they're doing. That's a little bit less accurate. We, adults can decode baby talk. And, um, I'm not saying that we're actually teaching baby talk, but we are teaching what younger kids that are just learning to speak would do naturally. And if the person who, if the child who struggles to speak, isn't doing what we would expect them to do naturally, and they're doing something odd. Then we're going to think about that. The phonological processes that we would replace these things with. I had a child the other day that was, um, um, deleting all devoiced consonants in the initial position. I'd rather that child say, but on my goat, mommy, than ut on i oat. [00:38:00] So I'm teaching voicing and that's erroneous, but he's not stimulable for devoiced consonants and the initial position just yet. And I will say though, that voicing errors are terrifying. We're really difficult to change. Would you agree, Amy? [00:38:21] Amy Wonkka:   I will. Am I shaking my head enthusiastically? I would. And I would say too, from a, like a kind of comes back to the earlier idea of the photo tactics is important. Right? So, so when you're taking sounds out, it makes it so much harder when you did the example. Um, oh, that is hard. If you don't have the context as a listener, that's really hard to figure out what that child is talking about, whereas substituting something that's, uh, that is a more traditional error pattern that we would see really helps the listener and that translates to the [00:39:00] child also feeling more effective as a speaker. So just getting back to that functional use, um, it, it makes such a difference in their experience as a speaker and using their oral speech.  [00:39:11] Nancy Kaufman:  Yeah. As soon as they are successful, it gives them more motivation and they want to learn more. They're going to use more words spontaneously, and the listener is going to give them reinforcement by understanding what they said. [00:39:26] Kate Grandbois:  And again, as I think it's impossible for me to take my behavior analyst hat on sometimes, but I'm hearing this is a shaping procedure. This is, and it makes a lot of sense. Um, we've talked about shaping on this podcast for a variety of different topics for treatments and interventions for selective mutism, for AAC and, and button icon selection, um, another com components of motor planning. So I, I think it's really, really interesting that this is, that's such a, uh, a component of this. [00:39:56] Nancy Kaufman:  You know, shaping [00:40:00] procedures have been done since the fifties. We all talk about BF Skinner's work and that, um, there's always, um, controversy about speech and language pathology. First of all, we're a young field. But, there just simply, can't be enough research to answer every question that we want to have answered so that we can move ahead and provide our therapy with all of that backup information. And the thing is though, is that shaping has a lot of research behind it.  [00:40:35] Kate Grandbois:  We do it a lot in speech pathology without realizing it  Nancy Kaufman: exactly. Kate Grandbois:  And I mean, not to get on that soap box and totally derailed cause I, I do, but I, I just think it's, it's interesting. Um, and if anybody is interested in learning more about shaping or what shaping. The quick and dirty definition is it's providing reinforcement for successive approximations of a target behavior. And we can list more information [00:41:00] about it in the show notes. Um, I wonder if we just sort of getting back to this compensatory placement idea, um, we were recently came to our attention as we were researching for this episode that it's somewhat controversial. And I don't, I wonder if you could tell us a little bit about that? [00:41:20] Nancy Kaufman:  Well, I didn't read probably what you did, but I'm guessing that the thought is is that if you teach a compensatory placement that it will stick and that it will never then continue on to the full adult form of an accuracy of the word. But, you know, um, I mean, I could tell you all sorts of things that people like to criticize, um, [00:41:44]  Kate Grandbois:  me too, but that's fine. That's another podcast episode.  [00:41:48] Nancy Kaufman:  The thing is, is that if you only teach words that contain the child repertoire, you're not going to be teaching very much and they are not going to be [00:42:00] moving ahead on therapy and moving into expressive language well.  [00:42:04] Amy Wonkka:  and back to your earlier point about, it's not just, you want the repeated practice, but it's not just drilling a set of flashcards. What if you get to know your client and all of their interests incorporate sounds or word shapes that aren't in their repertoire. [00:42:20] Nancy Kaufman:  Exactly. And not to mention, I might say after a while, Hey, now let's try to move your tongue back a little bit. Yeah, for sure. I'm going to, I'm going to try to gain accuracy as soon as possible. But, you know, if the child says, um, ook, ook at E and then they can say look and, you know, it's interesting because in terms of auditory and that's what we're trying to do, we're trying to give a compensatory placement that in an auditory manner, it's understood by the listener. If I said like, like, [00:43:00] like, like an I'm alternating my tongue movement, I don't think that you could tell that I changed it. [00:43:07] Amy Wonkka:  And it's certainly clearer as a listener than if you say Ike,  [00:43:12] Nancy Kaufman:  like type in the word, know, I, lot of kids have no, because it's more of like an automatic kind of knee jerk type of word. But if they don't have an n in their repertoire and I can't gain it, anchoring of dentalize it and then we'll get no. And all of a sudden that nis there. And that opens up a world of more words that are acoustically accurate for the list of.  [00:43:35] Amy Wonkka:  Well, and I have like, no, I have no evidence to back this up, but just thinking about it logically a lot of your examples regarding compensatory placement are about dentalizing sounds. And a lot of the errors are either about omitting those sounds or doing a further back production of the sound. So in some ways, I wonder if by dentalizing something that the child isn't yet [00:44:00] stimulable, like the adult alveolar production. Maybe if they're doing a back production, you're kind of overshooting that like desired motor movement anyway. So it, it just helps make that contrast better. I don't know if that,  [00:44:13] Nancy Kaufman:  like the kids that guy gah go go goo gug go gogay, you know, and they probably passably had pacifiers for quite a lengthy amount of time and learned to talk that way with backing. Um, but yes, you're right. Then we're pushing the tongue more forward where it belongs. [00:44:32] Kate Grandbois:  Sort of happening on the same theme of, um, controversial components of this. I, uh, one of our advisory board members, um, who helped us, who is, who specializes in motor speech disorders, sort of had a meeting with us to sort it, to come up with to help guide our questions when we chatted with you. And he mentioned, he's wonderful. Um, he mentioned that there were myths about [00:45:00] the KSLP approach, and there was a component of your website that debunked some of these myths. And I wonder if you wanted to take a minute and, and verbally debunk these myths for our audience. [00:45:12] Nancy Kaufman:  You know, I, I went back and looked at them. Um, I just don't think about these things, you know, um, currently, but, um, I mean, certainly one of them is that you should never teach an approximation to a child with apraxia of speech. And I get all sorts of criticism about that, although, um, I think that the people that understand it and implement the techniques are, are more in number than the naysayers or the critics. But, um, yeah, I just, uh, I think that I've learned through my own clinical experience, my [00:46:00] intuition, my, um, attempts at clinical excellence that shaping works. And the outcomes are positive. Um, if they weren't, I wouldn't be talking to you today. Um, and, uh, part of that, um, evidence informed practice or evidence-based practice is parent input and it's also, um, clinical success. And so, um, I have been shaped to learn that these methods are very successful. Um, and I don't understand why anyone would actually come out and say that you shouldn't teach an approximation. They obviously don't understand shaping and that we're always moving toward the target adult form of the word. We're not just stay [00:47:00] continuously reinforcing the approximation we're, we're working towards perfection and we will eliminate, um, the lesser approximations and only then reinforce closer approximations to the target and ultimately perfection. [00:47:19] Amy Wonkka:  And you mentioned just now that you're using your clinical data to make decisions about your actual clients and that's something else we talked, we've talked about quite a bit on this podcast is sort of that gap between the research of the research folks in their research institutions, and then the work done by clinicians who are typically not in those research settings and we're practicing and schools and clinics and all of these different places. Um, and you know, ASHA has on their website. They have that triangle now diamond that talks about evidence-based practice and they acknowledge, you know, the [00:48:00] importance of us as clinicians, our clinical information in our clinical data. Um, What are your thoughts about evidence? Like how does a clinician determine that evidence? Because it's not just reading. Well, this research paper told me, so there's an awful lot of weight that should be given to this is what seems to be working for my particular client or not working.  [00:48:26] Nancy Kaufman:  Well, I'll be honest with you. And I am going to bet that many SLPs feel the same way as me. I find research very difficult to read and to comprehend, and I'll go like everybody else, right to the conclusions. And the conclusions are always inconclusive that, that, you know, we found out this, but we still need a lot more research is very costly. It's sometimes biased. Um, and there's [00:49:00] research being done on the KSLP right now, as we speak. And I, um, I I'm excited about it. I invite it, but this is what happens, especially about trying to research, uh, therapy approaches. The KSLP is multifaceted. You have to know how to use reinforcement, strategically, gain, have motivation. You have to understand errorless teaching and error correction, which I know that you Kate would understand those terms. Um, you have to mix and vary your tasks so that you're not teaching overgeneralization. Um, you have to gain a lot of mass practice to distributed practice. You've got to coach parents and caregivers to carry this over into the natural environment. You have to understand shaping techniques and what would be best approximations and be fully aware of phonological processes. You also have to have a fun [00:50:00] personality as well, and to be able to implement this, um, seamlessly, that's a lot to try to replicate. And so what happens is when people do research on therapy approaches, they narrow it down into something that could be replicated and it just doesn't seem to equal what is really important within that particular approach. So I take it with a grain of salt. I'm interested to understand, uh, research that comes out, but I'm much more interested in clinical opinion. [00:50:39] Kate Grandbois:  And I just sort of piggyback on what you both said is the power there for internal data collection. I know that's sort of a repeat, but for people who are listening, who are feeling that they're doing all of those things at once, you know, they're trying, they're playing, they're being engaging. They're meeting their learners where they are. They're they're, um, you [00:51:00] know, doing, they're making their best efforts to provide these shaping procedure procedures, provide that reinforcement, provide those error correction procedures, provide those, that, those feedback cues and at the same time, [00:51:12] Nancy Kaufman:  I forgot about cues and how to feed them.  [00:51:16] Kate Grandbois:  Right. And, and, and problems and all of these things. I mean, being a clinician is hard. Doing clinical work is hard. And if we can find ways to, like Amy said, and like you said, do our own internal data collection to make sure that we're measuring. What we're, that what we're doing is working, you know, conclusions and research articles, as you mentioned, are often written for other researchers. So just because it's not in a research article, doesn't mean that it isn't evidence-based practice as long as you're relying heavily on your internal data collection and your client's values and perspectives. Remember, those are all, those are both components of our evidence-based practice triangle in conjunction with our clinical judgment. So [00:52:00] I really appreciate those comments because I think often in the field, we assume that evidence quote evidence-based practice is a research article. That's that's not true. That is one of four components of evidence-based practice.  [00:52:15] Amy Wonkka:  I didn't know if you could take a few minutes just because. You so nicely broke down all of those pieces that actually go into implementing an effective treatment package. Um, I wonder if you could talk a little bit about fading cues, talk a little bit about maybe what clinicians should be looking for, the types of cues that you have used successfully, um, and just give our listeners nothing super in depth, but just kind of an overview about some of the questions you might be asking yourself as a clinician or some of the techniques that you found to be successful in your practice. [00:52:54] Nancy Kaufman:  Yeah. So that's a whole subject in and of itself. Right. And, [00:53:00] um, in the KSLP there's cuing and there's scripting. So there's queuing for speech, motor scripting for expressive language. And the thing about the KSLP is that the importance of it is that it moves directly into functional expressive language. Um, so of course I've been where I've been using cues since the early eighties, and they're mostly visual. And by the way, I have hardly ever had to physically touch a person to provide them with a cue. That doesn't mean that you shouldn't, but I've never really had to, unless there's the child's minimally vocal and doesn't even hardly have any vowels or confidence in their repertoire. But here at my office at the KCC, we tend to use internal cues to the oral cavity. For such as like Renee Roy Hills apraxia shapes to try to gain some vowels and consonants and then start to shape them. Um, but I will use some visual cues for each vowel each [00:54:00] consonant, and that they're different from each other so that they don't get confusing and I'll do them on myself as a visual cue, not on the child. Um, but there are so many, uh, such as giving the first consonant and just oral posturing, the rest of the word, or giving the first syllable and oral posturing, the rest of the word, um, using fill in the blank cues so that the child's doing the work and you're not really giving them any piece of the word for them to retrieve. You know, there's, there's just so many, I don't even have a list in my mind right now. Um, the ones that I tend to use the most are. Uh, visual cues, oral postural, meaning that your mouth is just making the shape of the sound, but you're not saying anything. Um, I might go to a whisper cue even though you run the risk of the child whispering back. Um, and then I'll also go to, um, gestures. Um, so you want to fade from visual [00:55:00] auditory to visual only to no cues at all. And in terms of scripting, um, I might put the answer in my question. So I, if it were just naming, I'm going to say, baby, what is it? So I've said, baby, they already have that full cue. I, I push in a little bit of a question and then they will respond. Or I might say I'm walking the dog. What is the boy doing? Or tell me that the boy is walking the dog, the boy, and then I might give a cue for is, and then oral posture, the rest we want to keep the children supported to the level that they need. And, you know, just talking about this today is making me realize even more how complicated everything is. And, you know, I'm only talking about children with CAS and most SLPs have to work with all disorders, [00:56:00] all age groups. My daughter, Carly Weberman is an SLP in the schools. And so, you know, she informs me of all those challenges and, um, it's a lot. And then we don't have time to work with the children much, or they have to do groups only. There are a lot of challenges. Um, but yeah, it's, it's, um, there's a lot that goes into an approach and I've been trying to teach this approach, um, my whole career. And that's why I use numerous video examples when I do a conference. And I also like to talk about what I'm not doing appropriately. If I might catch myself in a video making mistakes. And I think that that makes it really real world for all of us. Um, and I have a whole section in my conference about, um, mistakes and what the [00:57:00] consequences are and why we should think about not doing those types of things. Um, and I think it's a really nice learning experience to talk about those. [00:57:11] Kate Grandbois:  We really appreciate all of your wisdom. I love the concept of embracing mistakes and, and having learning experiences. I mean, you can't learn without having those vulnerable moments and being able to self reflect. So thank you so much for mentioning that. I wonder in our last minute or two, um, if you have any, any words of advice for SLPs out there who are listening and maybe recent or recent grads, or going into the field of motor speech for the first time, um, any, any advice or words of wisdom? [00:57:49] Nancy Kaufman:  Well, I, I think that we have to be careful about only implementing, uh, approaches that so-called have [00:58:00] research behind them because then we're losing out on all of this clinical information that have been gleaned throughout a lot of years and a lot of different professionals. Um, and, um, and I think that that leads parents to want to only look for approaches that have research behind them. Um, and so I would say that that's one piece, but to really look further for, um, more clinical information testimonials, um, outcome pieces, um, uh, people that like to do blogs or, or explain what, what their experiences have been. I think all of those things are going to be important to the new clinicians out there. [00:58:46] Kate Grandbois:  That was very good advice. Thank you so much for your time and being here today and sharing this with all of us where we're so great. [00:58:55] Nancy Kaufman:  You are so welcome. I really enjoyed this.  [00:58:58] Kate Grandbois:  You're welcome back. Anytime. Open door [00:59:00] policy for you, Nancy.

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 the number one professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka: Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois: episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka: Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois: specified. We hope you enjoy  Announcer: the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Kate Grandbois: Welcome to SLP Nerdcast, everyone. Today, we are really excited to welcome two guests. We are here with Heather Casca and Kareena Khadi. Welcome, Heather and Kareena.  Karina Kadhi: Hi. Hi. Good morning. Thank you. And  Amy Wonkka: Heather and Kareena, [00:02:00] you are here to discuss the SLP's role in dyslexia. But before we get started, can you please tell us a little bit  Karina Kadhi: about yourselves? Yeah, sure. Um, so my name is Karina. I'm an SLPA. Um, I have been doing this for about 10 years now, uh, and my first job out of college. So I got my bachelor's degree at the University of Arizona. Um, and my first job out of college was, uh, with Heather. She was my first supervisor. So that's how we met. Um, I've worked in pediatrics ever since, both in a school and a private setting, um, and I just have a real passion for early language development, um, and Heather, when Heather and I cross paths, some of our like niche areas, kind of, um, Lined up and that's how we are, where we, how, why we are, where we are right now. Um, personally, I have two, two daughters, a six year old and a three year old, um, two, yeah, two girls. And yeah, it's a little bit about myself.[00:03:00]  Heather Caska: And I'm Heather, I, uh, live here in Arizona, uh, in the Phoenix area, just like a small little, actually, it's not small, it's growing quite a bit, but a suburban Phoenix. Um, I also have been a speech language pathologist for just about 10 years, um, have worked in private pediatric. Most of my career, I started in a nursing facility and found out quickly that was not for me where I wanted to be. Um, so I, A couple years after I graduated and working in pediatrics, um, I just found a passion for dyslexia. I first was introduced to it in undergrad, um, through Dr. Tiffany Hogan at the University of Arizona. She was one of my professors and she's incredible. Um, and so. Yeah, I just started doing as much training as I could, extra CEUs. Um, I went and got some training through the Academy of Wharton Gillingham, practitioners and educators on reading intervention. Um, and then just quickly learned that there was such a need for education in our field, um, and how important our [00:04:00] role is, uh, uh, in dyslexia and especially early identification and, and early intervention. And so again, that's how Karina and I kind of crossed paths. Cause she just loves that early intervention. I love the reading. Um, and. We just rolled with it. So I decided to, um, start my practice, uh, in the middle of the pandemic. Uh, craziest idea I've had, but, uh, it just been, been amazing ever since. Um, I just knew that I really wanted to go out on my own and be able to educate SLPs and do trainings and workshops, but also provide services for students. So, um, I also have two kids. I have a son who is also six and a daughter who is three. Um, my son just started first grade. We already started school here in Arizona. My husband and I have been married for about nine years and yeah, that's it. No one  Kate Grandbois: could see my eyes go wide when you said you've already started school. We're recording this at the very end of July. Um, we don't start school here in Massachusetts until late August, [00:05:00] September. So, um, it's always fun to hear about how different areas of the country do things. And we already talked about this before we hit the record button, but Amy and I don't know very much about dyslexia. This is not our area of clinical expertise. So we're very excited to learn from the both of you today. Before we get into the content, I do need to read our learning objectives and our financial and non financial disclosures, which are ASHA required. I'm going to get through those as quickly as possible, and then we'll get onto the good stuff. Learning objective number one, describe three additional service delivery domains outside of assessment and treatment that are essential when working with students with dyslexia. Learning objective number two, describe three barriers to upstream thinking when discussing prevention and early identification. And learning objective number three, discuss three ways you can play a role in upstream thinking for early identification of students who are already struggling with early literacy skills. Disclosures. Heather's financial disclosures. Heather received [00:06:00] 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 Soar with Words LLC and co manages the Soar 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 Soar with Words. Karina's financial disclosures. 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 Soar with Words. Kate, that's me. I am the owner and founder of Grand Blois Therapy and Consulting, LLC, and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12, I serve on the AAC Advisory Group for Massachusetts Advocates for Children, and I'm also a [00:07:00] member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka: Amy, that's me. Um, my financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I'm a member of ASHA Special Interest Group 12, and I participate in the AUC Advisory Group for Massachusetts Advocates for Children. All right. Now we're through that stuff. Heather and Karina, why don't you start us off by telling us a little bit about that first learning objective. So what are three additional service delivery domains outside of assessment and treatment? Because I have to say, I,  Heather Caska: I can't think  Karina Kadhi: of what those might be. Um, so the, the way we kind of like to break it down is we like to think about, um, the, in general, the service delivery domains that fall under our scope of practice as speech language pathologists. And so, um, straight from ASHA, they break that down into those, I mean, let me count them really quick. [00:08:00] One, two, three, four, five, six, seven, eight, eight of those, um, Service delivery domains and it's collaboration, counseling, prevention and wellness, screening, assessment, treatment, um, that modalities, uh, technologies, instrumentation, and then populations and systems. So that's, that's not new to us necessarily. We know those. And so the way that we like to, um, bring awareness to the role that we as speech therapists and speech pathologists can play, um, In dyslexia intervention is under each of those domains, bringing attention to things that we could do to support these students under collaboration under counseling under prevention and wellness, we recognize that the direct intervention. It's most likely not our role, especially in a school setting. We know that we're not the reading specialists, but we feel strongly that we can play a very impactful role in supporting these students because a lot of the skills [00:09:00] with literacy overlap in our wheelhouse, you know, um, So, uh, there's, there's eight different ways that we can support these students besides just intervention. Um, and we kind of want to go into each of those and talk a little bit about, um, how we can support these students. I also wonder  Kate Grandbois: if we could take a step back just for a second before we dive into each one of those because that was, those were all things I've never considered, uh, and thinking about the larger picture of dyslexia in general, could you tell us a little bit about, first of all, maybe defining it for us for any listeners out there who have been working in a sniff for the last time. Thank you. 15 years and need a refresher. Um, could you define dyslexia for us or talk a little bit about why early intervention is so important?  Heather Caska: I think so. This, this is such a great question. Um, and unfortunately there's not really [00:10:00] an easy answer for what dyslexia is. And it's actually one of the biggest barriers to identifying dyslexia is that across the board, there's many different professionals that are involved in research for reading disorders and learning how to read. Um, but. There's not really a consensus on what dyslexia is. So, um, I will read the International Dyslexia Association's, um, definition for dyslexia, but then kind of also talk about another definition that we really like. Um, so it's kind of a mouthful, but IDA's definition is dyslexia is a specific learning disability. That is neurobiological in origin. It is characterized by difficulties with accurate and or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to the other cognitive abilities and the provision of effective classroom instruction. And secondary consequences may include problems in reading comprehension and reduced reading [00:11:00] experience that can impede growth of vocabulary and background knowledge. So quite a mouthful. Um, there's a lot. I love that it highlights it really incorporates that reading comprehension, those secondary consequences that we see as far as A language development and and just reading comprehension, but one thing I don't love about it is the the line where it says these difficulties typically result from a deficit in the phonological component of language because more and more research is coming out showing that only about 50 percent of the kids with dyslexia actually have a phonological deficit, and then we're talking about phonological awareness so there's a couple different subsystems subtypes of dyslexia. Um, As far as like you have an orthographic piece where that's more of like those letter sequences, orthographic mapping, um, versus a phonological where someone's really struggling with that awareness of sounds and words. And so I think that definition specifically kind of eliminates. Or maybe, [00:12:00] um, if a, if a child is tested and they have really great phonological awareness skills, but they're struggling orthographically, if you're looking at that definition, then that child might not be classified as a student with dyslexia, but, but they are, um, so Dr. Hugh Katzen, Dr. Tiffany Hogan put out an article in 2021, um, that really talked a lot about more of looking at like multifactorial, um, basis of what dyslexia is and what these students are kind of experiencing. And so, um, the article is called dyslexia and ounce of prevention better than a pound of diagnosis and treatment. And so it's really talking about that early identification and prevention, which is. What we're so passionate about, but they kind of proposed this definition that dyslexia is a severe and persistent difficulty learning to read and spell words despite adequate opportunity and instruction. So we really like this model and this definition because it's highlighting [00:13:00] that there's no single deficit or even like a. small group of deficits that are consistently associated with dyslexia. And so it's letting you look, it's, it's highlighting a preventative model. I also want to highlight that we do know that there's no, really no cure for dyslexia, but when we're talking about prevention, what we're talking about is just identifying these students early and getting early intervention in place. So maybe they might not need an IEP or they might not struggle or fall as fall. As far behind in school they may, we may still see, you know, some, some difficulties that they have, um, because again, we know that there's no cure for it, but that early identification is so important. Um, so I mean, that's kind of a, uh, a long winded answer for that question as far as like what dyslexia is, but that's really how complicated it is, is that there's no, um, single definition. Yeah. There's no checklist that, you know, there's nothing that you can just check these boxes. Um, we really need to look at the whole child, but, um, [00:14:00] but yeah, that's kind of the definition that we really like and educate others on. Kate Grandbois: Seems like. There's a really big missing piece then in terms of making sure that kids can get identified to get the services that they need. Can you, this is sort of a tangential question, um, and maybe it's just because I'm not familiar with this area, but in terms of that differential diagnosis process, do you find that Most kids are getting picked up through the school screening system, or are they needing neuropsych evaluations? What does that identification process look like with this very loosey goosey or inaccurate definition of what it is?  Karina Kadhi: I feel like a lot of times in school settings, the approach that we see is that wait and see approach, um, especially for, um, early identification of things like this. Um, I kind of want to get into the Dyslexia Paradox right now. Heather, what are you thinking? Yeah. Okay. Um, so now I  Kate Grandbois: need to know what it is.  Karina Kadhi: [00:15:00] So you have to say it. Um, so there's the, um, let me go over here so I get my resources correct. One second. Um, there is this idea of Dyslexia Paradox. Heather, can you help me with the, um, referencing who it is? I know it's  Heather Caska: Dr. Nadine Gabb.  Karina Kadhi: Um, okay. And so it's the idea that, uh, intervention is most effective early on. Um, preschool, kindergarten years, um, maybe even first grade, right? But, um. Most students with dyslexia aren't formally diagnosed or even like  Heather Caska: identified,  Karina Kadhi: um, until like second or third grade, which means we missed that prime time for early intervention or identification in order to intervene early. Um, and so there's this sweet spot early on where intervention research shows is more effective. Um, And [00:16:00] so in, in, in school systems, especially in Arizona, what we're used to seeing is in kindergarten when, um, we might have students who have some, um, risk factors that we noticed, um, and most of them, by the way, are already on our caseloads for speech and language services, right? That we had, there's a lot of pushback with wanting to screen for other areas because they're the approaches. Well, they just haven't had time to adequate instruction. So we don't know yet. We have to wait and see. But going back to looking at the whole child. Yes, they may not have had enough time for adequate instruction but if we know that there's a speech and language. History, right? If there's deficits in that area or if there's family history of things, we could look at the whole child and kind of narrow it down and, um, decide that well now is the better time to intervene for that child versus the wait and see approach. So we really like to, um, that's why we [00:17:00] push so much for considering other factors in that because we see a lot of that wait and see. And by the time we see, uh, it's kind of late in the game for them in terms of intervention. Yeah.  Heather Caska: I think an important note too is a lot of states do have legislation are in the process of getting legislation in place. So Arizona specifically within the last couple of years passed legislation where all students, I think it's kinder through third are screened. For dyslexia using a universal screener. Um, and the state has approved screeners. So once, um, once the screener is administered, if they fall a certain below benchmark, then they are required to receive like tier two intervention. So we're seeing huge leaps, um, across the nation, I think, uh, which is great. But I think some of the missing piece too, is then what intervention is being. Implemented and how how strong is that intervention? And that comes down to [00:18:00] even just like educating teachers and and administrators specifically as to what needs to be done for these students. So we're seeing a big push and some gains in that early identification, but we are still seeing a lot of that. That wait and see, but again, kind of where Karina and I came in and we were like as speech language pathologists, we, like Karina mentioned already, so many of these students are on our caseload because of a speech or a language, um, disorder. And so if we, as SLPs are more aware of what some of these early indicators are and what dyslexia is and how we can kind of implement some of these. Early interventions into our speech and language therapy, we have a huge role in that prevention because we know that most likely that kindergartner that first grader is not going to get referred for testing in the school yet. They are going to have to go outside and get evaluated by an SLP or a neuropsychologist to for that, that diagnosis or that [00:19:00] identification I mean and we know that schools aren't going to diagnose students like in the school they're identified as SLD, you know, a specific learning disability. Thank you. In the schools, typically under like basic reading or older students are often like under reading comprehension, but,  Kate Grandbois: Can you tell us a little bit about any of the early indicators for  Karina Kadhi: dyslexia? Yeah, definitely. So some early indicators early on, like in those younger years, like maybe, um, preschool, kindergarten. Um, family history is a huge one family history of speech, language and learning difficulties. Um, on the intakes that we do, um, Heather mentions a lot that, um, oftentimes you,  you  Karina Kadhi: will get a skewed answer if you ask specifically for a history of dyslexia, right? Because most, most of the time, parents, um, don't have a diagnosis or don't. Don't realize that that's what they're struggling with, but once you start talking, uh, it may come out that, oh yeah, mom and dad had a hard time with school or grandpa struggled here, you know, and so, um, family history can really give [00:20:00] us a lot of information, um, delayed speech and language skills, um, the comorbidity rate between dyslexia and, uh, speech and language disorders is about 50%. Um, so that can be an early indicator, especially for those younger kids that, again, we might already have on our caseload. So when we're seeing some of these other, um, just oddities with them, um, that might stand out as an early indicator as well. Difficulty, um, with learning labels and names, vocabulary for things like shapes, colors, numbers, days of the week, or letters that, um, kind of speaks a lot to, uh, working memory and some underlying deficits that might, um, be associated with it. Um, difficulty pronouncing words, um, obviously we already talked about this. Speech skills, but these are more like abnormal pronunciations of things that don't, won't really be picked up on like a GFTA or an eval screener type thing, um, but you just notice something's off with the way they're pronouncing, um, [00:21:00] some words and then they might even be like word specific. mispronunciations. Um, we already mentioned, uh, difficulty learning new vocabulary, um, and rhyming and identifying sound so that those phonological awareness skills, um, might be low. And then in, uh, slightly older students, now maybe we're thinking second, third, older, um, difficulty with, uh, knowing left from right, kind of that, like, orientation, um, struggles with sight word recognition. Um, in a sense, all words become sight words because you don't decode them. Every single time, um, but with those true sight words, they might still be struggling at that, um, slightly older age with recognizing those sight words, um, poor spelling, uh, difficulty memorizing number facts. Um, so kind of, we mentioned it earlier, but bleeding into that math realm, right? Is it the math computation skills or more of like the language revolving around, um, math and math facts, things like that. Frustration with school and [00:22:00] homework, going back to that social emotional piece, um, difficulty understanding what is read, so comprehension, um, and written expression, putting ideas into writing, uh, could, might be really difficult. They might tell you this elaborate story, and they go to write it, and all of a sudden it turned into like this super dull, um, sentence. An example of that, I have a student, or I had a student years ago who, um, She was writing for me and she was going to write about the kitchen and she, instead of writing kitchen, when I looked over her sentence, she changed it to the chef, the cook's room. And I asked her, why did you call it the cook's room? That's interesting. And it was, um, she changed the whole sentence up, um, because she didn't know how to spell kitchen. And so, um, Getting those ideas into writing can be really difficult for a number of reasons, either that sentence, like generating the sentences or even making them more simple, just to avoid words that are going to be difficult to spell. So they're awesome. [00:23:00] Some indicators we might see in our younger and our older students. Kate Grandbois: I want to talk about some of these more specific components in our first learning objective about service delivery. And I have to assume that that is related to the SLP role here and you've already described. The SLP playing a role in early identification, right, if these kids are on our caseload. You've also described the SLP's role in, um, educating staff and, you know, that collaboration piece, right? So making people even aware of the holes in this definition, everything from, you know, that to how to use a screener or which screeners they should use. I can imagine that the collaboration and education pieces is really wide. Can you tell us a little bit more about. Just the role of the SLP and how that might relate to, um, the different service delivery areas. I'd also love a review of those service delivery areas sure.  Karina Kadhi: So should we, should we get into those and we can kind of go, um, kind of break down each of those [00:24:00] areas and think about our role in them through the lens of, um, supporting literacy skills, I guess, maybe that's not what we're, what we're thinking about when we go into our speech room and to do that intervention, but that's kind of what we want to bring awareness to today. So we could start off with collaboration if that's okay. Um, we've kind of already, uh, talked a little bit about that piece, but we, we know what, what collaboration means and in terms of how we can support these students in a school or even a clinic setting through collaboration, um, is that education PC already hit on that and educating the, the rest of their support team, right? Whether it's their teachers, um, whether it's, If we're, if we're working in a school setting and we know that they're getting intervention somewhere else, collaborating with that therapist, we all have that common goal, um, in supporting these students and so, um, collaboration is, uh, could be a big one in both in a school setting and in a. In that clinic setting, um, especially with the classroom [00:25:00] teachers, I think finding, um, as an, as the speech therapist at, at the campus, um, the skills that we possess really overlap with, um, literacy and structured literacy, which we'll get into a little bit later or next time, but, um, And so realizing that we possess a lot of the skills to support these students, even though we're not the ones doing the direct reading intervention. Counseling is another one, another big one that we really like to talk about and bring awareness to the role that we can play through that counseling domain. That just it just supporting our students with any, um, things that come from the speech or language disorder that they're dealing with right in this term and or in this case thinking about struggles that they might be dealing with, um, secondary to difficulties with reading and writing. And we see that that has been a huge one for us, [00:26:00] especially these last couple years, Heather and I have been working with older students and we're typically used to working with I worked with a group of middle school students, these past couple years and that my role in that counseling piece was huge for them because at that age. And at that point in their, the game for them and in terms of their learning, um, they had a lot of shame built around, um, their learning and themselves and their, their skills and they had already. These literacy skills were have been hard for them since kindergarten. Right. And at this point, we're in sixth, seventh grade, and they have this wall up in there. They truly had so much shame around their abilities. And, um, so our role in supporting these students and building rapport with them. Was huge because it wasn't until that, that we, um, got some breakthrough and were able to make some gains in their literacy skills, um, especially because in [00:27:00] that middle school age, they're, um, more embarrassed about it, right? They're more sensitive to that. And so coming into the speech room to work on this, it was not always fun for them. And so really building that rapport and that trust in the, with those students, um. Was crucial to then the learning that could happen after that. So our role in counseling, whether it's with your student has dyslexia or not, right? Like that rapport is so important. So our role in that counseling domain is really huge to, um, And one that in the last couple of years has come to light for us, um, and the impact we can play there.  Heather Caska: I think, too, there's a lot more research coming out as far as the relationship between dyslexia and anxiety. And they've found that, um, researchers found that anxiety to be related to decreased academic achievement, um, and Performance as early as first grade. So we're seeing it early on in these students. And again, remember a lot of these students aren't getting identified [00:28:00] yet. So there's definitely a bi directional relationship between these reading difficulties and anxiety. So like, obviously as reading difficulties are, are increasing, so are your levels of anxiety, but then also like increased levels of anxiety. Are going to negatively impact your response to intervention. So I, you know, I have parents ask me a lot to, you know, I'm seeing a lot of anxiety in my suit and my child, you know, around reading. And I was like, honestly, if we're not addressing that piece there, like if our students aren't mentally in a right place to learn, um, you know, and. And to, and to build, you know, these cognitive, um, connections, then no matter what intervention you can get the best interventionists and the best programs, like it's not going to be as beneficial. So I think we have to be really mindful of that and really working with our students. So, um, Dr. Sharon Vaughn, anything. Dr. Amy Grills, I think is her last name, or gills, I can't remember off the top of my head. But they are doing a [00:29:00] lot of research together as far as the anxiety and um, and dyslexia and the reading piece. We do have a couple links, um, on our Instagram and our bio to some videos. Um, I think it was through one of the dyslexia. Um, Programs. I can't remember off the top of my head, but they have some free videos online of presentations they did and a huge, um, really, really great resource, um, to kind of learn a little bit more about the anxiety piece and, and dyslexia. And kind of,  Karina Kadhi: we can tie this back to collaboration too, is if, if we're in a school setting where we don't have, um, a counselor, or we feel like we are not able to support these kids, knowing that we can, um, collaborate and refer out to get these students the support that they need, talking to their parents to refer out, or if we're in, um, a clinic setting, talking to some of our other, um, The therapist and within other disciplines or again, referring out. Um, so those kind [00:30:00] of always go hand in hand. We can always kind of tie back to that collaboration piece where if we don't, we don't know everything. We're lifelong learners, right? We can't fix it all, though. We think we can sometimes. Um, and so knowing that we can, um, refer out to support this area or any of any areas that fall under our domain service delivery domains, um, when needed. Kate Grandbois: I just want to take a minute to say thank you for unpacking the importance of mental health in the journey of our learners. Um, I know when I am anxious, I'm not available for much of anything, no, much less learning something that presents a challenge for me or learning something that I have already learned is difficult for me or getting my, you know, Getting that cool, common, collected feeling when you take on a challenge and you're really putting your all behind it. I'm not doing any of that if I'm anxious and I really appreciate you reminding us of that. Um, and [00:31:00] anybody who is listening, who is maybe reflecting on their learners on their caseload who might have dyslexia. Maybe considering the social emotional components of this as part of the treatment package, instead of just, Oh, that's something that the counselor down the hall deals with. That's not my domain.  Karina Kadhi: Absolutely. Yeah. It's our pleasure to do that. It's like I said, it's something that has really, um, come to light for us in these last couple of years, working with a slightly older population. Um, but quickly we realized that needed to be front and center for that. And then in terms of treatment, a way like we could adapt that is noticing, like, When we have to put our goals aside, right, to address the child in front of us,  and oftentimes I think we get stuck in, we got to collect data, we got to have this, we got to do this, and we push our agenda, right, not being mindful or noticing even some of the struggles the student might be dealing with. In front of us. And so if we have to set our goals or aside for a second to address that student that is still, um, With we're still [00:32:00] servicing them, right? Just in through a different domain. So,  Amy Wonkka: I think you make such great points to just for all of us and and like you had mentioned, I think, Karina, you know, regardless of sort of the Karina, specific challenges that have brought the student into our, into our therapy room, just being cognizant of the importance of relationship rapport, but also just creating a safe space where our clients are feeling empowered that they are able to do these things. And we're here to help them out, but we're not the fixer of all their problems. It's something that we're doing together and they can do it. Um, and, and their time with us is a place where they are safe. to kind of be the full spectrum of all the feelings that they're feeling in relationship to, um, the challenges that they're experiencing. So I think you make wonderful points for our people who are working with clients who have dyslexia, but also I think that these are wonderful points for all of us, you know, kind of regardless of who we're trying to help. So looking at your learning objectives, another term that I am not familiar with is the term [00:33:00] upstream thinking. So I don't, I don't want to rush you ahead, um, in your presentation, but it's something that I'm super curious about. I see it in two of the three learning objectives, um, and I'm just curious kind of what,  Heather Caska: what  Karina Kadhi: that means. You're actually segwaying us right into the next, uh, service delivery domain. So that was perfect. Um, and so that kind of hits that next, um, one of those eight service delivery domains we talked about, um, is prevention and wellness. And so that idea of Um, upstream thinking is stopping a problem before it happens, right? Getting ahead of something before it becomes problematic. Um, and so when we think about upstream thinking and, uh, dyslexia or upstream thinking, um, and the SLP, there's kind of three things that we can do to get ahead of something before it becomes, or get ahead of, uh, reading and writing difficulties, difficulty with those literacy skills before it really becomes [00:34:00] problematic. Um, and so it's through education, um, early identification, and then that early remediation are three ways that we can, um, be upstream thinkers or apply that idea of upstream thinking. Um, To, to, to prevent further difficulty or, um, maybe even a need for like an IEP like Heather mentioned earlier, um, and then with upstream thinking, we kind of break it down into, um, like everything there's barriers, right? Um, and so with upstream thinking, we, there are a few barriers that could get in the way, um, whether we're working in a school setting or a clinic setting. Um, and so those three barriers are, I can't see the problem. Thank you. So maybe, um, we have a student on our caseload who just has articulation goals, right? There's no reading things here. So why am I going to address this? Or the wait and see. They're just in kindergarten. It's not an issue yet. Um, the [00:35:00] problem isn't mine is another barrier. Maybe it's not within my scope of practice to address this reading. Uh, I'm not the reading specialist. So why am I working on this? Um, and then another barrier is I, I just can't deal with it right now. Thank you. Right. I don't. There's all of those, um, different admin and procedures. Um, Heather knows more about this area than I do. I don't do evals, obviously, but, um, just more of those. Uh, admin and things that kind of get in the way of, um, just screening a kid or e mailing a kid. Kind of those precursor things that, um, need to happen before. And so that, that is that idea of upstream thinking. And we would like to think, um, of speech therapists and SLPs as the, the perfect role to really play a huge role in upstream thinking when it comes to these students specifically. Thank you. Amy Wonkka: I was just going to ask. I know you mentioned a little bit earlier. I think [00:36:00] Heather, it was you who was who was talking about kind of other things that we might be able to do if we identify a student through a screen or they might get tier two intervention or something like that. Heather Caska: Do you have experience working  Amy Wonkka: with. Like schools, I guess, in particular, who do a really nice job with RTI, MTSS, and actually do kind of support kind of, to your point, Karina, support some of these students well enough through that intervention model that they actually don't need to go on to develop an IEP and have more of those  Heather Caska: specialized services. What might that, what might that look like? I, that's such a great question. Um, So I have, you know, I've worked in just a couple of different school district, not even districts are like charter schools in the area and we're right now, um, where we have been working as a private school. But as far as like what that would look like. I mean, all schools in Arizona right now are doing early identification early identification as far as those universal screeners but you know they [00:37:00] do that. Or two typically is looking like small group. What I've seen done a lot is they're going, you know, they go to a different classroom, but a lot of times it's a computer program, um, which I don't think is always super effective for these students. You know, it really just depends on the child. So, um, I think I saw more so recently last year to try to score was I was working out a little bit. They did a combination of both. So they had a they had someone in there that was doing more hands on intervention and the other students were kind of getting extra practice on a computer while she was working with a smaller group. And I think that can be really effective. But I think just that tier two intervention if it's always just like a computer program where they go and they're sitting by themselves. So the computer and they're just getting this extra practice of that phonics instruction is not always going to be super effective. I still think that hands on, um, and small group, like in person instruction with a body, with a teacher, um, that, that one is also educated in, in dyslexia and what that intervention should look like. Um, [00:38:00] another. The case that Arizona implemented is they have each school, um, each elementary school, K through five, um, must have what they call a dyslexia trainee designee, um, and so it's typically a kinder through third grade teacher, one teacher that gets extra, you know, they, they're kind of in charge of getting all of that dyslexia education, you know, continuing. Education. And they're kind of like the go to person for that school campus. So I always tell the SLPs, find out who your dyslexia training designee is at that school and become best friends with them. Like together, you two can make a world of difference for those students. Um, so I think that's kind of my big thing again, you know, there's great programs out there. Um, but I just, there's something to be said about that. You know, doing that intervention like with the student and having a body and not just putting them as a tier two, like putting them on the computer program to kind of  Karina Kadhi: piggyback off of that, Heather. I think the thing that is. That is said about that in person intervention is that the, the clinical skills that [00:39:00] the, whether it's the reading interventionalist or the therapist can bring to the table, um, in terms of individualizing the, the intervention, right? Um, these programs are like the online practice that Heather's mentioning, things like that are. It's going to be the same for the kid that logs on, for every kid that logs on. Nothing's really individualized in terms of cues or visuals or supports that they might need. And so while it might work for one kid, it's not going to be designed to be effective for every single student that gets on there. Right. And that's where that, those clinical skills really come in where we can individualize those supports and scaffold things appropriately. Um, so that we can, uh, ensure like, uh, a cognitive connection there, you know, and not just exposure to material kind of a thing. Um, so I think that's another, um, huge benefit of being able to support students, um, outside of just, uh, an online program. Kate Grandbois: I [00:40:00] have a question related to this concept of upstream thinking. Is that what it is? Upstream? Yes. So this concept of, uh, upstream thinking and. The general nature of the infrastructure that we work in. So I always use this colleague as an example, but I have a colleague who works in a public school district here in Massachusetts, and she has a caseload of 100 and some students and, you know, it's, it's knowing that for a lot of us working in schools, our resources are limited. Um, are the support that we have from our administrators is limited, and our scope of practice is so wide that I can see the situation arise frequently where there's the, and I think every state does it differently so your resource specialist or your reading teacher. Or whatever your designated person is, I could see that the experience of, well, I don't have time to do that. I don't know anything about X. That's Linda's job [00:41:00] down the hall. Um, I don't have this in my scope of competence, so I'm just going to work on phonology. How would you recommend an SLP Get ahead or do that sort of upstream thinking in terms of addressing some of these resource deficits or competency deficits in a way that feels a little bit more manageable. What made me think of it was when you said become their best friend, because I genuinely do think that sometimes when we even have lunch with a colleague who has a difference and we're talking about our weekends, there can be this experience of shared knowledge. Um, and I just, I didn't know if you had any suggestions for how to specifically address. Some of these real world issues that we're facing in terms of, of the resources that we have available  Heather Caska: to us. Yeah, that's, and all of those things that you brought up are what we hear from SLPs all the time. So some things that I would recommend doing is we're required, you know, for our license to get continuing education. [00:42:00] We have to. You every year. Um, so the International Dyslexia Association, they offer CEUs local branches, even if it's not your state, um, different state branches offer CEUs and they offer ASHA CEUs for speech language pathologists. So that's, it's a great resource to get a little bit more education and competency in this area. Um, And so the International Dyslexia Association has a big conference every year, just like, uh, ASHA does. So that's one way, um, and in your, if you're in the schools really advocating, um, to be part of some of these literacy trainings, um, because like I said, every, most states have some sort of legislation now. The schools and where they're having to have more education on it. And so you might, and I think even a lot of schools will require you to participate in certain, a number of professional development every year. Just advocate as an SLP. Like I'd like to be involved in some of these literacy, you know, trainings or for reading to, [00:43:00] to really kind of increase that competency. And again, we, we recognize that SLPs cannot now just be like, okay, that kid has dyslexia. They need to be on my caseload. That's not realistic. And we completely understand that, but just by kind of educating yourself and being a little bit more aware, there are a lot of things that you can do just to support these students with what you're already doing. So one thing we kind of always talk about is this common knowledge versus common practice. So a lot of what we do in our trainings and what we tell SLPs, it's may not necessarily be like. Brand new information. Like we're not going to really blow your minds, but what we're going to do is help increase that awareness and help you identify activities and things that you can do to be a little bit more intentional with what you're already doing to support these students. And most of what we do in our therapies, um, like in our clinic and with our students, we don't have fancy materials. We have a whiteboard. [00:44:00] Dry and dry erase markers, you know, so you should see my pictures. Yeah, I mean, we create, we create materials for students, um, like therapy materials for them to take home with literally construction paper or index cards and markers. And we have them drawing. And I mean, there's a ton of great resources out there for dyslexia. Um, and materials, but we also understand that like, that's not always realistic to have to have those accessible to you. So there's a lot that we do and we try to share a lot on our social media of like practical things we're doing in our therapy sessions. Um, that you with things you already have. In your classroom.  Karina Kadhi: Um, I want to, if I could add something to that, another thing that Heather does really well in terms of that, um, kind of addressing the issue, uh, with, um, resources in a school and getting these kids identified and stuff is, um, collaborating with the rest of the evaluation team and like the school psychs and stuff. She does a really great job at that. And even [00:45:00] sometimes Heather, maybe you can go into more of that, but like breaking up the. Um, like the subtests and like one that you may do versus the psych. And, um, so I think she does a really good job and maybe that kind of. helps with some of those, um, access to the resources and things to make this, um, a smoother process. Yeah.  Heather Caska: I, I've definitely heard horror stories from other SLPs about their relationship with like the school psychologist that they've worked with. I fortunately have never had that experience, you know, because I think sometimes we get that pushback, like, Hey, stay in your lane. Like I, you know, I'm the school psychologist and nothing again. And school psychs, but I have had the absolute pleasure of working. I've worked with two school psychs, um, in my career and have. Developed like the best relationship with both of them. Um, they're another one that you should definitely try to make your besty in, um, when you're working in the school setting. And we [00:46:00] have just collaborated so well as far as, um, the evaluations, you know, when there was one time where. There was a student that was referred an older student that was referred due to academic concerns like reading comprehension and they're like, I don't think we need speech, you know, it's just academics, it's just reading comprehension. And I was like, Whoa, hold on. And I was like, you do need us. And I said, because reading comprehension is decoding word recognition, and then language comprehension, like we are the ones that should be, they do, they will, you know, school psychs will assess language. To an extent, but we're going to do a more in depth thorough analysis of their language skills. And so we absolutely should be involved in those. And again, I know people are like, well, I can't add any more evaluations to my schedule either. And I, and I understand that, but at least Consulting being advocate to be consulted. Um, when it comes to these other referrals, especially if it comes to, to reading. I mean, and I see this in even with math students that are really struggling with math. [00:47:00] Is it math computation? Are they struggling with the language of math? The word problems, you know, um, and so we definitely have like a big role when it comes to, and again, all this ties in, right? This goes back to the collaboration piece and, um, and that prevention, because again, we'll probably, we're probably more likely to test these students In first grade than a school psychologist would so I really recommend making sure you're incorporating if there's a if there is, you know, it's a speech sound disorder concern and you're testing for articulation, you should also be assessing phonological processing as well and phonological awareness, you know, to make sure that there isn't something going on. Because most of the time they're there is, um, so you're kind of getting your foot in the door before the school psychologist is going to come  Karina Kadhi: in, which kind of takes us to that next, um, service delivery domain, Heather of screening, which kind of might even uncover a little bit more information on how we're identifying these kids in order to have them on our radar and then [00:48:00] collaborate with those other professionals and stuff. So, um, yeah, one of those other areas, service delivery. Don't domain. Sorry. Um, is screening. And, um, that's kind of in the realm of what we're already talking about in, um, identifying these kids. These kiddos early and stuff and so we can, um, get into maybe some areas to screen if we have students already existing on our speech and language, um, caseload for speech sound like whatever they're already on there for, um, we could be more aware and intentional about some of these other early indicators, um, or even Do little screenings with them. Um, if we suspect something. Yeah,  Heather Caska: I think to to add on to that, Karina is when you again, most states, most school districts are probably already doing some of these universal [00:49:00] screenings, um, where they're meeting these requirements. So like kindergarten, you want to make sure you're assessing phonological and phonemic awareness like segment segmentation blending. Um. correspondence, looking at nonsense, word fluency, rapid automatic naming. Those are a lot of skills like in kindergarten. So those are typically probably already being done by the teacher. But if this student is on your caseload, you know, check in with the teacher, how did they do with their screening? You know, how did, how did they perform on any areas come up as, you know, concerns, are they meeting benchmark on everything? And if not, then how can we also support that skill specifically? So, um, you know, like let's say they're really. Struggling with that sound letter correspondence, but you're working with them for like articulation or speech sound disorders, then you incorporate that, that visual, that grapheme with it. So if you're working on that snake sound, you better have that S up on the board and talking about, this is the letter. So when you see that this is the sound it makes. And so that's going to be another really important piece. [00:50:00] Um, as far as maybe you're not the one doing the screening, um, but. Check in goes back to that collaboration. Check in with the teacher are where are they struggling? Are they struggling anything I can do to support them while we're working on, you know, whatever you may be working on in the classroom.  Karina Kadhi: Because that phonemic awareness can easily easily ties into right that articulation therapy that we're doing. Amy Wonkka: Well, and it sounds like just to connect it back to some of those learning objectives. One of the things we can do with SLPs to sort of get on that upstream thinking is making sure we're acting, asking these really specific questions with the other, you know, particularly if we're school based, but  Heather Caska: also if you're in a clinic, you know, like you can, as long as you have consent,  Amy Wonkka: like reach out and collaborate and have those ongoing conversations with the other, with the other members of the child's team. And I think I liked your point just about asking. Asking questions about the specifics of the things that they're looking for in the classroom too, not just, Oh, how generally, how are they doing, but [00:51:00] how did they do on this measure that you looked at for all of the students in the classroom? Was there a pattern in their errors or something like that? So I think those are really helpful points. And again, not, not limited to the setting in which you're working, like be part of, be part of the team as much as you can, no matter where, you  Heather Caska: know, no matter where your  Karina Kadhi: office is. That makes me think of another point that we, going again back to collaboration, um, that I I didn't mention it, but I want to highlight, um, just that collaboration, even within your own discipline, within your own team. I always like to highlight the relationship between an SLPA and an SLP, um, because most of the time I'm the one that's doing the intervention and Heather is doing the assessment and send the evals, right? And so I'm, it's the SLP, the one who's doing, or the SLPA rather, who is going to notice these, um, Maybe early indicators or these red flags or, um, these areas to screen. And so that collaboration with your supervisor as well, even [00:52:00] amongst your own team. Um, is really important because oftentimes the SLP who is gonna, who might be doing the collaboration with the, um, other disciplines, um, they may not know that student as closely as the treating therapist, right? So even, uh, collaboration within your own team helps these other, um, service delivery domains like screening and, and other ones we've mentioned. That's a great point.  Kate Grandbois: Can you tell us a little bit about the assessment process and all of this? I know we've sort of touched on it briefly in terms of whether or not the school is going to do the assessment, you know, how, but what is the SLPs role in all of this? You all obviously have a unique relationship and that one of you is an SLPA. So that role is clearly delineated. But for a lot of us working in the schools, I say us, I never worked in a school for a lot of SLPs who work in schools. Okay. Thank you. You know, based on your state, based on your caseload, that might not be in [00:53:00] your case. Yeah. And in your role on the team that might not be part of your role. So what is this upstream thinking? How does that, how are those two things related?  Heather Caska: So the first thing I would, I want to highlight are just the areas, um, that we always assess when we're trying to identify a student with dyslexia. So we're always looking at phonological awareness. executive function, working memory, rapid automatic naming skills, receptive and expressive language, phonics, so that's that nonsense word and real word, um, assessments, reading comprehension, spelling, um, oral reading fluency. So just like reading fluency at the word level, sentence level, and you then even. paragraphs and then written expression. So again, like the spelling and sentence fluency. So a lot of those skills are, are, we're already assessing anyway, as an SLP. And I always tell parents too, that come to me, like in just in a private practice setting, I'm going to give the same assessment, maybe not [00:54:00] the exact. Same test, but I'm going to be assessing the exact same skills that were assessed or would be assessed by the school psychologist and the SLP in the schools. So it definitely overlaps. But again, the difference is the school's not going to give you a formal diagnosis. They can't. That's not what they do. They are going to find you eligible under certain criterias in different categories. Um, so if I have a student and they say, well, they were just assessed at the school by the school psychologist, you know, within the last few months, um, and the SLP, then I'm just going to ask to review that testing. I don't necessarily need to do a full blown evaluation. The data is there. They, they may not be able to give that diagnosis, um, there, but based on that data, and I typically. They will do a little more like baseline assessments or screeners. Um, a lot of times you're not as they don't do as much oral language testing. So maybe that's what I do is I add more oral language testing in, um, you know, to kind of look at that. There's a big debate in our field whether or not SLPs can diagnose dyslexia, and I'm a big advocate that we can, [00:55:00] um, it falls under our scope of practice, um, but again, it's not something that if you're not well trained or knowledgeable in reading development, reading disorders, and you shouldn't be assessing and diagnosing without I'm not going to walk into a hospital and try to give relationships with someone. Um, you know, like a fees exam or something like that. It's under my scope of practice. I technically could do it, but I don't know anything about that, you know? And so it's, it's kind of the same thing. We do have a very broad scope of practice. Um, You know, and, and it depends, you know, the diagnosis codes and, you know, that kind of gets into a whole other ball game, but, um, like within our state. There is like a scholarship that's that parents can get through the state, you know, to get services. And recently one of my, one of my students was given, you know, sent their, their evaluation and that I did, um, he was diagnosed with a mixed expressive receptive language disorder, a reading disorder. Um, and I always just put in, you know, fits the profile of a [00:56:00] child with dyslexia, kind of like in my writeup. And then they were denied because they were told that I'm not a qualified professional. And I like, and so it's, it's infuriating as an SLP who is a late were language experts. Um, there's no diagnosis code for reading comprehension. So if they're struggling with reading comprehension, which is well within our scope of practice. I mean it's language, right, that we're still being seen as unqualified professionals. And so that's kind of like my next mission is like, I'm going to get that changed because you can't tell me that, uh, that a pediatrician or a doctor. Or a licensed psychologist is more qualified to diagnose the student with a language disorder. And I think part of it comes back to like I, the fact that there was a reading disorder diagnosis on there too, but I was like that is reading falls under our scope of practice you look at Asha like how. How are we still being seen [00:57:00] as unqualified professionals for this? Like it's, it's so maddening. Obviously I feel very strong, have very strong feelings about this because, um, it's, it's, it's just frustrating. Like, and I, I think that happens to us a lot in our field, you know, where we're not. I mean, acknowledged, acknowledged or recognized, we're not acknowledged or recognized, you know, for, for how much we do and how much knowledge we, we possess, you know, and what a difference we can make. And so it's, it's just frustrating. But, um, I could talk about that all day. So, um, but yeah, so as far as like just being part of that assessment process, it really just, it depends on your role. I'm a big advocate that we should be involved. Um, there's a really great, uh, quote from Dr. Alt from Mary Alt. She's a professor at university of Arizona and she, um, her and Dr. Shelley Gray, there's a, there's a whole collection of, uh, professors, um, from all over that are working on some [00:58:00] working memory research, and they had a podcast. Episode with Dr. Tiffany Hogan, where they were talking about some of their results as far as working memory and word learning. Um, and she said, we don't always do a great job figuring out when kids have both oral and written language issues. And there's a lot of research that they're, you know, from their research that they're finding that, you know, students that have both oral and written language disorders struggle. There's there's. They, there's, they're significantly slower to, to, to learn, you know, and we're learning. So we have to get a lot better at. Being part of that and identifying, you know, it's not just academics, there's probably some oral language things going on as well.  Karina Kadhi: And that ties back to upstream thinking just with that early identification piece, the, the sooner and kind of that dyslexia paradox idea that we can play a role in upstream thinking through assessment by identifying early assessing early and therefore remediating earlier. And really. [00:59:00] Um, getting a hold of these students, if you will, um, during that time when intervention is most effective. And I  Amy Wonkka: think to the point that you both made too, sorry, just to connect back to assessment by conducting that comprehensive assessment. Not only are you ideally remediating early, but you're remediating in all of the areas in which there are  Heather Caska: deficits. So if you're early.  Amy Wonkka: Ignoring kind of that oral language component and you actually have a student where that's a big challenge area for them and nobody's remediating in that area, that's probably also going to really influence their ability to have success and make progress in the way  Heather Caska: that everybody wants them to. Absolutely.  Karina Kadhi: So we have a few, um, like three more, um, service delivery domains to touch on. Um, Okay. One that we can kind of do quickly is so one of those eight is treatment, but treatment I think we're going to cover our role in treatment, how we can support these [01:00:00] underlying literacy skills in the speech and language therapy that we are already doing. On, on our next one. That one's going to be all about treatment. If so, it's such a in depth one that, um, treatment gets its own, uh, little dedicated spot, but  Kate Grandbois: for those of you listening, if you are really dying to know about treatment, stay tuned because they're going to come back for another episode. That was a teaser. Heather Caska: Sorry,  Karina Kadhi: spoiler. Um, but in terms of our, our role in, uh, under treatment, I think the biggest thing to point that we want to point out is that our roles are going to be different in different settings, right? In a clinic setting versus a school setting, our, our role for treatment in a school setting is not going to be directly, um, those, the reading goals or the writing goals. It's their speech and language goals, but to understand that we have, we do have a role in supporting that through the speech and language. That we're already addressing. And then obviously in a private practice or clinic setting you have a little [01:01:00] bit more flexibility where you might be actually addressing some of their reading or writing goals. Um, another service delivery domain that falls under our scope of practice is that modalities technology and instrumentation. Um, and I like to call this just assistive technology. These past couple years working with that older population again, I've learned so much about, um, how to support them under this domain. Um, have you guys heard of read and write? It's, um, yeah. Yeah. Okay. So they use it a lot in the school. Um, uh, so it is an amazing plugin that you add on to like your Google accounts and it, the tools that it gives you. I can do like the basics of like you highlight things and it'll read it for you. Um, or you can like the voice to type voice to text thing. Um, but also some more. Complicated things [01:02:00] like you can if you're if you have a student who's researching something it can minimize the text on any website, so it makes it more manageable for them versus like this whole web page that not only I have to read, and then somehow understand it can it will minimize it for them so there's some algorithm it uses where it just minimize simplifies the context so that they get the main idea out of it. You can generate vocabulary lists. Through what you're doing like just amazing, amazing supports and I was lucky enough last year I was working with a, a girl who, um, she really took hold of this and found just, she was so empowered by access to her regular academic stuff guys just on her computer right like she was so excited to be able to have access to this and, um, Participate in the class activities like the rest of her peers. So, um, read and write is awesome. There's a ton of things that like orbit note. Um, so many audio books obviously are a good one too. So, so many things we could be [01:03:00] doing under this domain to support these students as well. Um, and then that brings us to the last area, populations and system. Um, how do you want to talk about this one? Heather Caska: Yeah. So this kind of really just ties everything together. So as far as population and systems is, you know, we can play a big part of helping, um, kind of streamline everything a little bit more, whether you're in the clinic setting. I mean, we, my, my company specifically, we obviously we specialize in dyslexia, um, you know, and so that's kind of what I've based my whole practice around, but in the schools, it goes back to collaborating, you know, be part of that team, really. We have so much to bring to the table, but then we can learn so much from others. Supporting the classroom teachers, collaborating with, you know, if you have something like we do here in Arizona, like the dyslexia training designee, occupational therapist, reading interventionist, a school psychologist, um, and then just always supporting those demanding, those demands, you know, like creating... So just being more aware of, you know, that the 80 and [01:04:00] how can we support that in the classroom? Um, and then educating, you know, that's the big piece to really just educating others on our role, like what we can't, what we do and, and how great we are. Um, and how much we can support, you know, other, other professionals. Um, and parents and students. So that's kind of the big piece too. It goes back, just keeps going back to collaborating and educating and, you know, just being aware of, of what we can really do.  Karina Kadhi: Those, what it really goes back to is those three areas of upstream thinking and those things that we can do to that. So that, um, That education, that early identification and that remediation. And that brings me  Kate Grandbois: to my favorite question, which is what can our clinicians do from here? What are your words of wisdom for people who are listening to this, what action steps can we take from here? Karina Kadhi: Oh, great question. So we always like to end with a little bit of self reflection and a plan of [01:05:00] action. Um, and then we want to leave you guys with one of our favorite quotes too. So I'll start with that. Um, this quote is by Rita Pearson. Every child deserves a champion, an adult who will never give up on them, who understands the power of connection and insists that they become the best that they can possibly be. And so, um, we want to be our students champions, right? We want to help them, um, get through those difficult things and help them know that they can and that it's possible for them. And so, um, a plan of action, we like to break it up into two like short term and long term so short term going back to school and, uh, now if you're in Arizona, or here in a month or so. What, what is it that you can implement when you get back to work, Monday or next time you you get back there like what is something that you can start doing in that your speech and language intervention that you're already doing what else can you start incorporating what other which one of those other domains. Um, can you, uh, [01:06:00] maybe support them better or do something differently, maybe something you're not doing yet, um, and then try to think of two students on your school caseload or two clients that you might have, um, that might have some of those, um, early indicators of, um, later reading difficulty, and if they're already on your caseload or speech and language goals, um, then that's a, uh, kind of an indicator that there's, Some things you can embed into your intervention to support those underlying skills. So those are, um, kind of two reflecting prompts we like to do for short term.  Heather Caska: And then long term, I, some things that we like to recommend is do some research, find out what your dyslexia legislation is in your state. Um, you can literally Google, just put that in the Google, like Q would be Arizona dyslexia legislation. Um, we have a dyslexia handbook through our department of education. And so most states will have that as well too. Um, I also really encourage you reach out to your local [01:07:00] international dyslexia association branches. All states have them. Um, if that, and that could mean literally just. Following them on social media. Cause then you're going to stay in the know of when they're offering um, workshops or CEUs, things like that. Um, and then also just thinking about how can you support kind of like what credo is saying that an implement some of that early identification, um, you know, so just maybe pick one of those specific service delivery domains at first, so it feels manageable and, and what can I do like create a site differently or, or implement. This has all been  Kate Grandbois: so incredibly helpful. Thank you so much for sharing your knowledge and your time with us. For anyone listening, if you heard us discuss anything that piqued your interest, we will have a list of references in the show notes, including some hyperlinks to some resources that you all discussed today. And as they both already mentioned, you can get in touch with these two lovely human beings at, um. At soar with words through their through their social [01:08:00] media channels at sore with words. Um, is there anything else you'd like to say?  Heather Caska: Thank you. Yeah. Thank you so much for having us. Thank  Kate Grandbois: you both. Great. Thank you so much for being here. Sponsor 2 Outro Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you 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 . Kizzy Searle [00:00:00]  Intro Kate Grandbois: Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  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 Kate Grandbois: Welcome everyone. We are so excited for today's episode. We are here with Kizzy Srl. Welcome Kizzy.  Kizzy Searle: Thank you. I'm really happy to be here. Thanks for having me  Amy Wonkka: Now, Kizzy, you [00:02:00] are here to discuss speech therapy using a psychosocial and trauma-informed approach. And before we get started, can you tell  Kizzy Searle: us a little bit about yourself? Yes, sure. So I am a community-based speech pathologist in Australia. And, um, really just very, very passionate about working in that mental health trauma space, um, because of kind of living, breathing it and just loving it so much and really excited to talk about it today.  Kate Grandbois: And I love that you are in Australia. This is such a cool experience. You're, we've already discussed this, but I feel like I have to say it for our listeners. It is 5:00 PM here ish in Massachusetts. And you are, what time is it where you are?  Kizzy Searle: It's 7:00 AM The next day. The next day  Kate Grandbois: you're in tomorrow. It blows my mind. This whole time zone thing. So you are in the future. Yes. And we [00:03:00] are here in Massachusetts one day behind you in the past talking about science and speech pathology. I mean, if this is not the coolest intersection of all my favorite things, time, travel, sci-fi. Anyway, I don't wanna get too off topic.   We're so excited to have this conversation with you today. We've already had a chance to talk with you a little bit before we hit the record button to sort of see the edges of how this topic, this, this topic of trauma-informed a trauma-informed approach to speech therapy intersects with communication. And we can't wait to get into it with you first. I do need to read our learning objectives as well as our financial and non-financial disclosures. So let's get that over with and then we will hop right into all the good stuff learning. Objective number one, describe the psychosocial and trauma-informed approach to speech therapy learning objective number two, identify at least three psychosocial factors that can make an impact on speech therapy. Learning objective number three, describe how speech therapy [00:04:00] fits into a bottom-up brain-based framework. Disclosures. Izzy's financial disclosures. Kizzy received an honorarium for participating in this course. Kizzy is the owner of Attuned Speech, which provides speech therapy, work, supervision, and webinars. Kizzy is also a consumer advisor for mental health in the Sydney Local Health District. Izzy's Non-Financial Disclosures. Kizzy is on the Trauma and Mental Health Advisory Board for Speech Pathology Australia. Kizzy is also a member of Speech Pathology Australia and runs a social media platform called Attuned Speech Kate. That's me, my financial disclosures. I'm the owner and founder of Grand Block Therapy and Consulting, L L c and co-founder of S L P Nerd Cast. My non-financial disclosures. I'm a member of SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. All right, Amy.  Amy Wonkka: That's me. Uh, my financial disclosures are that I'm an employee of a public school [00:05:00] system and co-founder of S L P Nerd Cast. And my non-financial disclosures are that I'm a member of asha. I'm in special Interest Group 12, and I participate in the a c advisory group for Massachusetts Advocates for Children. All right. We've made it through all the bits, all the mandatory bits. Um, ki why don't you start us off by telling us a little bit about the first learning objective. And maybe you can start off just sort of helping define. What do we need to think about under that psychosocial lens, um, and trauma?  Kizzy Searle: That sounds good. Yes, because they're a bit of a mouthful. So I, um, I guess the psychosocial component and the trauma-informed component I see as really complimentary elements to the work that I really love doing. The, the psychosocial part is technically biopsychosocial and basically all it really means is a combination of, you [00:06:00] know, the biological aspects as well as the psycho psychological and social aspects and how they actually impact on everything to do with speech therapy. So for me, it's the way that I understand and think about every single one of my cases or clients and their families, um, And because it's combined with trauma, I'm thinking for example, from the biological perspective, how developmental trauma can actually impact the way the brain grows and also the way the brain is structured and functions and how that impacts on engagement, learning development, the use of social, the use of speech language and communication skills. Um, and then of course the, in terms of the psychosocial elements we're talking about the social environment, you know, the family, school life. Um, we're talking about culture. All of those things that I think many of us are aware of. But I'm really keeping that in mind all the time. In particular when I'm getting to know a client. And [00:07:00] that is then basically having an influence on. How I'm then responding. So that how is basically, to me at least the trauma-informed aspect where I'm thinking about really shifting the way I see speech therapy fitting in into a really, a bigger kind of trauma-informed framework. And I'm embedding all of those trauma-informed principles into every part of my work. So that's a bit of a overview, I guess.  Amy Wonkka: that's really helpful. The zoomed out view. Um, and I think, you know, it,  Kizzy Searle: it  Amy Wonkka: makes me wonder as, as a practitioner who doesn't know a lot about psychosocial and trauma informed approaches, like how, how might that look different? So I am looking forward to having a conversation with you and learning a bit more about what that means for me as a clinician. Not only about how I think about my clients, like you were saying, but also. How I might change, whether it's my interactions, um, [00:08:00] or, or kind of my clinical approach to be more accommodating of sort of that broader global view. Kate Grandbois: That's what I was gonna say is as I think as clinicians in, in our field, in in speech pathology, we often think of our role as, we also didn't think of this broader role as part of allied health. So we are fitting into the picture with ot. We're fitting into the picture with pt, special education, respiratory therapist, depending on your setting. I don't my experience, my professional experience to date, we have not had this component of a mental health alliance or this psychosocial focus. But the way that you're describing it, it makes complete sense that we would be nested in this much broader picture of the individual's biopsychosocial existence. Kizzy Searle: Yes. I, I love that the both of you said that. I think that, um, [00:09:00] at least when I was learning and studying in here in Australia, you know, we were taught, and I understand why, you know, we were taught about each of these speech, language and communication elements in isolation because we really needed to understand what each of them actually were, how to identify, you know, what they were and how to work specifically with them. Um, but we weren't really taught that in real life they don't actually exist in isolation, which I know you've spoken about in previous podcast episodes, um, and how it's actually a part of a whole human being. And in fact, unfortunately we can't truly, I mean, sometimes we can, you know, it depends, but often we can't actually be working on each of these skills Totally. In isolation because, They're, they're impacted by the rest of life and the rest of, so, and they also impact on the rest of life. So we do [00:10:00] have to be kind of taking that step back and thinking to ourselves, well, I often find I do anyway is, you know, what else is happening in this person's life? Thinking about their past, you know, thinking about their present, thinking about their future and, and how that is actually impacting on their ability to develop their skills as well as use their skills in real life Well, and I think, you know,  Amy Wonkka: we have, we have talked about this a bit before on the podcast, but when we think about communication, it's an interpersonal experience. It's something, you know, it's something that involves at least two people. Um, and all of us are bringing our own, you know, our own histories, our own present, our own future. We're, we're coming to that, that interaction with all of those pieces of ourselves, um, whether that's known to our communication partner or not, like that's, that's having an effect on our interaction. And I think, you know, there are some, there are some pieces of like the isolation that's maybe a little bit easier to pull out. Maybe it's a little bit easier to pull out and [00:11:00] say, I'm looking at articulation through this very narrow lens and, you know, we're thinking about it over here. But I think especially, uh, when we think about. Some areas like pragmatics or you know, any of those areas within our scope of practice, uh, that like you've really, really, you can't separate them out from somebody's psychosocial kind of experience within the world. I wonder if it would be helpful, I'm gonna jump ahead a little bit. I do this sometimes, but if you can talk to us a little bit about that second learning objective, just thinking about some of what those psychosocial factors actually are. Um, you shared with us some references that we'll put in the show notes too. Um, but I know, you know, one of the pieces you had referenced and Asha Leader article, uh, that just talked about even the differences between trauma and stress and the idea that some, I wanna think it was 60% of adults or something like that are, are kind of moving through their life, having experienced [00:12:00] some sort of trauma. So, you know, just what are some of those factors? That, that may be, you know, at play when we're thinking about interacting with our clients and their families and trying to come up with a respectful and meaningful and evidence-based treatment plan  Kizzy Searle: for them. Yes. Um, wonderful question. I, I wanted to first just agree with, with what you were saying about, um, you know, communication and interaction, how it's, it's all one and the same, isn't it? And it's, it's so deeply psychological and our, our communication is also deeply rooted in our survival. You know, we communicate to survive, that's one of the first things we learn as babies. We have to be able to communicate, we communicate through crying and all those kinds of things. And as we grow, it becomes a little bit more, um, maybe abstract and we add all these different elements into it. Um, and, and so, so yeah, it, it is all just enmeshed in each other. [00:13:00] Um, in terms of your question about the second learning objective, Yeah, so one of the things that kind of comes to mind to start is, uh, my work that I do with a lot of teenagers and often they come to me wanting to, uh, work on things like, you know, friendships and being able to participate more in group situations. And they're usually really motivated to work with me. I find at least when they come to me of their own choice. Um, and, you know, I'll start working with them and I'll notice that they kind of fade out a little bit. They don't always seem to be really engaged with me. They may have started the session really alert, and I notice as the session goes on, they're starting to yawn and yawn and they can't keep their eyes open anymore and they don't know why they're doing what they're doing. Um, and the way I understand, and then perhaps as well, you [00:14:00] know, over a number of sessions, They might go away and come back and nothing's happened. You know, they haven't worked on what they said they would work on, or they're starting to, this doesn't happen to me too much anymore, but they might start not showing up. And the way I understand this from that bio-psychosocial lens is by looking at the broader context. Yes, they're coming to me. Yes, they have clear goals. Yes, they're motivated, but they've probably had past experiences of going into school environments, of being socially isolated, of being teased and bullied for the way that they speak or the way that they sound, how they might seem different. And that is incredibly. Distressing for any person to go through. And if they've gone through that, not just in high school, maybe in primary school, maybe even in preschool, perhaps they've had early experiences in their life where they've been really often misunderstood or their needs haven't been met purely because they've been all of these [00:15:00] frequent communication breakdowns and, and it's been no one's fault, you know, not the child's fault, not the parent's fault, but that's just how it's. All of that accumulation of stress, you know, perhaps there are less protective factors can increase the risk of trauma. And we also know, um, there's lots and lots of research to show that, you know, when there is that long-term exposure to trauma, when we, and we don't have as many protective factors, for example, that really, really securely attached caregiver or were just exposed to lots and lots of different stresses that this can actually change the way the brain actually grows, in particular impacting In terms of the, um, well there are a couple of different impacts. I'll just mention one for now, but that prefrontal cortex area, which I think also may have been mentioned previously, uh, in another episode, but that prefrontal cortex area, which is where, where we call our, um, our executive functions live. Something that Terra Sumter also mentioned. I [00:16:00] wish I, and I love her work. I just had to give a shout out. I dunno her, but I had to say it cuz I love her work. Um,  Kate Grandbois: we'll make sure she knows she's, she's wonderful. We'll make sure we pass it on. And anybody who's listening who has not listened to this episode, we highly recommend it. Go back and listen. I can't remember what season is, but we interviewed Tara Sumter, Tara Sumter about executive functioning skills, which is what we're referencing. But anyway, as you were.  Kizzy Searle: Amazing episode. I totally recommend it as well. Really great episode. But yeah, so those are our thinking, learning, decision making, problem solving skills, and that can often be really significantly impacted in the presence of long-term, chronic, you know, complex, however we wanna call it trauma. So I'm potentially coming back to the present now with this. Teenage client of mine potentially working not just with a client who has had lots of distressing experiences, um, you know, in the peer kind of world. And therefore having to talk to me about these [00:17:00] kinds of social communication areas is actually really, really hard for him and potentially quite triggering. So it actually makes sense that his, you know, zoning out in my sessions is starting to yawn. He's shutting down basically, you know, his mind has gone, this is too much. I can't handle this anymore. I'm talking about something that I find really traumatic. I'm gonna numb myself to this situation. So even though he wants to be there, this is what he is fighting internally. And that's probably also why, you know, part of the reason why he's going away and is forgetting. To work on what we've worked on, but also he may be forgetting because his executive functions may have been impacted by potentially long-term trauma. So, so that's just a really quick, um, yeah, example of how I might actually be thinking about that psychosocial element in real life with my clients. Kate Grandbois: I may be jumping ahead a little bit, but now I, now you have me wondering about some of the other things that a therapist might look [00:18:00] for or consider. So in terms of, you know, zooming way out, zooming way, in terms of zooming way out and thinking about the broader context, making sure you're considering. An individual's lived experience, what's happening in their lives outside of the classroom, outside of your therapy room or outside of the classroom. Understanding this connection between brain development trauma and how traumatic experiences can shape our communication skills. What are some of the other components or are there other components besides executive functioning that a therapist maybe who's listening to this who doesn't have a lot of experience in this area might also look out for? Kizzy Searle: Yes. So, um, the two, I would say that there are, Quite a few different parts of the brain, honestly, that get impacted, but the probably the two other key areas that I like to talk about. Um, so, so I like to talk about three parts of the brain. Basically we've got the bottom [00:19:00] part, the middle part, and the top part. So we've got our brainstem at the bottom. The middle part is our limbic system, and the top part is our prefrontal cortex. And so we've spoken about the prefrontal cortex, the top bit, the middle bit, um, with the limbic system. I like to think of two areas. So there's the hippocampus and the amygdala, basically that is, I'm summarizing this here, but memory and emotional regulation, and then we've got the bottom part of the brainstem, which is where our actual stress responses live, I guess you could say. Those fight, flight, freeze, collapse responses. That's kind of where they come from. So, and I hope I've understood your question correctly, but when there is potentially the presence of trauma, we don't always know. You know, sometimes someone will come to us with a clear history or a diagnosis. Other times they won't. But I might imagine, based on what I understand of their past experiences, that there could have been some kind of traumatic experience. Um, but so basically yes, when, when there is [00:20:00] potentially trauma, what can also happen is the amygdala, which is that kind of emotion place that's also our threat detector can become overactive. So it can start to be registering potential threats even when they're not maybe there. And, and result in some, I guess, startle responses that, that are perhaps more common or often are come more frequently than other people. They might be constantly on the lookout, you know, for, for potential dangers. Even when they're fairly feeling fairly safe and regulated, they're still really, you know, constantly, they're observing little changes in facial expression. They're thinking about what's behind them, um, you know, always ready to go. And then of course, just the brainstem is more likely to be activated and they're more likely to go into those stress responses as well. So that's also just what I'm thinking about when I'm with my clients.  Kate Grandbois: No, that's very helpful. I know that a lot of times we end up in, we're in our workplace situations, we end up in [00:21:00] situations where we're treating individuals where we don't have a complex history profile on them, or the parents are not available to collect more information. Um, or maybe a therapist might get the sense that something is sensitive and they're not really sure how to move forward. I, I, I love the way that you painted the picture of just things to consider if you do suspect that someone who's sitting across the therapy table from you is having a more difficult time or could even just the idea that they could have experienced trauma, I think is an important thing to consider that often our, in our society we don't necessarily focus on, and a lot of us, were not trained on this in graduate school. So I think even just acknowledging those things is really helpful. So thank you for, thank you  Kizzy Searle: for sharing that. No problem. Actually, that's a, that's a really good point. So I, I mean, personally also just because I love this area so much, but I do use this trauma-informed approach and psychosocial lens with everyone I work with, regardless of if they're coming to [00:22:00] me with, um, because I'm, you know, a person who loves working in this area. So it is the approach they use regardless, because you can never know, you know, you, I, I didn't know about my own trauma until 27. Uh, sorry until I was 27. So, you know, I'd been living my whole life with all of this really complex trauma and I could have benefited from that kind of psychosocial trauma-informed approach for so many years before I realized it myself and was able to go, hang on, this is what I now need. Um, so it, it's really not as obvious, you know, sometimes our stress responses, like those freeze collapse responses, uh, they're not big responses. They can be really subtle and if we're not trained up in it, we can't always pick it up. So you, because the fight flight, they can sometimes be quite big, you know, responses like actually fighting or absconding. Um, but then other times the signs are really, really subtle. And so I actually think that it's, my [00:23:00] recommendation is often just take the, take that approach. But in particular, like you said, if you have a question like why is something just not working, something just doesn't feel right or there's some kind of weird. Dissonance, you know, something weird going on. Then maybe there's time to think a little bit about that psychosocial trauma-informed approach.  Kate Grandbois: I just love that so much, Amy, I'm so sorry. I can see that you wanna talk and I just jumped right in. I'm so sorry. I just love that so, so much. And I think it speaks to what we can bring to our therapy rooms to create safer spaces that are focused on trust and compassion and person-centered care, regardless of the history that you know. So thank you so much for saying that. Amy, take it away. I am sorry that I interrupted you.  Amy Wonkka: No, it's fine. I was just going to thank you, Kizzy, for answering the question that I didn't ask, which was this seems like it, like there's absolutely [00:24:00] no harm in utilizing this approach with everybody and potential harm in only utilizing it with the clients or family systems who, you know, have a certain history. Um, I think connected with that. I guess a question that I have is, As a clinician who's looking to change my approach a little bit, to be more trauma informed, to be more psychosocially oriented. What are some things, like, how, I guess if we can go back to your example of your high school student, um, how might you change the way you interact with him or change, like, I'm just thinking perhaps if you weren't using a trauma-informed approach, you might think, all right, well he's not doing his homework. Maybe I'm going to set up some type of incentive plan to get him to do his homework. Um, that might be what you would do, but I'm wondering if it might look a little bit different when you're approaching it from this [00:25:00] broader framework. Um, and if you could just talk us through some, some sort of examples or like what that process, how that process might look a little different. Um, so we can, we can try that on in our therapy.  Kizzy Searle: Yeah. Great. That sounds good. Um, I, yeah, so I guess this brings me into that trauma-informed section where, you know, I think of that as the actual doing bit. The, so we know the kind of, you know, I, I guess we know the why maybe. And this is like the, how, how do we actually change our approach? What do we actually do? Because of course it's kind of like, it's great to know all these things, but you know, now what do we do? So, um, so basically the, there are a few things. Um, maybe the first one I will cover is Dr. Bruce Perry's neuros sequential model. So he, he has this one aspect of, uh, part of the model. So I haven't kind of done all the learnings and courses in depth cause it's quite, quite intense. [00:26:00] But he has this one approach that's called the three Rs, um, which is basically, Uh, regulate, relate and reason. So I think of it as like a framework or a bit of a, um, a reverse pyramid with regulate at the bottom, relate in the middle, and then reason at the top. And it's basically in line with the three parts of the brain that I spoke about before. We've got the brain sim at the bottom, the limbic system in the middle, and then the prefrontal cortex at the top. And I like to think of a lot of that, those really in-depth speechy things that we do as living in that top part, that reason section. And actually, no, it's not an upside down pyramid. Sorry. Got it the wrong way to, it's a normal way pyramid, if you know what I mean. So, um, yeah, so was recent at the top. So, um, Naturally we've got our regulate section, which is all about the window of tolerance, which is, [00:27:00] which means, you know, how we remain regulated. You know, for any of you who are maybe a little bit confused about what regulation actually is, naturally includes when we're in that calm state. But it's actually, you know, when we can be in a whole range of different emotions, from happy to sad, to angry, but we're still able to reason, problem solve, make decisions, and be responsive. When we move into our, we're reactive. Now we've gone, you know, mind blank. We're just, we've got all this, you know, the pumping heart rate. We're just ready to fight and go. That's when we've gone into a stress response. We're now dysregulated, you know, we're in that fight, flight, freeze collapse, which we all go through regardless of if we have, you know, history of mental health and trauma or not. It's just that it's much more common, um, and much more difficult to perhaps get a handle on. If you do have that, if you are impacted by trauma, basically, So, so there's that, that first element is what I think about with my clients is how are they doing regulation [00:28:00] wise, because what we know, um, from, so now I'm just gonna introduce something else. Uh, there's this hand model of the brain by Dr. Dan Siegel, which is a really, really simple model where he basically shows what happens in the presence of a stress response. So usually you can think of the brain as like a fist, basically a closed fist. And what happens is when you have a stress response, what he says is, we flip our lid. And that means that that top part of the brain, which is our prefrontal cortex, actually turns off. And, and now what I've done is I've like lifted up my. My fingers, so they're no longer connected to the rest. So I'm kind of like a palm now, no longer connected to the rest of the brain. So now what we've got exposed is the limbic brain, which is the middle part limbic system, the middle part of the brain and the brain stem. And they're now completely in control. So our, our ability to think, problem solve, reason, you know, communicate, [00:29:00] all of those things are actually offline during a stress response. We can't access them and we need all of those things to engage properly, to learn, to actually to grow. And so we're potentially working with people in our sessions who don't actually have access to that learning, thinking, decision making part of their brain when they. When they're dysregulated. So that's why it's so important for us to first be thinking what is their regulation like, how are they doing? Do I see signs of fight, flight, freeze collapse? What do I know about them? Do they seem to be, you know, a bit zoned out? Are they obviously really fidgety and they need to move around? Cuz these could be signs that it doesn't. I can't actually say to them, uh, communicate with them verbally at the moment. It's just not going to work. So that's that, that bottom bit. And then of course the next part is the relating section, which is where we're really focusing on connecting. It's that trust [00:30:00] that that, um, so the bottom bit is the safety, the middle bit is that trust, the connection, the, and, and I really, really focus a lot of time on this section. Naturally, I know, you know, the states, it's a very different environment, funding environment. So I can't, I, I don't know how much time, you know, you guys have to do this kind of stuff too. Sometimes that's the case too, where restricted by funding, but wherever possible, I'm actually spending a lot of time on the relationship because we also know, based on the brain, That the more they feel connected to us, the more they actually trust us, the more they're going to learn. So the more time I spend on those two bottom sections, the more likely speech therapy is to be extremely effective and actually happen really, really quickly. Rather than me kind of feeling like I'm just like, what's that term? Um, I dunno, I, it's a bit early for me, so I can't think of the term, but kinda like, I'm like just really chipping away and I'm not getting [00:31:00] anywhere. But I find when I focus a lot on the regulate relate, the, the reason bit, the goal setting speechy bit just happens so quickly.  Amy Wonkka: I, I love everything that you just said. I'm gonna jump in, in front of Kate. Sorry. Same, same, same, same,  Kate Grandbois: same, same buddy. But I, I  Amy Wonkka: think, you know, we, we talk a lot on this, but Kate and I both work in AAC and I feel like we talk a lot in this podcast about the set framework. I love the set framework, which is a framework for thinking about assistive technology. But one of the pieces I love about it the most is that it gives us the ability to identify the environment and analyze variables in the environment. And when you were speaking, I was like, regulation is part of the environment, right? Like so, so this regulation piece, the environment is not  Kizzy Searle: just how  Amy Wonkka: noisy is it and how much movement is there in the background, and is it like a distracting visual environment? It is also, As much as we can tell and we can't be inside somebody else's body. [00:32:00] Um, but, you know, what is your internal environment as a client and your availability for being there? And I think,  Kizzy Searle: you know, I thinking  Amy Wonkka: about having that in the back of your mind as you're working with a client, I think is a, is a really, it's a really important layer I think that perhaps many of us are, are not like giving those discrete thoughts to, um, because I would imagine if you're in that, you know, like your, your lid is up, your fingers are up and you're not able to access sort of that ability to learn and be present in a learning exchange that also could potentially escalate things and make the whole experience even more negative. So then the next time the client comes back, that was their previous experience was this escalated negative experience. Um,  Kizzy Searle: so. Thank you. I guess  Kate Grandbois: I was, was just gonna second all those comments [00:33:00] because the, the image of the fist and then the fingers going up, you can just see how parts of the brain are just not available. I don't know. Something about that visual was incredibly helpful for me, so thank you so much for sharing that. The other piece that it made me, that, that came to my mind as you were talking was, I know as therapists we're taught to build rapport to make it fun, right? I mean, everybody knows that if you're in pediatrics, you're on the floor. You might play a session, spend a session or two playing. If you're working in a hospital, you might spend a session or two having a conversation and get, make, you know, being friendly and making the person feel at ease. But that is so much more important than just. Having fun when you were talking about this, it is a critical, it made me realize that this is a critical piece of someone making progress. This is a critical piece of their [00:34:00] neurology. This is a critical piece of, um, you know, making sure that we do no harm by accident, unintentionally. And I think that there is something fundamental in that. Again, just do this all the time. Don't wait for the red flag. Um, you know, don't wait for the explicit in the, go ahead. The green light. Well, this person has trauma, so you should use a trauma informed Glen's now. No, I mean, this are, these are cornerstones of learning. It's just my, my brain's going off here. It was just so, so helpful.  I Amy Wonkka: Have a question. I have, I have a question about kind of piggybacking on Kate's comment about fun. And I think fun is important too. Like, I mean, I, I'm more engaged when things are fun. Um, but the idea of co-regulation and  Kizzy Searle: so as, as a speech pathologist who doesn't  Amy Wonkka: have a lot of background in this area, like not this, the same approach is not going to help regulate our every client, [00:35:00] right? So I don't know if you can talk a little bit about that and just, you know, not that everybody's gonna listen to this podcast and be an expert, but, you know, I think there are different things that we might do in the interaction with the client, depending upon what signs the client is giving us to help make that a more comfortable and accommodating space. And I don't know if there are any tips you have, um, for listeners for me and Kate.  Kizzy Searle: Yeah, I, I, um, I love the concept of co-regulation and it is, again, one of those really jargony words that can just seem like, oh, you know what even is that? Um, so yeah, I would love to speak a bit about it. It, it's basically, I, I mean, I guess yes, if I, if I were to summarize it, it's occurs at the nervous system level and it's basically when you can help soothe another person's. Nervous system through your nervous system. So that's [00:36:00] kind of at that kind of nervous system level. And we can think about it when we, we, I guess we can better understand when we think about maybe a mom and the baby, you know, when a baby becomes distressed or dysregulated and they start crying, you know, the mom usually comes over, identifies they're upset, picks them up, soothes them, uses all of that beautiful, you know, like, sure. Whatever it is, you know, all of that beautiful tone and volume and, and the baby can naturally be soothed sometimes the mom also recognizes that there's a need that needs to be met. Perhaps the baby's hungry, she meets that need soothes the baby, and the baby's okay. During that process at the nervous system level, you know, when the mum connects with the distressed baby, her nervous system also becomes dysregulated. She feels this baby's pain. She's distressed by the baby's distress, and as she's soothing the baby, she's actually also soothing herself. They're coming back into a state of regulation together. And what's happening is because [00:37:00] self-regulation is heavily reliant on executive functions, in fact, it is an executive function skill and a baby's brain executive functions are not developed. We know that that prefrontal cortex is the very last thing to develop. In fact, I think it only fully develops, and please don't quote me on this, was it 25 or something like that? You know something much, much later. Yeah. The baby doesn't have skills of self-regulation. We, we naturally learn these skills through doing it together with an adult who already has those skills. So that is a really, really natural, normal thing that moms or parents will do for their children. And something that we can also be doing as adults for our clients too. In fact, adults co-regulate other adults too. My dog helps me co-regulate, you know, he co regulates with me. So it doesn't have to be human to human like is, but it's, it's a very, very natural, [00:38:00] normal thing that a lot of us do intuitively we're not even aware that we're doing. But because of trauma, you know, our ability to self-regulate can be greatly impacted. And this is the case for me, you know, so I had a lot of challenges self-regulating into my adulthood, and I had to, I had to actively learn that as an adult. So, you know, so the first thing that I actually like to think about as speech therapists is, you know, what is your own ability to self-regulate? You know, checking in with yourself. What do you do when something stressful happens? How do you respond? Do you find hard to think? You know, do things kind of just become a mess? And how do you bring yourself back into that state of regulation? Are you able to do it yourself? Do you rely on someone else? You know, what do you do? How do you go through that process? Because first we need to become more aware of how we self-regulate before we can then go, okay, now that I know how I do it, [00:39:00] I can now think about how I can be co-regulating with my client who hasn't learned to do it themselves yet. So, yes, co-regulation.  Kate Grandbois: I love this idea. I think, um, you had said something earlier in the podcast that made me think of this too, this idea that, We are providing person-centered care. We are looking at the broader context of our students, clients, and patients. But we are also people in a therapy room, right? We are bringing humanity into our therapy room when we bring ourselves into a therapy room. And I think we have to give ourselves the, the head nod, the acknowledgement that there is a possibility that we're stressed or overworked or hungry or tired. Um, we have another podcast episode where we interviewed Dr. David Luterman on counseling, and he says that the best thing we can do for our patients is eat lunch. The best thing we can do is, you know, engage in some of that self-care so that [00:40:00] we are bringing our regulated selves into the therapy room. Um, and there, there's something really, really whole about that, that I, I really appreciate in, in. Just acknowledging that there are two people in the therapy room together. Mm-hmm.  Kizzy Searle: We're only human, you know, and we have our own traumas. We have our own stressful lives. Uh, and so we're not perfect and that's okay. Um, and we are going to need help and that's okay. We are going to need a bit of co-regulation ourselves and emotional support ourselves, and that is totally okay. And there are gonna be days where we can't provide that co-regulation, and that's okay too. Um, so, and, and I also realized I didn't actually say much about how you actually co-regulate, so I thought I'd. Briefly just touch a bit on that. Um, and, and that is through those kind of like with the mom and the child, you know, a lot of that soothing connection, um, bringing in that safety, bringing in that, um, that regulation component. It could be through movement, it [00:41:00] could be through gentle, you know, it, it could be through your tone of voice. But I definitely find that, um, you are much more likely to be successful in co-regulating another person if you've already developed that relationship with them. So hopefully your very first session or very first interaction with them won't be, sometimes it is, won't be at this incredibly, you know, dysregulated place. But, and, and you do get a bit of that opportunity to first really focus on that connection because, you know, we do all get taught about the importance of rapport, but sometimes we don't really get taught about why, why it's so important. And like you were saying before, Kate, it is from that neuro. Neurobiological level, it is just crucial. We can't do without it, you know, we need that connection to feel safe. We need that connection to learn more effectively, and we need that connection if we want to be able to regulate as well with another person. [00:42:00]  Amy Wonkka: I really liked the question that you had us all ask ourselves in terms of how do we regulate, how do we do those pieces for ourselves? Um, because it makes me think about, you know, professional development in a much broader sense, right? I think that when we think about professional development, we often think through this really narrow lens about those really narrow areas of the field that you talked about earlier. I'm gonna learn more about phonology, I'm gonna learn what, and all of those pieces are super important and we need to continue learning in those areas. But I think it also, you know, the questions that you're raising, I. Broaden that view a little bit further to where, you know, we are going to be better able to be there for our clients when we better understand ourselves and our ability to navigate these things ourselves and how that might look in the context of a therapy session. Um, so it's also interesting to [00:43:00] broaden that scope a little bit when we think about professional development and recognize that that's also has to do with us as the other person in, in the communication dynamic.  Kate Grandbois: I love that so much, and I wanna piggyback on it quickly to talk about the intersection between professional development and personal development and how you develop as a person will influence how you show up in your therapy room. Just as a quick example that I thought of while you were talking a personal example, I am a very different clinician now that I am also a parent. I am a parent of two school-aged children. I have a deeper understanding of what it means to be a parent, to have a busy household, to experience parental stress because it's real. And if anybody tells you it's not real, they're lying to you. So, and I can, I reflect on myself as a clinician before becoming a parent and the things I would say to parents not really having an understanding of what their, what their lives were like. So my personal development [00:44:00] has really had a big impact on what I bring to the therapy room. And I just love this idea of reflecting on your own personal development and whatever that is, you know, whatever that is for you as a person, but just considering how that influences how you show up in your therapy room. I just love this. A brain's exploding all over the place. It's amazing. um, I wonder if you could tell us a little bit about the bottom up brain-based framework. What, what is that? I'm imagining now another pyramid somehow maybe flipped upside down, but, but can you tell us a little bit about  Kizzy Searle: that? Yes. So I, I, um, that, that was the, the framework actually. Um, so it is because there are, I guess, Lots of different frameworks out there. I, I thought I'd use that term. But basically the three Rs from the neuro [00:45:00] sequential model is that bottom up base. Yes, whatever I call it, bottom up brain-based framework. So basically, yes, it's because it's about all about the brain, um, based in how the brain works and it's bottom up because we start with that regulation part of it. That doesn't mean to say that it's, it's not a like a step one, step two, step three formula that we have to follow. It's really individual. So it really depends on who we're working with at the time, what the current situation is. You know, I will always do the relating section, so that connection part I will always, um, work on regardless. But I don't always have to be really working on the regulation. You know, sometimes I'm working really closely with the occupational therapists and psychologists if they're available to figure out some really good sensory processing strategies or. Practicing some of those regulation things that I'm aware of that, and that the client understands how to do them with me [00:46:00] so that I can basically prompt them a bit if they're needed. But other times, you know, I'm really just realizing that I can, through my, um, through thinking about safety with them. So thinking about the way I'm presenting myself, my facial expressions, my volume, you know, how distant I am or close to them. I am physically thinking about the actual sensory environments of space around me, how private it is, how it's set up that I can already pro be providing them with enough for them to feel regulated so that we can focus more on that relating aspect, which I, where I do a lot of creative like play. Yeah, it, it's fun. It's a, it's about being creative. There's no right or wrong. It's really flexible. It's obviously really person led. And then when we can, we're building in all of those really, really, um, Skill focused elements of speech therapy.  Kate Grandbois: Thank you for clarifying that. That was really helpful. [00:47:00] Um, in reading some of the notes that you submitted before we recorded the podcast, you list some psychosocial and you, you list some other factors that are, that can be related to trauma. I know we've reviewed a lot of them. One of the notes that you have here is cultural influences, and I wonder if you could take a second to talk about the intersection between, um, cultural influences and a trauma informed lens in therapy.  Kizzy Searle: Mm, yeah. Great question. Um, so I, I guess. Because a trauma-informed approach is really about, you know, it's, it's a strengths-based approach. It's about following the person's lead, you know, meeting them where they're at. Sometimes I just, this is just the example that I can currently think of, but sometimes I'll engage with a client and their family where they're, they really want a medical model from me. [00:48:00] You know, they, they really want me to be the expert and to tell them what they're supposed to do, what their goals are, and how I'm, I'm, you know, I'm telling them what to do, basically. And I find that sometimes it's not appropriate for me to, to jump into my, well actually, you know, I use a strength based client, you know, I client led approach and, and all of these sorts of things because they're not ready for that. You know, their, their culture and their understanding of the d the relationship between professionals and clients is totally different to the way that I like to work. And if I like, push them to try to work in the way that I want to work, what I'm instead doing is I, I'm no longer being respectful of their diversity. I'm no longer, um, giving them that choice and control. That is another. Those are some aspects of a, of trauma-informed practice principles. Um, and, and therefore I'm kind of leaving them behind. I'm dropping them a little bit. And this is also the case when I come across families who [00:49:00] sometimes think very differently to me about the presence of trauma, about the impact of trauma, and also about neurodiversity. You know, sometimes we can have very, very, very different opinions and I might really, really disagree and in fact might even be angry internally. But I will still. Respect them, their, their opinions and meet them where they are at, and slowly walk to work towards a bit more of a balanced approach between the two of us. And that's because of two reasons. One, of course, as I mentioned, that respect of diversity and different belief systems, but also because what we know about trauma and, and you know, again, you never know who's been through trauma and who hasn't, but there are strong defense mechanisms that we have as a result of trauma, and they are there to protect ourselves from what we cannot basically handle. You know, all of those intense emotional thoughts, perhaps as guilt, you know, perhaps as fear. And we can't handle them. We basically develop these [00:50:00] defenses like beliefs, um, like behaviors and, and different things that help protect our mind from what we can't handle. So I don't want to be shaking a person up and trying to remove them of their beliefs and what they're clinging to, because I don't know what I'm potentially doing to them by taking it away from them. So, I hope that answered your question.  Kate Grandbois: It did, and it, it brought to mind something that I, I learned on this podcast in the last 18 months or so, which was the word, uh, cultural humility and bringing, again, this intersection of personal development, professional development, taking a moment to enter a. An interaction with humility, with cultural humility to center someone else's culture. Um, and I think that's, that's also a very personal journey in terms of how you consume information about different cultures, reflecting on your own culture or your own privilege. Um, and [00:51:00] so I, I, I really appreciated the way you described, making sure that you're centering the other person throughout the entire interaction. That was really helpful. Thank you.  Kizzy Searle: Actually that, that made me think of something else that, um, I've been on my own learning journey about, , you know, just because I believe something to be true or to be right doesn't actually mean that it's, you know, there's nothing wrong with me totally believing in something and totally believing it to be the truth and, and the, and, right. But that, that doesn't mean I have to enforce it on anyone else. And that doesn't mean that anyone else has to believe that either. And I find that, you know, even though we get taught to, to identify our biases and think about how they might be influencing on others, it's not always so simple because our biases are unconscious. We're not aware of them until we're made aware of them. And often that happens through. Just coincidence, you know, just through, uh, maybe a massive conflict that we suddenly realize, oh, hang on, the rest of the world doesn't think the way that I think. [00:52:00] Um, and so something that I like to share with others is when you are trying to become a bit more aware of what some of your biases might be and how they might be influencing on your interactions with your clients and how you're potentially responding to them, to, to basically try to notice whenever you are, you are getting that weird feeling of, um, sometimes it's like a disdain or it's like a bit of an anger or a hatred or a, or a, just a weird feeling of rejection for something that someone has said and you're not really sure why. You know, if you can happen to catch latch onto that, that weird feeling that you get when someone says something that might be your body hinting to you that you have a bit of a bias in this area. And it could be something to explore if you feel your, it's safe enough for you to explore, because sometimes those feelings can be a bit intense. Thank you.  Amy Wonkka: I love that. I also really appreciated, um, in your previous example that it incorporated, you know, uh, a [00:53:00] family system, right? Because depending upon the age group who you're working with, you may have a client who's coming with their care caregivers or their spouse. Um, and I think being aware to have this expanded perspective in this expanded model, not just for our client, but for the people who are part of their communication circle, um, is also really helpful. Um, And there must be, I mean, not that you're having the same depth of relationship with those caregivers in broader circle, uh, but I think in your interactions with those people, are you also sort of applying the same  Kizzy Searle: approach? Yes, I am. That's a great question. I apply it to absolutely everyone I work with as a speech pathologist, so including, you know, other professionals as well. I'm also thinking, you know, sometimes, so parents, other professionals can sometimes also be really dysregulated. It's just that because they're adults, they're better at masking [00:54:00] it. So sometimes when I find I'm trying to have a conversation with them and for some reason we're just really not on the same page, or I've said something a few times already and I don't know why they, there seems to be a bit of anger or something like that, you know, I'm thinking, hmm, maybe they don't feel too safe at the ma moment. Maybe they're not. Feeling very regulated at the moment. Maybe they've had a past experience with another speech pathologist who has been really quite rude to them and or, or they've just for some reason had some major misunderstanding and I'm now coming in without that information and that context, and so I need to take a step back and be like, hang on a minute. Can they maybe also benefit from a bit of co-regulation? I'm also checking with myself, you know, is my heart a bit elevated right now? My also son to engage in a bit of a conflict, so maybe I need to take a step back and have a bit of a breather. And then really just focusing on the connection as well. Sometimes I'm actually spending way more time with the parents than I am with the client because I realize that in quotation marks, you know, the, the real client [00:55:00] is kind of the parent and not, not the child because the child's already doing as much as they can and, and perhaps it's more about me really getting a better understanding of what's happening with the parents and what supports they need so that we can then be working through them with the client. I love all  Kate Grandbois: of this. This has been so incredibly helpful. We've covered so much material today. One thing that we did forget to mention is that you've provided a free resource for all of our listeners, um, and it's, we'll be available for download on our website. There will be a link to the course in the show notes. This is a material that you've created to help put some of these things into the therapy room to help a clinician bring some of this material with them into therapy. So thank you so much for creating that for us. I know you have a lot of other additional resources on your site. We will put some links in our show notes to that as well in our last few minutes, do you have any parting words [00:56:00] of wisdom for our, for any speech pathologist or special educator who might be interested in learning more about this or is just beginning their journey with trauma informed care? I would say  Kizzy Searle: that the. Only thing, um, that I wanted to perhaps emphasize is kindness towards yourself. You know, because we live in a day and age where we are constantly bombarded with information. There are all of these movements happening around us, and we are only human. We can only learn what we're able to learn at the time that we're learning. And we've just got, we've got the rest of life to deal with too. So, you know, there is no pressure to be walking away from this podcast episode thinking, right? Oh my gosh, I've gotta suddenly completely change the way I'm working. Or I've gotta rethink, you know, how I'm thinking about the client and think about the regulation and the relating, and then all [00:57:00] this kind of stuff. It's, it's a lot to take on in particular, if this is maybe one of your first interactions with this way of thinking and working. Um, and so I totally understand, you know, just, just taking on one thing, which is too, To reevaluate how, how much time you spend just for yourself, because to do this work long term sustainably in the way that I've been describing, you do really need to be thinking about how much time you are allocating to yourself, which I know is incredibly difficult to do. But the more that we can try to find some regular time to ourselves just for ourselves, you know, whether it be on our own or with an emotional connection where we can receive some of that co-regulation, the more space we're gonna have to actually be able to think about some of these things that we've been talking about and therefore implement them. So I guess that's the only thing that I would say. I really don't want anyone to walk away [00:58:00] feeling horrible about the way that they work and guilty that they haven't done this or thought about this already. Because, I mean, I went through a massive wake up call myself before I was able to change and, and think about these ways of working. And I, yeah, I just really don't want anyone feeling. Bad. That was  Kate Grandbois: such wonderful advice. I appreciated that so much as a human. Thank you so much for sharing that. Thank you. You've been just such a wonderful guest.  Kizzy Searle: Thank you. Um, and, and also, so just one thing I thought of, um, you are very welcome to get in touch with me. By the way, anyone listening to this, I love questions. Please feel free. You know, um, Kate's already mentioned my, um, my Instagram, so I'm assuming they'll be in the show notes. So you'll be able to go take a look, send me a message, or of course I have my website too, where you can just, you know, fill in the form and, and reach out to me there as well. Um, and hopefully I'll be able to come out with some additional, you know, webinars or [00:59:00] resources and maybe an online course, fingers crossed, um, that you'll be able to access. Thank you. That you'll be able to access in the future to further the learning. Fantastic. Thank  Amy Wonkka: you so much, Kizzy.  Kizzy Searle: Thank you. No problem. Thank you for having me. I, I was a little bit starstruck honestly, when I got the email that I would be on this podcast. Oh man.  Kate Grandbois: Don't know how much of a mess I am. That's, that's,  Amy Wonkka: that's what that means. We're all a mess and it's  Kizzy Searle: okay. Exactly, yes. Now  Kate Grandbois: there's um, there's modeling, compassion and kindness. There you go. Bringing in full circle. Kizzy, it was so great to have you. Thank you so much for being here.  Kizzy Searle: Thank, thank you so much. Honestly, I've really enjoyed this conversation. I really appreciate you having me on your show. Sponsor Outro Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this [01:00:00] 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 March 27th, 2023. The podcast episode is offered for .1 ASHA CEUs. This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate 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 nerdcaster10. A link for membership is in the show notes.  Episode [00:01:43] Kate Grandbois:  Hello everyone. Welcome to today's episode. We have a really, really interesting topic today that I am really excited to learn about. As our expert guest, we have Ginny Weill joining us today. She is a speech [00:02:00] language pathologist who works in a nicu, um, which is a setting I have had the pleasure of never setting foot in because I have children, and my children were never in the nicu So welcome, Ginny.  [00:02:11] Virginia Weill:  Thank you. Thank you so much for inviting me. I'm excited.  [00:02:15] Kate Grandbois:  I'm so glad that you're here. This is gonna be great. Um, I wonder if you could tell us a little bit about yourself before we get started.  [00:02:23] Virginia Weill:  Sure. So I, um, grew up in Maine, so I'm a New Englander. Um, I went off, I did, you know, most of my schooling undergrad here in New England, and I thought for grad school, let's get outta New England, go south. So I went to Virginia. Um, and then I realized there that I missed the fall. I missed New England, I missed the snow. So, um, when we had an opportunity in grad school to start doing clinical placements, I found, you know, my two up in New England at hospitals. Um, and that's kind of how I found my journey back up into this area. Um, so I [00:03:00] actually worked in Connecticut at a standalone pediatric hospital there for about eight years. Um, I did my clinical fellowship year there. I did a clinical placement there and they were gracious enough to, uh, invite me to stay a little longer. So I started out in outpatient therapy actually. So, you know, doing your typical autism AAC voice, um, articulation. And then slowly as I became more competent, I got invited to start to do some more inpatient work. Um, so I started to see more of the medical side of things, more of the medical side of patients and how a speech pathologist can help these kiddos, um, in the hospital. Um, and then I started doing more swallow studies. So I did mbss, the modified barium swallow studies. I started to do fees. Those are the fiber optic endoscopic evaluation of swallowing along with the otolaryngologists or the ENTs. Um, I started, you know, throwing myself into clinics and being a standalone pediatric hospital, we had countless [00:04:00] clinics. So I did aero digestive clinic, um, cleft pallet clinic, voice clinic, fees clinic, and even feeding team. Um, and then in my last few years there I was, um, I started to get into the nicu and then, um, you know, about four years ago, this hospital that I'm currently in had a nicu speech pathology position, stars aligned and I actually was able to move back home to Maine. So I've been here at the hospital that I currently am at for a little over four years, where I'm focused more in the nicu. But of course I still do, you know, countless swallow studies. I do fees with our ENTs. I do a couple clinics here, the Aero Digestive and the Cleft Palate Clinic. Um, and then I starting to focus more on cardiac and aero digestive patients. Also on the pediatric floor. So like outside of that NICU group, but just on pediatrics. Um,  [00:04:56] Kate Grandbois:  so you really went from an [00:05:00] outpatient SLP in a hospital, really immersed yourself into the medical world. I mean, I am not that familiar with what happens in a nicu. I'm about to learn from you, but I imagine it is a much more intense medical environment when compared to, let's say, an outpatient AAC clinic, which is where I was. [00:05:16] Virginia Weill:  110%. And I think, you know, all of the experience that I had up until that point prepared me for the high intensity of the nicu. You know, if I had just gone from outpatient or the school systems, if I had a placement in, I don't think mentally I could have handled the nicu. I think I had, you know, having all those years of experience, um, kind of preparing me and getting me, getting my feet wet and how do I talk to a physician? How do I argue with a physician respectfully? Um, how do I talk?  [00:05:48] Kate Grandbois:  Oh, I wanna hear that story. Oh gosh, I think we all wanna hear that .  [00:05:54] Virginia Weill:  Um, but yeah, it really prepared me for the nicu, so I'm very thankful for all the experience I had at that hospital. It [00:06:00] really, um, prepared me for my love. And my love is the NICU and the families and the patients, and. [00:06:06] Kate Grandbois:  Well, I can't wait to hear more about it. Before we get into all of the good stuff, we do have to read our learning objectives and financial and non-financial disclosures, so I'm gonna read through those as quickly as I can to get them over with, and then you can shower us with all of your knowledge and teach me everything about the nicu. All right, learning objective number one. Identify three roles of the SLP in the NICU. Learning objective number two, identify two reasons why thickening with cereal is not recommended in the NICU, and learning objective number three, identify two possible etiologies of strider in an infant disclosures. Ginny Wild's financial disclosures.  [00:06:43] Kate Grandbois:  Ginny receives a salary working in a NICU as part of a level one trauma hospital. Ginny is a member of Asha Sig 13. Kate, that's me. My financial disclosures. I am the owner and founder of GrandboisTherapy and Consulting, LLC and co-founder of SLP Nerd Cast my non-financial disclosures. I am [00:07:00] 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. All of that stuff is behind us. I'm here. I'm ready to learn from you. I'm very excited. Why don't you start off by telling us a little bit about. What it is, like the first learning objective is there are three roles of the SLP in the nicu, and I can only really guess what one of them is. So I'm really excited to hear more about what that is actually like for you on a day in and day out basis. [00:07:40] Virginia Weill:  Sure, of course. Um, so before I get into that, um, exactly what my role is in our nicu, I just wanted to talk a little bit about what the NICU levels are. So there's not just a nicu, there's actually four different levels. Um, and the one I work in is actually, well, we have kind of two, A level two and a level [00:08:00] three. Um, so a level two is just a special care nursery. We call ours a continuing care nursery or ccn. Um, this is intermediate level care for moderately preterm infants. Um, they maybe need a little bit of respiratory support, mostly working on feeding and growing. Um, and then our level three nicu, which is really our NICU here. Um, high level diagnostics, um, intensive care, um, a lot of surgical subspecialties for cardiology. Um, and the level four, which is not us, but like for example, Boston Children's is a level four and they can do things like ecmo, the um, mechanical oxygenation. So here in our NICU at our level two and three primary job, oral stimulation, um, a lot of times we'll do oral stem on our trached, invent kiddos that are not necessarily safe to orally feed yet. But we wanna keep positive learning experiences and positive oral experiences, um, frequent throughout the day. [00:09:00] Um, we do, this is a lot feeding and swallowing assessments at bed, at bedside. Um, we can dive into a lot more of that later. We do our modified barium swallow studies or video fluroscopic swallow studies. Um, we do fees with ENT. Um, we work a lot with communication and cognition. Um, specifically right now we have a lot of trached and vent kiddos are a little bit older, and so we're doing a lot of communication language, cognition and, you know, collaborating with OT and PT during those sessions. Um, and then this is day in and day out collaboration with families and the team. Um, they listen a lot to our recommendations in terms of whether we wanna get other people involved, like the pulmonologist, the ENT, the gastroenterologist. Um, and then another thing that we do is education. Education for the nurses. The physicians, a lot of the families. Um, and yeah.  [00:09:56] Kate Grandbois:  Okay, so you just blew my mind. I would've said, uh, [00:10:00] feeding and swallowing . That was the one thing I was pretty sure a speech pathologist did in the nicu. I have a lot of questions. I'm wondering what oral stimulation looks like. What does that, what do you do? What does that look like?  [00:10:11] Virginia Weill:  It's a fancy term for, for example, offering a pacifier, offering a pacifier dipped in the mother's milk or in formula. Um, we do a lot of like, uh, perioral stimulation, like massage to the cheeks, to the chin, to the lips with glove finger to the forehead. Miss that specifically is for the kiddos who have had tape on their face a lot, have had like the masks for breathing, and they just are so, um, hypersensitive, hyper aware of anyone that touches their face. They have this knee jerk reaction and so we kind of have to calm those senses, um, so that they can tolerate things around their mouth and their face again.  [00:10:54] Kate Grandbois:  I feel like before we get any further, I wanna address a, a thought that I keep having, [00:11:00] which is that these are tiny, tiny humans. I mean, it, it's something when you just said, I don't know if anybody's watching this on YouTube. They probably saw me frown when you said they've got tape all over their faces. Cuz I'm imagining this, you know, little preemie, these little babies with tubes and tape. I mean, that, that must be challenging.  [00:11:17] Virginia Weill:  Yeah, it's very hard. And you know, the nurses do such an amazing job with, you know, two person cares to really try to calm the one nurse will calm the baby and really contain them and then the other nurse, you know, does the feeding tube or the diaper change or you know, whatever medically they need to do. But it's so important and our NICU was so great at really making sure and trying to protect the baby from all this noxious stimuli.  [00:11:42] Kate Grandbois:  And I love the idea of considering, you know, on this show we talk about person-centered care all the time, um, and really bringing an individual's values or a family's values into our care. So when you're talking about trying to create positive [00:12:00] experiences and taking into consideration the level of sensitivity on the face where they, that might not be a critical piece of keeping them alive, per se, right? Or a critical piece related to preventing aspiration.  [00:12:16] Virginia Weill:  But it's a critical piece of their quality of life, their tiny little faces, because they're still creating, I mean, their brain is still growing so much and creating all these different pathways and every stick, every tape removal, every gag on the pacifier, every cough on a bottle, you know, that's gonna set them up for those positive or negative experiences down the road, or, you know, it's so every little thing counts. And so we have to do everything in our power to protect them.  [00:12:42] Kate Grandbois:  Okay. So going back to, um, the different roles of the SLP, so you also mentioned collaboration and education. I have to assume that this is a huge part of your job when someone so little is so medically fragile.  [00:12:59] Virginia Weill:  [00:13:00] Absolutely. So, um, we, as the therapist, we get invited a lot to the NICU skills fair. So from an education for the nurse standpoint, I mean, the nurses, even if they've been there decades, they still learn something new from us. You know, it's still beneficial for us to update them on the newest research out there in terms of nipple flow rates or, um, formulas that are no longer existing anymore. Or, you know, positioners, you know, for OT and PT. So it's, you know, every day we are talking to nurses and, you know, obviously the families can get into that later. Um, on the importance of reading the baby's feeding cues. If they're sleeping, you let them sleep. You don't need a stick of bottle in their mouth. Um, why it's important not to do, you know, popsicles or lollipops with trach kids. You know, why it's just as important and to do the pacifier dip of the mother's milk, you know, so it's, it's education every day to ensure the best care for these little ones.  [00:13:59] Kate Grandbois:  And collaboration too. I'm [00:14:00] sure there are a lot of critical decisions being made in a moment's notice, um, information from all your different colleagues, not just nursing, but you've, you've listed so many already, cardiology, pulmonology, I mean, I'm sure these little babies being in the NICU have many people on their medical team, and I'm sure you have to do, you have to be a really effective communicator and collaborator to facilitate those decisions. [00:14:26] Virginia Weill:  Absolutely. And, and now that babies are being born sooner and sooner, earlier and earlier, um, you know, pulmonary, a lot of them are on oxygen pulmonary involved a lot from the beginning. Um, and you know, the impact of breathing on feeding, it's huge. And so communicating with the pulmonologist on kiddos that we think are aspirating. When do we do swallow studies? When do we thicken? Um, and, you know, the cardiac babies, you know, if they go in for surgery and maybe they have a vocal cord paralyzed afterwards, depending on where the, the surgery was, you know, getting ENT involved to take a look. And so it's all [00:15:00] that. You know, communication back and forth. What's going on in your head? This is my plan. What are your thoughts on my plan? Um, so it's always, you need to always have good communication skills and, and be willing to listen and compromise too.  [00:15:14] Kate Grandbois:  Well now, you know, I'm gonna ask the question that I wanted to ask before. How do you disagree respectfully with the physician? [00:15:21] Virginia Weill:  Oh, um, actually one of the case studies that I wanna talk about, there was a little bit of a disagreement. Um, I, what I do is I verbalize my most up to date evidence based practice, what I feel is gold standard. Um, I usually explain why I am not recommending what they would like me to do, um, and then I leave it up to them to make the choice of what to do. Uh, it's, it's, it's challenging and, you know, sometimes it is, like, for example, right now we have a kiddo in the NICU and the doctor really wants to use cereal to [00:16:00] thicken. And I really don't want to use it be, but she's,  [00:16:03] Kate Grandbois:  oh, because of that second learning objective we haven't gotten to yet. Why not to use cereal? [00:16:08] Virginia Weill:  But she wants to use it because guess what? It's full of carbs and it's gonna make the baby gain weight. I get it. But at the same time, we have to protect her lungs. She's still on oxygen. She was on a lot of oxygen a week ago. So it's, what are we gonna do? So tomorrow we're gonna sit down together and we're gonna have a discussion with the, um, registered dietician, the physician and myself and, and problem solve and see how we can make sure this baby gains weight for brain development, but also protects their lungs. So,  [00:16:37] Kate Grandbois:  holy moly. So, I mean, these are really, really heavy decisions. Not only are you talking about potentially life altering clinical decisions, but this is also, again, just a tiny little person. I keep thinking about that. [00:16:48] Virginia Weill:  I know. Yeah. So it's, you know, it's all about communication and, um, communication and education. I feel like. [00:17:00] Because that's the only way you can communicate effectively is to educate them as to why you're recommending what you're recommending.  [00:17:07] Kate Grandbois:  Right. Okay. Well, out of all of the roles that you've mentioned, which was, which was many, I wonder if you could tell us a little bit more about the feeding and swallowing piece and lead us into that second learning objective and why you're gonna go into this meeting tomorrow about not thinking, not thickening with cereal. [00:17:25] Virginia Weill:  I would say currently right now, the, the earliest baby we have born, I think was maybe 23 weeks. Right. 23 weeks. Wow. To 40 weeks. Some of them are born at term, but they have, you know, certain diagnoses that place them at risk for, um, feeding issues or breathing issues. Um, so yeah, so I, you know, I start to see babies typically right now when they start to bottle feed our breastfeed. Usually the lactation consultants, um, see most of just the solo breast feeders [00:18:00] or chest feeders. Um, you know, if they have concerns about aspiration they'll bring in the speech pathologist, but most of our kiddos are bottle feeding that I specifically see. Um, and if they're born this early, they don't have that coordinated suck swallow breath that they need for air way protection. And so my role is to basically teach that. Teach that by choosing the right bottle, by choosing the right nipple flow rate, um, choosing the right position that they're fed in, you know, cradle versus side lying on the left versus on the right. Um, you know, pacing them, meaning, you know, emptying the nipple so that they cue the baby to stop and catch their breath. Um, so this is what I do day in and day out and it's a lot of education for the families. It's cause new, cause a lot of families have babies born full term first and then this now a pre, and they're like, I don't know how to feed a kid. My baby, you know, this is how I fed him before. What do you mean sidelying? [00:18:56] Kate Grandbois:  So I was just having these thoughts while you were talking [00:19:00] because I have two babies. I had two full term babies who never visited the NICU and feeding my babies, I breastfed my babies, but feeding them was one of the most stressful experiences of my early parenting life. Now they're older and they give me a whole other headache of stressful problems, but this is a tremendous stressor on these families. I have to imagine, I'm imagining myself in that position having just physically experienced birth, or maybe they've been there for a while and you're healed a little bit, but even so, you have got a sick, a sick baby in the nicu that the counseling piece for you must be critical. It must be a huge part of what you do. [00:19:50] Virginia Weill:  It is, and you know, it's the nurses, you know, when the babies transition from our NICU into our continuing care nursery, the nurses and the NICU almost [00:20:00] say like, it's to graduation. It's closer, one up closer to going home because we kind of label our continuing care nursery. That's the feeders and growers. Those are the kids that are learning how to feed and then they'll go home. And the nurses and even our, the, the feeding therapists, we say to the families when we meet them, not in like a pessimistic, you know, glass half empty way, but feeding is what's gonna keep you here. It is the hardest thing to learn because the baby is in control. The only way you can speed up your discharge date is by just reading your baby's cues. And even if that's letting the baby sleep through a care time or sleep through a feed. You are still helping them get to that end goal of going home. And I think that's the hardest and most frustrating thing, certainly for these families who have been there since 28 weeks and now their babies are 38 weeks and the moms and dads have been in there every single day. [00:20:54] Kate Grandbois:  Oh my gosh. The stress. I can't even, yeah, I mean, you're, you're, you're not sleeping. [00:21:00] You're not even in your own home. You may have had to take extended or unpaid paternity or maternity leave. There are so many stressors that go into those first few weeks of parenthood alone. Um, so I, I, I can't imagine as the professional, as the speech pathologist focused on feeding, knowing that that is the root of what they need to do in the nicu or to, or to, as you said, quote, graduate from the nicu. That's a tremendous, that's a tremendous responsibility. Yeah.  [00:21:32] Virginia Weill:  And I try to, you know, say to the families, I try to be gentle, you know, and just provide that education. Give them the handout, you know, once your baby starts to feed in the nicu. But if they don't and they start to push their children, or they, you know, aren’t respecting the baby's cues and, and forcing that bottle into their mouth, that's when I start to try to scare them almost because I want them to know that, like we've talked about before, every little thing you do now you're gonna set them up for either [00:22:00] success or failure with feeding down the road, being a picky eater,  Kate Grandbois:  no pressure.  Virginia Weill: Yeah. Right. I mean, but that's sometimes what parents need to hear because we, in the medical profession, I feel like sometimes we talk so softly, we talk very gently because we don't wanna scare people. We don't, cuz you're already in a stressful situation. But when these little ones lives and feeding, you know, trajectories are in the balance. You do want the best for them. And if the family isn't listening, then you have to say, Hey, do you want a clear communicator? Yeah. Do you want your kid to be a picky eater? Do you want your kid to go home with a feeding tube? You know, this is, we're trying to avoid this, so you need to listen and follow these recommendations. Um, we don't encounter that too often, but unfortunately, you know, it does exist.  [00:22:46] Kate Grandbois:  It does happen. Well, and, and as the clinician. Putting on your counseling hat on and knowing when to be direct. Knowing when to do active listening. Yeah. Knowing when to softly educate, knowing when to let them have a grieving, stressful moment [00:23:00] because they're new parents under a lot of duress. I feel like those are all the counseling skills that we need, um, that we don't necessarily get in graduate school. So I always love, I feel like counseling is such a huge part of our jobs across the continuum of scope of practice and speech pathology. So I always like to just pause and highlight that for a second. Um, I wonder if you could, just thinking again about our sec, our second learning objective and the thickening, the with cereal, how do you, how do you get there? I assume you mentioned bedside swallow, you mentioned mbs. I assume that there is an assessment or procedure that happens first.  [00:23:36] Virginia Weill:  Yes, of course. So, um, I actually have a little case study if you would be okay with me kind of going through that, like how we in this kiddo, we actually, um, thickened, um, after a little discussion with the medical team. Um, so, let me give you a little background here. So this patient, this baby, um, was born late preterm and at outside hospital. She was transferred to us on day of life [00:24:00] three for prematurity, but also desaturation specifically with feeding. Um, she also  [00:24:06] Kate Grandbois:  desaturation, what do you mean, desaturation?  [00:24:09] Virginia Weill:  So the oxygen levels go down.  [00:24:10] Kate Grandbois:  Oh, oh, uh, oxygen desaturation. Yes. Okay.  [00:24:14] Virginia Weill:  Um, so we call them dsat. So, but also saturations. Uh, she also had hypoglycemia at birth and needed some oral glucose gel. So for a feeding therapist, um, anytime a baby has difficulty managing sugars or the mother was a diabetic during pregnancy, um, sometimes that can impact, um, brain development and the impact on feeding may delay their feeding skills a little bit. So that's also a very important red flag for me to kind of think of in terms of chart reviewing before I go see this kid. Um, she started developing desaturations, requiring a little bit of oxygen at the outside hospital. And then once she was transferred to our nicu, we quickly weaned her down to room air, which is great. It's a good sign. Um, and then the nurse reached out to [00:25:00] me about the concerns with feeding. Um, luckily at our hospital and our nicu, um, we get automatic orders. So anytime a baby's admitted, uh, either in our hospital or from an outside hospital, we get automatic orders and it's our decision of whether we see them that day or the baby may be too young or too medically complex. So we kind of, we wait and defer until they're more appropriate. Um, and of note, this baby did not have a nasogastric tube in place, an NG tube, um, which typically a lot of our NICU kiddos get one placed just to start fluid and hydration. Um, so I get called up to go see this kiddo. Um, I feed her with, so our hospital, our NICU carries a Dr. Brown's bottle system, and we have all the nipple flow rates out there for Dr. Brown's. So I started her with the Dr. Brown's preemie. Um, because of her age, I felt she was appropriate and should probably be able to handle this flow rate. However, she immediately started coughing. Her face turned color [00:26:00] to blue gray.  [00:26:01] Kate Grandbois: Oh my gosh, I'm already having so much anxiety for you. This is what, just what you do on a regular basis. I'd be so nervous. [00:26:06] Virginia Weill:  I know. It's, it's, and the parents are standing there too, so it's, you know, you have a crowd. The nurse is standing there. Cuz you know, as a speech pathologist, we are the experts in feeding and swallowing. We are.  [00:26:19] Kate Grandbois:  We, I'm not, yeah. ,  [00:26:21] Virginia Weill:  they're watching, they're seeing what I'm doing, you know? Right. Um, and of course oxygen drops. She has desaturations, which would be associated with that color change. So I stop and I say, all right, let's try the ultra preemie. So Dr. Browns makes an ultra preemie, which is pretty slow. Um, but when I gave it to her, she was inefficient. She couldn't get anything out. So she was sucking like eight times before she could swallow, which. It's not, that's not efficient, it's not functional for a baby. So I went back to the preemie. I tried to do strategies like nipple half filled and pacing, didn't work, coughing, changing, clear signs of aspiration and distress. So I stopped the [00:27:00] feed and I said, I'll come back at the next one and I'm gonna see if I can find a different bottle system that hopefully the flow rate is between the ultra and the preemie. So we're hitting somewhere in the middle. So that was the plan. So I come back, so this time I'm, I try all the Avid bottle system. So they've come out with a new nipple flow rate and, um, we're still all the feeding therapists here, still trying to figure 'em all out. But I try the two slowest flow rates and she still gulped, face turned color desaturating. Um, so I stopped that, went back to the preemie again, tried to pace a little bit more, like literally every suck. I was giving her a break to catch her breath. Still coughing, oxygen dropping. So I actually turned to the family who witnessed all of this very stoically and I said, you know, I am gonna talk to the doctors, but I am gonna recommend consideration of a little feeding tube in the nose for just, you know, short term as she continues to grow and [00:28:00] her brain continues to develop. I said, she's still a little early, she may just need some more time. And they were totally on board.  [00:28:07] Kate Grandbois:  So as you're going through this process, at what point would you recommend an mbs?  [00:28:14] Virginia Weill:  So this kiddo, if I wanna say she was 36 and change, not even 37 weeks yet. So typically at our hospital, we don't recommend an MBS until about 38 weeks. Now, of course, Our kids, yes. Because we want them, we wanna maxi, I mean, it has radiation and we wanna maximize. Their neurodevelopment time so that when we finally do the modified, we're not setting them up for, you know, for failure in the sense of, uh, false positives for aspiration, or they still are so discoordinated because they're just still too early. Like we know that they're not gonna be coordinated and they're not gonna do well in terms of airway protection. So that's why I did not jump on the modified barium swallow study. So I [00:29:00] went out to the team and luckily they were rounding right then and there, and I told them everything. I saw what I talked to the family about, that I recommended the ng, and the doctor said no. And I said, oh, oh, okay. Well we can't continue to feed like this. It's not safe, you know, airways,  Kate Grandbois: why did they say no?  Virginia Weill:  Well, because they wanted to try thickened feeds. And I said,  Kate Grandbois: here we go.  Virginia Weill:  Uh, yes. And I said, thickened feeds for a kiddo under 38. Typically we don't recommend, just like we typically don't rec, recommend a swallow study for under 38 weeks. And they said, well, she's showing enough clinical symptoms at bedside that, uh, she's aspirating in, that she's in distress. So wouldn't she show those same signs with thickened if she were aspirating thickened? Because what I said is the, you shouldn't, if a, if a patient, whether it's an adult or a baby, is showing signs of aspiration, we don't, with thin liquids for example, we don't know if [00:30:00] we give 'em thickened. They may silently be aspirating thickened. So that's why we need to test using an instrumental swallow study to make sure that they're actually safe on the thickened. And certainly with these babies, a lot of times they don't have the mecca, the cough mechanism yet to tell us. That they’re aspirating, right? [00:30:17] Kate Grandbois: Tiny little ribs and they're tiny little muscles.  [00:30:20] Virginia Weill:  And the lor, was it the laryngeal? The cough reflux doesn't even develop until past 40 weeks. So if this baby is younger than 37 and coughing with feeds, she's probably aspirating a lot. But that's why I said I think we should hold off on thicken and just give her a few days with a feeding tube. And the team still wanted to do thickened. So this is a perfect example of, I said my, what I knew was evidence based, correct? Um, and I explained my rationale to why, but I also saw their side of, well, if she's showing such gross signs of, of aspiration with thin, wouldn't she show it with thickened? [00:31:00] Which I, I can't really argue with. I can say, actually, you're probably right. My gut is that she still would cough, um, or desaturate, or her face would change color. So I said, all right, at the next feed, I will try thickened feeds. And it was not cereal though. It was a, a formula that we use that's naturally thicker and she did great. I know. Kate Grandbois:  It has a happy ending.  Virginia Weill: She did a happy ending. I'm so glad to hear that. So that's, that's, I think the, the, the piece here is yes, you have disagreements with people and you may be wrong and they may be right, but at the same time you learn from each other, you know, and the patient really is, is the reason why you do all this and who you're protecting. And so as long as she looks safe and she doesn't drop her heart rate, or doesn't drop her oxygen, and she's taking her volumes and she's growing that I'm happy. And the medical team is happy. Right?  [00:31:55] Kate Grandbois:  It's a great example of leaving your ego at the door because you're not there to have an [00:32:00] argument or a pissing contest with another colleague, you're there in your case to save a little baby. Right. And you've mentioned a couple of reasons or a couple scenarios when you wouldn't offer thickened liquids. So if they're under 38 weeks, um, you mentioned that it can create distress with, with breathing or with the lungs. Um, and it's not indicated for other pulmonary reasons, but what's with the cereal? Why were we thickening with cereal?  [00:32:26] Virginia Weill:  Yeah. So back in the day we did rice and oatmeal all the time. And then, you know, arsenic became the big thing with rice and so everyone went to oatmeal. But, um, the big thing is a lot of babies in the nicu, um, their parents are able to either purchase donor breast milk or they're able to pump themselves and have breast milk or chest milk. So we can't thicken breast milk with cereal because of the amylase enzyme breaks down the cereal or the carb. In the mixture, [00:33:00] which then reduces the effectiveness of the thickened liquids. Does that make sense? And  [00:33:05] Kate Grandbois:  that's unique to breast milk and chest milk.  [00:33:07] Virginia Weill:  Just breast milk and chest milk. Yeah. Oh man. That's like a cereals of carb, and so that enzyme breaks it down. So literally we've seen it when I first started, you know, they would do it a little bit more often, and you would see the breast milk and the cereal, and then thick, and then all of a sudden in five minutes, thin all broken down. Interesting. It's very interesting. But that's the reason why we should not be using cereal with breast milk.  [00:33:30] Kate Grandbois:  What if it's, um, formula?  [00:33:34] Virginia Weill:  Formula is okay.  [00:33:36] Kate Grandbois:  To thicken with cereal. For those of you listening at home, she's grimacing while she's sitting. [00:33:43] Virginia Weill:   I, I know. Even with my mask on the doctors know. Cause I can tell by my eyes I'm grimacing Um, yes. So, you know, we weigh the pros and cons of using cereal. Um, it adds in a lot of unneeded carbs in terms of the [00:34:00] microbiome of the baby. So nutritionists, um, or the dieticians don't love it, um, because it may set these kiddos up if, you know, they're on the cereal for long term, for a high rate of diabetes, obesity, you know, down the road, which we try to avoid. Everything we do now is impacting these kids later in life. So that's why we really try not to use. That being said, with current, uh, manufacturing issues, a lot of the formulas that we use to thicken, well actually the formula we use like nil AR is not being produced right now. So families literally are going to 10 different Walmarts and 10 different targets to try to find this formula. And so this discussion tomorrow that I'm having with the physician and the, um, the dietician is, well, the family can't find it. We need to have another option. We need this baby to gain weight. So cereal is what we're gonna do. So that's, so yeah, cereal can be used, but it, pros and cons of it need to be discussed with the medical team and with the family so that they're aware. [00:34:59] Kate Grandbois:  What, is [00:35:00] there a reason why you are not thickening with other traditional thickening agents that you would use in the hospital for, for adults?  Virginia Weill: Like simply thick?  Kate Grandbois: Yeah. Is that a silly question? Virginia Weill:  No, not a silly,  Kate Grandbois: it's clearly me showing my, I don't work in a medical facility.  [00:35:18] Virginia Weill:  Great question. So we're actually working on a thickening guideline right now for our neonates and then also just our pediatric population. So yes, absolutely. There are tons of thickening agents out there that I love and I highly recommend, like Simply Thick, for example. It's a beautiful gel that just dissolves, um, super expensive though. Um, or another xantham gum based powder, uh, like Thicken Up. Clear. I love that. That's powder pretty cheap. Families can find it on Amazon. The problem is you can't recommend those younger than 12 months of age.  [00:35:52] Kate Grandbois:  Interesting. For dietary reasons? [00:35:54] Virginia Weill:  Dietary, but also gut. So they, um, there was a recall [00:36:00] Ooh, years ago, right? I think when I started working, um, on a certain product because they, they were, it was being used in neonates and it caused NEC or nec, necrotizing enter colitis, which is basically part of the, the gut dies and some babies actually passed away. So that's why thickening agents really got strict on what age, um, you can start to use it because of the impact on the gut.  [00:36:29] Kate Grandbois:  I'm glad I asked. I'm sure it wouldn't happen in any nicu, but that, that seems very, very serious. [00:36:36] Virginia Weill:  Yeah. And actually Gel Mix is another product that came out. I'm not endorsing any of them, I'm just saying what's out there. Um, but Gel Mix just came out and that's a Cara Bean based thickener. We can use that in breast milk actually. But, here's the but, you can't use it in kids younger than 42 weeks or um, 42 weeks and they have to be six pounds. Okay. [00:37:00] So a lot of these babies that we see usually are younger than 42. And so we have to try to find something like NL AR to use instead cuz we gotta wait until they hit that 42 week and six pound mark to try all the, the gel mix with moms. [00:37:13] Kate Grandbois:  So there's a pretty narrow window of application for that. Yeah, that makes a lot of sense.  [00:37:20] Virginia Weill:  But a lot of hospitals are using it appropriately, you know, for when those babies reach that age.  [00:37:25] Kate Grandbois:  Okay. Are there any other reasons to not use cereal for thickening?  [00:37:32] Virginia Weill: No, I would say it's not in breast milk. Cause it breaks down the carbs, it breaks down the cereal, so you have an inconsistent viscosity and then, um, it's just a lot of carbs and a lot of calories, empty calories that messes up their gut biome, I mean, and sets 'em up for potential issues down the road. [00:37:53] Kate Grandbois:  Okay, so earlier in this conversation we were talking about. Before we got into the thickening and other interventions, we were talking [00:38:00] about, um, the assessment piece. And this is when you shared the, the clinical story with us about this baby who I'm so glad, had the positive outcome and did well. If there are instances where you, or, or I guess are there instances where you do recommend an MBS and have other unwanted outcome? Like you go through an MBS and they need a persistent application of an NG tube?  [00:38:33] Virginia Weill:  Yes. So the hard parts of my job are when I have to say to the family, I'm not recommending that he consistently take the bottle or be allowed to have a full volume, or I am gonna recommend a G-tube or a longer, longer means of nutrition. Usually how I put it, um, I will say 99% of the time, I personally do not recommend strict NPO due to aspiration, [00:39:00] which I know is a very, um, controversial discussion topic between pulmonologists and the speech pathologist. And I'm sure it's different at each, um, hospital in between clinicians. Um, but I come from the background of, you know, if you, if I see aspiration on a mbs, on a baby, on a NICU baby, and I say you strict npo, how are we going to practice in this key timeframe that their brain is still developing this whole suck swallow breathe. How are they gonna practice if they can't eat anything? So what I've, you know, brought to our institution or supported it, is small volumes. So I actually have another case that I can talk about specifically about mbss, where, uh, I limited, I limited his volumes to 10 mls, 15 mls, 20 mls until he got better protected his airway better, um, and could prove that [00:40:00] his lung status wasn't being impacted by potential aspiration. [00:40:06] Kate Grandbois:  Okay, that makes a lot of sense. So, moving into our third learning objective, you've got this fancy word in here, strider. I know what it means. But I wonder if you can tell us a little bit about what it is. [00:40:16] Virginia Weill:  Yes. So this is one of my, um, uh, I don't say like pet peeves, but it's, it's something that always I wanna educate everybody on. And I actually am doing a talk for our hospital soon, and this is one of the things that I'm talking about.  [00:40:30] Kate Grandbois:  You brought a, so you have a soapbox. You brought the soapbox with you,  [00:40:32] Virginia Weill:   Yeah.  [00:40:33] Kate Grandbois:  So get on it. Get on up there.  [00:40:35] Virginia Weill:  Yeah. So, uh, let's see, Strider. So Strider is that squeaking sound that you hear, so I'm going to imitate it cuz people say, do a good job of it. It's that. So you can hear this when you're changing their diaper and they're crying. You can hear this just when they're sleeping, sometimes on their back, if their tongue is a little bit more floppy or their jaws recessed a little bit, you can hear like, you know, [00:41:00] like deeper sound. Um, or what I focus more on is the feeding piece of when you just hear strider with feeding, what does that mean? Why aren't you hearing it throughout the day or throughout the, the care time with the child? And you know, I, because I'm on Aerodigestive team, I see some of these outpatients referred from pediatricians for laryngeal malaysia because they have strider and the ENT scopes and there's no laryngealmalaysia,  [00:41:28] Kate Grandbois:  okay. To level the playing field. Give me a reminder of what Ingal Malaysia is.  [00:41:32] Virginia Weill:  Laryngomalaysia is basically a floppy upper airway. So you have Laryngeal Malaysia, tracheal Malaysia, and Barco Malaysia. Okay. And sometimes you can have all three. Okay. Um, and usually what I, um, deal with, if I can put it that way, more is the LaryngoMalaysia. Cuz people wanna know why are they squeaking so much? Um, is it airway protection? Is it a vocal cord out? [00:42:00] Um, you know, in the cardiac babies who have surgery, they hit the recurrent laryngeal nerve sometimes just to move it around to get to the heart and it tweaks a vocal cord so the vocal cord doesn't move all the way. It's kind of paralyzed in a specific position and that kiddo's gonna have strider as well. So anytime, I guess my big takeaway for this is anytime you have a patient, whether it's a neonate, outpatient, pediatric, and you hear strider, ask an ENT to take a look and see what is the reason for the strider, because it is not always laryngo malaysia. Okay. I had one kid, um, I saw a kiddo on pediatrics. She was older, like a few months old. Came in for actually failure to thrive, meaning just her weight isn't good. Um, and I was feeding and I heard this strider. I'm like, no one's mentioned this. And so I brought it to the residents and they said, oh yeah, let's get ENT to come take a look. She actually had a paralyzed vocal cord and they had no idea why. She had never [00:43:00] had cardiac surgery or no two cords. Both of her cords were paralyzed and like this kind of the between middle and uh, open and closed paramedial position. And, um, so thank goodness, you know, they did an MRI to make sure she didn't have any neurologic involvement, which thank goodness she didn't. But, you know, ENT then continued to follow her about every three months and rescope her just to see what was going on with her vocal cords. So like that's, again, you've gotta get ENT involved and have them take a look at these kiddos. [00:43:27] Kate Grandbois:  That's so interesting. So is it, just to say this back to you to make sure I've understood, it sounds like any time there is strider, it warrants a referral to ENTTo get scoped. Virginia Weill:  Yep. Same with, yeah. Yes.  Kate Grandbois: And you would say that for even, would you say that for babies outside the nicu  [00:43:49] Virginia Weill:  Yes. Everywhere. Any infant full term, just going to the pediatricians. Um, kiddo. Yeah. Any, even if you're visiting your friend who just had a baby and [00:44:00] they're feeding and all of a sudden you're like, wow, that kid sounds like a mouse over there. I don't know if your friend would be open to it, but you would say, Hey, has your pediatrician recommended an ENT consult because you don't know why the baby's squeaking and you'd wanna find out.  [00:44:15] Kate Grandbois:  Interesting. Okay. Okay. So you've gone over two possible etiologies of strider in infants. Um, you've mentioned to us all of the reasons why we should be concerned about a potential strider and when to refer. The answer is 100% of the time.  I, I know that you have some other case studies that you brought to us. Do you wanna walk us through those? Sure.  [00:44:39] Virginia Weill:  So one of them kind of goes back to, um, your MBS question in the NICU and when it, when you redo them. So I guess another one of my soapbox things besides strider is mbss. They are not a pass or fail, and I. Even some of my, uh, [00:45:00] colleagues will say they pass and I turn to them and I say, it is not a pass or fail. I don't know what you're, like. You are smart. Stop saying this. Um, and a lot of physicians will just say, both in the adult world and the pediatric world, well did they pass? And I said, there's no pass or fail. It is, you are assessing. Our job as a speech pathologist is to assess the biomechanics of the swallow. You know, you are providing the team basically a risk level of whether you think airway compromise is gonna happen and why. And I think you always have to ask yourself, why am I seeing what I'm seeing? Sure. You can list residue, you can list, you know, material in the nose, up in the nasal cavity. You can list aspiration, but that doesn't tell the treating therapist or the physicians why this is happening. They wanna know what can they do to help prevent this in the future. So I think that's where we really need to not, you know, minimize our role in a [00:46:00] patient's medical workup. We have a huge advantage here to really show the family, the patient, the medical team, what we do and how important it is in the health of the patient. Um, it's, you know, mbss are just a moment in time, so I'm just looking at my little dots here. My bullets, mbss are not, are just a moment in time. So if you see aspiration, great. If you don't see aspiration, it doesn't mean it's not gonna happen or it's not happening. Same with reflux cuz so many res, so  Kate Grandbois: great reminder. Mm-hmm. .  Virginia Weill: Yeah. Reflux. Well first of all, as swallow study is not a test for reflux, but if we see it, great. If we don't see it doesn't mean that your child doesn't have reflux. And I always have to say that to families. Just cause we didn't see it doesn't mean it's not happening. I believe you, your story, I believe you, you know,  [00:46:45] Kate Grandbois:  and how validating that must be. I think the, the, the quote that you just said, that it's a snapshot of a moment in time is such a good reminder of what that test actually is and does. [00:46:56] Virginia Weill:  Yeah. So, um, kind [00:47:00] of, so talking about, uh, mbss in the nicu, like I talked about before, we usually don't complete them younger than 38 weeks, but of course there are those outliers. Um, and of course we've completed them before 38 weeks, but that's kind of our, our our time. Okay. Um, we usually recommend a swallow study once we've trialed all the other strategies at bedside and we're still concerned about airway compromise. So in that first case study that I talked about, the thickening kiddo, if she had been older, if she had been 38 or 37 and change, I probably would've said, let's do a swallow study. Let's take her down and let's really see what's going on. Um, because she was showing so many overt signs of distress at bedside. Um, we try to complete the swallow studies at around a feed time. So in the nicu, babies are fed on a certain time schedule every three hours typically. And so we try to complete the study at that time so the babies are hungry and then they are awake and rooting and engaged in the feed. Um, we feed the [00:48:00] baby downstairs and fluro in the same position that they're gonna be fed upstairs and at home. So we're really, yeah, we're really mimicking. We're trying to the best we can, what a natural feed looks like. Um, and then I have the family or the nurses bring down all the bottles that the babies are using or could use or have brought, you know, have trialed at bedside. Just who knows, you know, maybe with an AVMP bottle they're aspirating, but with the Dr. Brown, they're not. So I have all those bottles down there to try. Um, and I think, you know, I know Boston Children's does this and so we've started to do it too where, um, certainly with Dr. Browns, we give them a new nipple for every swallow study so that we're standardizing that flow rate even more. So some kids babies will use the same ultra preemie nipple for two weeks, but if they come down for a swallow, guess what? Whoop, you're getting a brand new one so that we know the flow rate is perfect. [00:48:51] Kate Grandbois:  Okay, that makes a lot of sense [00:48:53] Virginia Weill: . Yeah. Um, and then in our NICU kids, sometimes we have a [00:49:00] very small window of a couple minutes that we have this baby with enough respiratory support to actually feed and go to get a good assessment. So I know, um, I think, you know, researchers are working on the baby imp, which is similar to the MBS imp, which,  [00:49:16] Kate Grandbois:  what's an imp What, what is the imp?  [00:49:18] Virginia Weill:  It's a profile Impairment Profile, , and it's a standardized assessment.  [00:49:24] Kate Grandbois:  I don't mean to put you on the spot, but it is an acronym. Yeah. That refers to an assessment measure. [00:49:29] Virginia Weill:  Yes. And, uh, okay, don't, okay. I'm not great with adults, but I believe the mbsm is a standardized way to complete swallow studies. Okay. And so now they're trying to create,  Kate Grandbois: you know more than me, keep going,  Virginia Weill:  now they're trying to create a baby imp. Okay, so, um, where was I getting? Oh, so I, so I know like you're supposed to, you know, start with a certain consistency and kind of go from there. But with NICU babies you have, like I said, maybe a couple minutes of time and [00:50:00] you gotta use it to the best to gain as much information as you can in that two minutes. So, for example, this kiddo that, um, we did this swallow study on he upstairs showing overt signs of aspiration, pulling off the nipple, coughing, random desaturations, random heart rate drops. [00:50:20] Kate Grandbois:  I would be terrified. I'm, I'm having secondary fear just listening to this story. Keep going.  [00:50:25] Virginia Weill:  Uh, so we,  [00:50:26] Kate Grandbois:  it is very, going back to what you said at the beginning, it's a very intense environment. It is giving credit where it's due.  [00:50:32] Virginia Weill:  Um, so we knew he was likely aspirating within liquids, but our question was, is he safe on thickened? So I started that specific swallow study with thickened liquids because I knew I had my two minute window to get the information I needed. And sure enough, we did it. He, we got a good assessment downstairs on the thickened. Um, unfortunately he was aspirating it. Um, and he, I then had time to still do thin liquids under fluoroscopy [00:51:00] and he was aspirating that. But this is a perfect example of, I cleared him for very minimal amounts of PO. Meaning by mouth. Um, and I got, I got pulmonary involved, got him on some oxygen to help with his worker breathing and his tachypnea and tachypnea just fast breathing.  [00:51:18] Kate Grandbois:  Um, thank you for defining that. You knew that was coming out of my mouth in two seconds. [00:51:21] Virginia Weill:  Yeah, you're, um, and then, I mean the, the end for this kiddo, he went home actually with an ng, so I did not recommend a G-tube for him. I thought he just needed a little bit more time, maybe a few weeks and then he could probably get his act together.  [00:51:39] Kate Grandbois:  So through, at, even after you recommended the NG tube, was he still cleared for small amounts just to sort of keep up that positive relationship with oral motor movement, sex, swallow, braid, all of that kind of stuff? [00:51:52] Virginia Weill:  Exactly, yes. And the other positive thing is, um, I forgot to mention before, um, a lot of the kids who [00:52:00] I, who are aspirating, but I let them have a small volume, it's because they're on breast milk. Okay, so the breast milk, not the pulmonologist like me to say this, but it's a bodily fluid that the babies already know. So if it's going into their lungs, their lungs already know what breast, what that breast milk is, and they don't react as much as to a formula with rice starch.  Kate Grandbois: Is that's true.  Virginia Weill: Yeah. So, um, like in the adult world, you know, think about the Frazier water protocol. I dunno what that is, right? Oh, okay. Um, I think it's, you know, like if you have, you have to fit all this criteria, but basically you're allowed water, free water knowing that you're gonna aspirate a little bit of it. Same thing with ladies. You don't have protocol, but the pulmonologist say, okay, Ginny, if he is on breast milk and you're limiting the volume, I'm, I'm okay with him having a little bit to keep up the.  [00:52:53] Kate Grandbois:  Okay. That's so interesting and makes a lot of sense.  [00:52:56] Virginia Weill:  Yeah, I mean, that's what we do here. So, I mean, I don't know what other hospitals, I [00:53:00] know other hospitals can be a little bit more strict in terms of no strict NPO we need to protect the lungs at, at any cost. But I think, you know, we compromise a lot here and hopefully to benefit the patient.  [00:53:11] Kate Grandbois:  Well, and I think the takeaway is if you're listening and you're an SLP either in a NICU or interested in getting into a nicu, at the end of the day, this is really about collaborative medical decision making, um, and working within the, the practice of, of your workplace setting. So don't worry, we, we know that the information you're giving us is not the end all and be all of what you should, what should've do. These are all case by case decisions, um, made with the rest of the medical team. You have covered so much ground with us today, and before we wrap up, I just have two questions. Okay. The first question is about something you mentioned at the beginning of this episode, um, related to the role of the slp, which was working on communication in a nicu, communication and language. And I'm a pediatric therapist. When [00:54:00] I, when my, my intervention is games and activities and, you know, I've got my, my bubbles and my star charts and, and whatever I've got pulled together. I'm having a really hard time imagining what communication and language intervention looks at, looks like in tiny, tiny babies, number one, but also in a really intense medical environment. So can you tell us a little bit about what that looks like?  [00:54:26] Virginia Weill:  Sure. That's a great question. Uh, so funny, I'll start it with a funny thing. Um, when I enter the room and meet the family for the first time, I say, hi, my name is Ginny. I'm one of the speech pathologists, and then I say, who focuses on feeding? Because I've had so many parents say, you're a speech therapist. Well, my kid's not talking. Like, you don't need to teach them anything. Yeah. [00:54:49] Kate Grandbois:  My, my tiny baby is, is 30 weeks old. Yeah. I'm not sure why you're here .  [00:54:52] Virginia Weill:  Literally, and I totally get it.  [00:54:56] Kate Grandbois:  I mean, it's related to my question, like, what does that even look like?  [00:54:59] Virginia Weill:  Yeah. So, and [00:55:00] I, so I, first I start out, if they do say that I, you know, gently start sarcastically, respond back with actually I'm helping you learn the communication that your body or that your baby is giving you, you know, by the hand going up, the baby, turning their head when you give them the nipple, that's communication between the baby and to you. Um, and then the other piece of it, uh, is just. Having the babies listen to the adults talk, just the exposure to language. I know a lot of bigger hospitals are starting reading programs where volunteers just go into their room and they read books just out loud so the babies can hear language and not hear the beeps and the alarms all go on off all the time. Um, and you know, for us, when babies reach a certain age, we kind of put them in baby rehab. We call it baby steps program, where we give the families boxes, little Tupperwares full of books, rattles, um, sensory those soft [00:56:00] books that, you know, scratching  Kate Grandbois: the crinkle ones.  Virginia Weill: Yeah, crinkle. Yeah, yeah, yeah. Um, and so I think it's at 42 weeks they start to do that. And the nurses, the families, the therapists, the volunteers hold the baby and they literally are reading the books to these kids.  Kate Grandbois: That sounds like so much fun.  Virginia Weill: It is so much fun. The families love it. They love seeing their baby Almost normalize cuz we have them on a mat doing be tummy time, you know? Um, and then even for the older kids, like sometimes, you know, tra to invent kiddos are with us for a longer period of time, we can start to actually work on signing, you know, working on imitation of blabs. I mean it's hard with the mask, but, um, parents. Um, working on gestures, you know, if the baby wants to get up, you know, lifting the arms up, you know, so then we kind of get more into the conventional communication, um, when the kiddos are older. But yeah, with, they're younger, it's just the exposure, exposure to language stimulation. [00:56:56] Kate Grandbois:  I, I really appreciated the description [00:57:00] of listening to human voices instead of beeps because it really sort of paints a picture in my mind of this sterile medical environment, you know, with the machines and the tubes and the plastic and the fluorescent lights and, and all of those kinds of things. And when you think about that in cont in contrast with how quickly these little brains are developing and how much they are absorbing something small, something as small as focusing on making sure that there is spoken language in the room could be, I have to assume a really big step. A really big deal.  [00:57:34] Virginia Weill:  I went to, um, one course years ago, and I can't remember what hospital it was, but they actually had a routine that when the nurses did handoff, they did it in the baby's room. So the babies, like, you're just adding to the amount of language and voice. Positive stimulation that these babies are listening to. And I just, I love that. Obviously it stick in my mind. It stuck in my mind. Um, but I, yeah, so I love it when hospitals do [00:58:00] things like that. [00:58:00] Kate Grandbois:  Yeah. That's awesome. Okay, so my second, my second question, which is my last question. Can you tell us a little bit about what an SLP can do if they are interested in working in a nicu? So, in all of, I'm somewhat familiar with the app, with the ASHA demographics data, just because I look at it all the time for other things and I, the NICU is not listed on there, there, I have to imagine that there are not a ton. Of LPs who are employed in a nicu. So if anybody is listening and wants to get into this workplace setting, what would you recommend? [00:58:36] Virginia Weill:  I would say, um, first just from my own experience, getting medical experience in general, getting into the hospital, whether it's adults or pediatrics, so you can learn, can I thrive in this environment because outpatient is so different from, so different. Um, so once you have experience in the medical setting, getting some pediatrics, so you're starting, you're starting this, you know, [00:59:00] broad and you're gonna start narrow, narrow narrowing your, um, experience. Um, and I found this, and I can post this later as a handout, but I found this on one of the journals. Um, they talked about a minimum of three years of experience practicing as a speech pathologist in the pediatric setting. It's highly recommended specialized mentoring in neonatal therapists, whether it's in, in neonatal therapy, whether it's in person or online. Um, initial and ongoing participation in peer reviewed education specific to neonatal therapy is necessary for safe and effective practice, um, and mentoring mentor practice hours and established competence in the nicu. Um, so I think it's,  Kate Grandbois: is that in an article,  Virginia Weill: uh, it's a journal, a perinatology,  [00:59:48] Kate Grandbois:  we, would you mind sending us that reference and we'll put it in the show notes for anybody who's interested in reading further? [00:59:53] Virginia Weill:  Absolutely. Um, and so, you know, I think I, I, and I admit it, I was very lucky the [01:00:00] stars align in how I got to where I am today. But I know that people have to work super hard to get into the nicu and it's exhausting. So if you, you know, have the pedia medical, you're in a hospital setting, you have that check that box, then you get into pediatrics, you check that box, you know, and being in a medical setting, a lot of what you do is feeding and swallowing. So you need to make sure you have good experience with that. Um, and yeah, you know, finding a good mentor too is really important.  [01:00:31] Kate Grandbois:  That's awesome. Thank you so much for sharing all of your knowledge with us today. We're so grateful for all of your time. This has been so, so wonderful to anybody who is listening. And if you're out on working out or folding your laundry or commuting, we will have all of the references and resources listed in the show notes. Um, they will also be listed on our website. Ginny, thank you again so much for being here.  [01:00:57] Virginia Weill:  You're very welcome. Thank you for inviting me.[01:01:00]  Closing [01:01:00] 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 March 13th, 2023. The podcast episode is offered for .05 ASHA CEUs. This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate 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 nerdcaster10. A link for membership is in the show notes.  Episode [00:01:41] Kate Grandbois:  Welcome everyone to today's episode. We are so excited to welcome back a guest who has been on our show before. Welcome Dr. Ali Arena. You are here today to talk to us about the use of improv and therapy, and I'm so excited. Welcome back to the show.  [00:01:58] Ali Arena:  Yeah. Thanks for having me. I love [00:02:00] being on with you guys  [00:02:02] Kate Grandbois:  Before we get started, and you, uh, put me through some very uncomfortable and awkward games and put me on the spot that you, that you gave me a warning about. This is gonna be an entertaining one, everybody. Yeah. Um, why don't you tell us a little bit about yourself and how you came to know improv.  [00:02:19] Ali Arena:  Yeah. Okay. So it's actually interesting. I wanted to take improv cuz I was reading a trauma book and it helps you feel more in your body. The thought of being put on the spot was terrifying, which kind of made me be like, wait a second. I do that to my clients all the time cuz I'm asking them open-ended questions cuz that used to be a goal I would always have for people. Right? And so I found improv through one my cousin, she does it for a living. And then my really good friend, Maya Watkins, who I will refer to a decent amount in this presentation, she teaches it specifically for Neurodiverse children. [00:03:00] So her and I had paired up because she was, oh, you work with Neurodiverse children, so do I. Let's run a group. And I really saw the power of not running a typical social skills group, right? I really saw the beauty in not having all the structure going with the flow. So things that we're actually trying to teach these kids, but we don't model all that often. Um, and I've just learned you know, improv is a pretty good rapport builder because, I'm gonna kind of put you on the spot, Kate. It's a little uncomfortable and it's good. It's kind of nice for, you know, your clients to see, oh, you can feel uncomfortable too, or We're learning together. So, I don't know. I just found it a great tool.  [00:03:43] Kate Grandbois:  I am a creature of comfort. I don't like change and I like to be in my routine. I'm already feeling a little nervous about what you're gonna, what you're gonna do, but I think you make an amazing point that this is what we are asking people to do when [00:04:00] they learn in our therapy rooms, is to be vulnerable and be put on the spot and have to engage in something new and different that makes 'em uncomfortable. So I'm here for it. You're gonna coach me through it and everything is gonna be fine. It's gonna be great. Um, before we, before we get started, I do need to read our learning objectives. So learning objective number one, identify the four competencies of the improv method that foster interpersonal relationships facilitate healing from trauma and that relate to neurodiverse minds. Learning objective number two, identify three games that correlate with your specific therapeutic interventions, and learning objective number three, identify the three core qualities of the improviser's mindset. Disclosures, Ali's, financial disclosures. Allie received an honorarium for participating in this course. Ali's non-financial disclosures. Ali has no non-financial relationships to disclose. Kate, that's me. I am the owner and founder [00:05:00] of GrandboisTherapy 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 Analysis International with the corresponding speech pathology and applied behavior analysis special interest group. Okay, we've gotten through the boring stuff. I think we should start with you telling us a little bit. Improv. So when I think of improv, I think of Saturday Night Live, I think of Second City, I think it's called. Yeah. Cool. Um, the school that teaches the famous school that teaches improv, um, I think of standup comedy. I don't think of intervention. So tell us a little bit more about what improv is.  [00:05:48] Ali Arena:  Yeah. So it, it is exactly what you're saying, right? Improv is truly being in the moment and being flexible. So a big part of improv is a concept called, Yes, and [00:06:00] so , um, I wanna go out this weekend and I wanna have pizza. Yeah. And we should do this other thing. The other big part about improv is you can't be wrong. So it's not, um, yes. And I wanna go pee, get pizza, and then go to a circus and someone can't go, no, there's no circus this weekend. You can't do that. There's no, you don't call people out. You really have to go with what a person is saying. So really talented improvisers, um, Will Ferrell, Steve Corell, these people The Office. A lot of that's improvised. You have to realize they're really present and they're just listening to what the person is saying. Taking that and making another thought with it. Um, and you, when you look at that, that humor is so amazing cause it's so simple. They're not doing anything crazy. They're just being present, being flexible, and they have enough knowledge to keep going back and forth in a conversation. So if [00:07:00] you think about therapy, what we're really trying to do is help our students, clients, whatever words we wanna use to be more present, to have reciprocal conversation, to have more flexible thinking, to take perspective. And these are all things that an improviser is doing, but they learned them. Yes I think some people have a natural skill, unlike you and I who are , oh my God, don't put me on the spot.  Kate Grandbois: Please don't talk to me. Ali Arena: But they still, they have learned these skills over time. Um, another thing about improvising is, You have to be pretty good at reading people's body language. You have to be okay with the unexpected. That is what improv is. Um, Tina Faye in her book, Bossy Pants, I don't know if you read that, talks about, I've seen it, I haven't read it, talks about how improv is The secret weapon and how, um, she talks about how the, lipstick basically someone just made that up, that's a creation that [00:08:00] someone was, oh, I'll just put in this little tube, and then women could put it on their lips. She'd be, that's a form of improvising. It really is just taking a concept and continuing to go with it.  [00:08:10] Kate Grandbois: I love the component of not being able to be wrong. I think that alleviates so much of the pressure and insec, I, I'm speaking for myself here, the pressure and insecurity that you might feel when you're in a vulnerable position doing something new for the first time, and you don't wanna upset anyone. You don't wanna say something, quote stupid, you don't wanna be made fun of. You don't wanna, you know, there's all of this insecurity and worry about your actions. So if one of the rules is that you can't be wrong, How much more fun is that that really alleviates so much of that pressure to perform, I guess. [00:08:46] Ali Arena:  Yeah, and it's, you know, uh, schools are now using improv a lot as processing groups. With Covid, they would use it, um, they would just kind of have these classes where they play games and we're gonna play a game [00:09:00] together. And it's more, you'll be surprised what kids will talk about, I did this, two or three years ago, and a lot of kids would say Trump. They'd be, Trump, Trump, Trump. And they were using it to be funny. But over time they were also saying other words, uh, , nuclear war, financial distractions. Oh my goodness, oh, okay. So if this is what you're saying in improv, this is what's on your mind, right?  It, sometimes kids do it for reaction, but other times you're , that's the thought that came to you that quickly. You are really thinking about this. So improv can also be a really good way to see. What's on someone's mind, right. If you, if you and I played in [00:09:38] Kate Grandbois:  sort of like a free flow sort of stream of consciousness. Yes. Interesting. Yeah. Okay. So how is the improv method as an intervention technique different from improv in general or, you know, as a general concept?  [00:09:57] Ali Arena:  So I think with the [00:10:00] method, what, um, I did and, and Maya Walkins, she's a social and emotional, uh, counselor and teacher, and she created these games. So I just wanna give her credit as we started to play. But her and I really sat and we’re, okay, what are things that we're constantly working on with the kiddos that we see. And we realize, we talk about self-agency a lot. We talk about executive functioning, we talk about interpersonal skills, and we talk about boundaries. But if I were to sit with you and I was, okay, Kate, we're gonna talk about your boundaries. Are you following your time boundaries or do you have social boundaries? You would be like, no,  [00:10:33] Kate Grandbois:  I just fell asleep. I'm not here anymore. I don't wanna be here. [00:10:35] Ali Arena:  And also, you can't say the word boundaries to a five-year-old.  That doesn't do anything. Right? Right. So we realized, okay, if these are things that we're talking about all the time, let's just create games that correlate with them. That's really what the improv method is. and I love it for my Neurodiverse kids and anyone who's had a decent amount of trauma [00:11:00] and typically my trauma and Neurodiverse kids are, they're both a lot of times, right. But because if you think about someone with a neurodiverse brain, they often struggle with being in the moment and attending cuz they're so in their head. They struggle with black and white thinking. They struggle with perspective taking. So if you're creating games that directly relate to these, it's just a different way to have fun in therapy. Um, I don't know, do you know who Esther Parrell is? She's a famous psychologist. She is, um, I love her. She has one of those amazing therapies, soothing voices. She has a great podcast, but her whole thing, she does a lot of couples counseling, but she just created a game and she did all this research about, essentially play is what's healed a lot of couples, not intensive therapy going back and forth with checklist checklists. It was play. So that's where the improv method has come from.[00:12:00]  [00:12:01] Kate Grandbois:  Okay. That's awesome. That's really, really helpful. I'm wondering if you can tell us a little bit about, um, whether or not this intervention is used only in direct service from if in in, in other words, if we have people who are listening and thinking, okay, this might be a really nice tool for me to use in my sessions. Is this something you can do one-on-one? Does it require a group? I'm thinking about, you know, what I've seen in improv, I, I guess commercially, it's almost always a group of individuals, but is this something that you can easily incorporate into your sessions regardless of what kind of service delivery model you have? [00:12:39] Ali Arena:  Yeah, so I definitely, I love group, um, purely just cuz you're getting more answers, right? Or you're getting more responses. But I do try to do improv a decent amount in my individual sessions as a continual rapport. Loosen up sometimes with my ADHD kiddos when they've just [00:13:00] gone, you know, to another place. I try to bring 'em back with, um, an improv game. So I love this one game. I'll do one right now. Um, that's called. Zip zap zop. Right? And literally when I get to zop, you would turn and you and I would say a word, right? And let's say you said, Chocolate and I said Milk, then we're gonna turn back around and go zip Zap, zop and see if we can get a word that's almost the same. So most likely you and I would say chocolate milk, but sometimes someone might say Spider-Man. And I might say, I [00:13:34] Kate Grandbois:   was gonna say this sounds maybe harder than . [00:13:35] Ali Arena:  Yeah, no, for sure. But  Kate Grandbois: I think sounds harder than maybe. I think it is,  Ali Arena:  yeah. I mean, look, I think again, so you're not gonna be wrong, but you're also a clinician. So let's say you do three rounds of that. You're still saying , you're trying and the kid's maybe not picking up on it. You're like, you know what? We need a new game. Let's try something different. Right. Okay. Um, so it's, again, it's, it's showing [00:14:00] that flexibility. I love when I'm doing improv with a client and they're quicker than me and I'm like, oh my God, wait. You, this is a part of your brain I haven't seen. So that's another cool thing about when you're doing it individually, you might see strengths you didn't know they had. Um, there's a lot of research. I think it's even in our stuttering research, right? When kids are sort of acting or they're in a different form of themselves, you'll see a different version. They're able to turn off some of those other barriers and you can see them really blossom. So I think, I think therapists have played games similar to this. Let's tell a story together. So a princess went to the forest and then, and you can have a kid fill in, right? and then you keep going back and forth. So that's improv. It's, it's being flexible. The other thing, and I should have said this at the beginning, improv does not require supplies. So that's why it's so beautiful for group. It's great for [00:15:00] camp, it's great for parents in the car, right? There's no, you don't have to ha, there's no materials to do improv. It is all imaginary and it's all on the spot.  [00:15:10] Kate Grandbois:  That sounds awesome. Yeah. I'm looking at our first learning objective. Do you have in, in these four competencies? I, I feel like you've mentioned. You must have mentioned a handful of them already or some of them already. Do you have a list, like a concrete list of the competencies that go into successful, the successful application of the improv method? [00:15:33] Ali Arena:  Yeah, so again, it's hitting self-agency, executive functioning, interpersonal skills and boundaries, but so, What I do have is, I mean, we could go through, could I do a case study with you really quick to give you an example of, okay, so we're gonna talk about Paul. Paul is 32, he is autistic. He also has some childhood trauma. Um, he is, uh, [00:16:00] in a lot of ways he is done really great. He's a personal trainer, but he's ready for more of a corporate job and he realized he's actually really good at coding. Um, so now he has to start interviewing. So originally I did the old school, okay, let's practice an interview back and forth and I'm gonna ask you questions and you're gonna tell me answers. And it was the most painful thing ever. He actually deteriorated. I was, wait, no, we've had better conversations than this. What's happening? And I think it's, I put him on the spot, right? So when I started to say things, Okay, let's just do, yes, and let's get you outta your head. Let's get movement going. Um, I would have him play numerous games and then we would start to do interview. He was much better. So, It with Paul, the fact that we did improv before his confidence increased, so I, it's kind of, it's a little bit like an ABA principle of shaping too, right? Okay, let's do a lot of things that you're gonna feel good and [00:17:00] successful at and confident before going into. Maybe more of a strategic interview. The other thing about not being wrong is really helpful. If he says an answer that I'm, okay, there's more. I can literally say, okay, yes, and tell me more about this and tell me more about this. And by the end, we had a full answer. So I guess the competencies it's, or the, yeah, the competencies is really, That you are looking at what your client needs to do social and emotionally and seeing what games you can pair with it. And I can give you Kate after a handout of games that match.  Kate Grandbois: That would be awesome. That would be awesome.  Ali Arena: Like YouTube videos, I think it's helpful for people to have a little bit of a reference, um, cuz it's hard vocally hearing someone do this. Um, and then I know you had also asked about just kind of , so what is the improviser's mindset right? And I think it's important to remember that an improviser is going to be flexible, [00:18:00] right? So they're, they're open, they're observant. And this is something that I think is really important as, um, clinicians, we forget this. We can say , okay, new choice. , so if someone's doing something that's not working, we can show, you know what? Let's do a new choice. Let's, um, this happens a lot. I don't know if you've ever been in a conversation with a client where, They've gone down a zone. Actually, I was just talking to a client who, um, was, is very upset about our political cl uh, climate, which fair, but he was going for a while, and so a little bit through it, I was, okay, you know what? We're gonna be flexible right now. We're gonna do a new choice of topic. And it's just such an easier way of saying, let's change the topic as opposed to, You've been on this topic too long and it's not, it's too long and you've gone too far. And we need to,  [00:18:47] Kate Grandbois:  which is so much negative feedback. I mean, that doesn't feel good, right? I mean that's, you know, criticism. Yeah. Use plain language.  [00:18:56] Ali Arena:  It is. And, but we, you know, I think as clinic, I'm guilty of [00:19:00] this, so I'm not like acting like I've never done that. I think we're taught so often to, our job is to support and in some ways correct. Right. So we might go into that mode and there's just, I think improv has taught me to be kinder and flexible in what I'm doing. So that's part of the improviser's mindset. So just adding flexibility. Um, and also when you kind of have this mindset, you're able to simultaneously teach and learn. And what I mean about that is you're able to, when you are being flexible, I think you're able to take in what your client's saying a little bit more as opposed to being so in your head of, okay, we did this goal. We have to move to this goal. And I've been there, we've all had crazy caseloads, but it just teaches you to be a little bit more flexible. The other big part of an improviser's mindset is receptivity. So it's patience to allow individuals to [00:20:00] practice the task at hand. Um, you have to trust your partner in improv. You have to trust the clinician. You have to trust other people, um, and you have to trust that everyone's being present in a game. And it also really talks about receptivity, is listening, responding, and modeling. So let's say you and I are playing a game. And you, you kind of say something that I'm like, whoa, that was a little wacky. I can model how to bring it back as opposed to, um, I am putting Kate on the spot. We did not rehearse this at all. Kate, what's your favorite? Um,  Kate Grandbois: here it comes. I'm ready.  Ali Arena: You ready? What's your favorite movie? But I want you to say something , Inappropriate. A movie that I would be , oh, we shouldn't talk about that one. [00:20:44] Kate Grandbois:  Um, let's see. Indecent proposal. Yeah.  [00:20:47] Ali Arena:  Okay. Oh, indecent proposal.  [00:20:49] Kate Grandbois:  Um, it dates me too.  [00:20:52] Ali Arena:  It's fine. Moving on. I could be like indecent proposal. Proposal. Isn't that when people get married? Who hears a movie where people [00:21:00] get married? Right. So it's just , Moving it and I'm modeling a different way to talk about something. Okay. I'm also modeling an appropriate transition. Um, but I, the receptivity is there and me saying indecent proposal. Okay, proposal and moving on. So I'm not saying , , that movie is rated R, you shouldn't see that movie. Or , how did you see that movie? Or , you know? Right, right.  [00:21:23] Kate Grandbois:  Um, you're just kinda So it's a yes and instead of no, we don't talk about that here. That was an appropriate Correct. Yourself, it's sort of reflecting and modeling way to shift towards something that might be received differently.  [00:21:39] Ali Arena:  Yes. And you're modeling it for kids cuz there are plenty of things that are either said to kids or that's around them, that they don't know how to respond. You're modeling how to transition appropriately. Um, and you're also, you're facilitating trust. Trust that I can say whatever, and you'll move it along. So let's say [00:22:00] you, I literally had a kid do this one time where you're playing a categories game and he would just go, Trump or Butt. Those were the only things he would say to me, . And so I would be , we'd go around. And he would say, Trump. And I'd be like, yeah, Trump. Yes. And, and I would say orange hair, I'd be funny with it. And then a kid would go, oh, orange Pony. So again, I'm not, cuz when you pause, you make it weird for everyone. Right. You, if you go, oh, he's saying Trump. That gives him an opportunity to start saying whatever else. Um, so when you are more in the moment, you're able to move things along better. Um, and the last core quality of an improviser's mindset is adaptation. So it's being able to adapt, right? So it's building off the strengths of each individual. It's having confidence that you're prepared for any situation that might come up while you're using your imagination.  [00:22:55] Kate Grandbois:  That's huge. Yes. Yes. In life. I mean, I'm, I want, I, I feel like I [00:23:00] need to practice my own improv skills. I mean, these are really wonderful qualities to have in terms of quality of life and fulfillment as a person, not just because you have a communication disorder. [00:23:12] Ali Arena:  Absolutely. No, I com and that's why I think I love this so much and it's the last part of adaptation is just like. And learning what triggers may arise and adjusting your behaviors in a thoughtful way. So , you know, let's say I've had kids before. sexually has come up a lot. Um, I work with a lot of clients who are variant into anime, and I don't know if you know this, there's a huge debate over Subverse, not Subbed, right? And , if you like subtitles, then you're not a true anime user. Right. Interesting. Yeah. I've learned so much about just things I never knew about, but, so I've been in debates with these individuals and we've been able to have them move, have the confidence to have their opinion, but to move on. So let's say I was like, no, Kate, [00:24:00] um, If you don't listen to things without subtitles, you don't really enjoy Japanese culture, okay, let's say I go there and you kind of sit there frozen. I can intervene and say, yeah, you know what? I don't know that much about Japanese culture. Can people start to tell me parts of Japanese culture? Right? It's just a way of adapting what someone said, and if you do that enough, other people see it and they'll model that as well. That's what's really cool about these groups is I start to see. Do what I'm doing. They basically make me not important, which is amazing. They, they kind of try to get me out of the group. I think that's great.  [00:24:39] Kate Grandbois:  That's awesome. Well, I think it might be time to, for you to give me some games. What are some games that we can play? So what, and um, just for the sake of saying it, for everybody who's listening at home, we will thank you so much for offering the handout. Yeah. It will be linked in the show notes. Um, and we'll have it available for download for free on our [00:25:00] website for anyone who is listening and would like to get a copy.  [00:25:04] Ali Arena:  Perfect. I just need to canva it up a little bit. It just is links at the moment. Um, so, and I also, if people are interested, I can send you, I'll just confirm with Maya, she recorded some of these on YouTube and what's really cool is she made them adaptable to both verbal and non-verbal children. So again, this is, you can usually, that's awesome. And be a part of improv. So here is, actually, we didn't review this one, Kate, she's on the spot right now. Um, this is one that you could do that's totally non-verbal. So Kate, I'm gonna give you a ball and you can hold this ball. And based on how you're feeling, you can make the ball smaller, you can make it huge, you can make it medium, and you're gonna pass it back to me. So here's your ball.  [00:25:49] Kate Grandbois:  You're gonna have to narrate for our use for our listeners. Yeah. On the podcast what I'm doing. Okay.  [00:25:54] Ali Arena:  So, okay, so my hands are open. I hand Kate a ball. She now has the ball. Okay. Her ball's medium [00:26:00] sized. Um, can you give me back the ball? Thank you. Oh, my ball just got so much bigger. All right, Kate, here's my big ball. What are you gonna, oh, nice. Okay. You kept it big. We could do that back and forth for a while. And it's kind of interesting, a lot of kids will start with a super small ball and then it will get bigger and bigger. Sometimes I ask them if they're able to communicate, what color is your ball? Um, a question I ask a lot of kids when I start groups that I'm amazed by the answer, what color represents how you feel today? Um, because yes, as an adult, that's actually hard to answer. Some kids have the most, one kid told me that he was like the macaroni and cheese. Because, oh, that's amazing. He felt very neutral. He was just kind of muted today. That's literally what he said. And then I've had a kid say, I'm lime green because I have as much energy as when I'm playing soccer, and that's the color of my jersey. Yeah, that's [00:27:00] amazing. Yes, but it's so different than, How are you doing today, ? They're just gonna say good, right? [00:27:06] Kate Grandbois:  Oh, it's so much more creative. There's so much more emotion and person personality. And personal experience involved in a question like that. I absolutely loved that.  [00:27:19] Ali Arena:  And it just adds fun. Another one, I'm not gonna make you do this cause I feel like as an adult it's just uncomfortable, but it's called stone face. And so you have a kid go up and he's stone face, he's not gonna have any reaction. And then we all pick a word that we can say to try to make him laugh. So our word, it could be, let's have it be pizza. So the only thing we could do is say pizza, to try to make stone face laugh. But you can do whatever you want with your body, right? Or you can scream pizza, you can whisper pizza, you can say pizza far away. So again, I love these because it's you have to be in your body, you're thinking about your [00:28:00] nonverbals. Um, it's really great cuz kids laugh immediately. Stone face never lasts that long. Um, it's, and it's fun. It's fun. What's great about it too is if I'm like, okay, everyone, let's pick a word and let's say Mary says pizza. I'd be like, oh, love pizza. Let's do pizza. And I'm moving quickly, right? So it's not like I, I don't, I try not to even let a kid get to a point. They're like, no, wait, I wanted it to be Spider-Man. Right? Because again, you can't pick a wrong word. So if that were to happen, I'd say, great. Next word, spider-Man. Keep going and move it along. Um, so I'll play one more game with you. We did, we went over this, everybody. So we'll see. , .  Kate Grandbois: Okay, I'm ready.    Ali Arena: Okay, so this is called gift giving. So you could do this two ways. You could intentionally give a gi, give someone a gift they won't like. I would do this for someone who's very rigid, right? Who only sees a certain purpose in things. I would intentionally try to give them something they don't like. Someone who also maybe [00:29:00] has a hard time taking perspective. I would give them a gift that's super neutral, a lamp. And then for someone who I'm just trying to figure out what they do, like I try to give them gifts I think they like. So again, improv, you're not physically giving them anything. So for Kate, let's go with neutral. I'm gonna give Kate a lamp. All she has to do is say thank you. You have to say thank you every time cause it's a gift. And that's kind that Also teaches even if you get a gift at the holidays and it's not what you want and a lamp, you still say thank you. Right, right. So you say thank you and what you can do with it. So Kate, here is your lamp.  [00:29:35] Kate Grandbois: Thank you so much for this lamp. I am going to put it in my closet for when I read. In my closet because my closet is really dark and, and there's no, there's no lamp in my closet.  [00:29:51] Ali Arena: I love that you have a cozy place in your closet for reading. That's, [00:29:56] Kate Grandbois:   I tried to get a really creative answer cause love that I'm reading my closet, but I love [00:30:00] that there's sort of, the sky is the limit aspects of this in terms of what you come up with and there's no wrong answer. That's so great.  [00:30:07] Ali Arena:  So Kate, can you give me a gift that's , that you think would, I wouldn't want, so kind of a crappy gift. , kids have given me poop before. That's how,  [00:30:15] Kate Grandbois:  Okay. okay.. Allie, I just got you this gift at the pet store. It's some cat litter.  [00:30:25] Ali Arena:  Thank you. I am going to bring this to a shelter where they have cats because I don't have one. . Okay.  [00:30:32] Kate Grandbois:  Right. I'm so glad, I'm so glad that you that you liked the gift I gave you [00:30:35] Ali Arena:  Yes. So, see how it's, um, see how someone could, I could have been like, Kate, I don't have a cat. I have a dog. Right, right. , I could've given you attitude, but it's just the, it's the receptivity. It's the going back and forth. Um, the last thing I'll say, cause I know we have to kind of wrap up, is these games are meant to be short. I'm not talking, you're doing these for 10 minutes, you're doing this. [00:31:00] Two to possibly three minutes. These aren't meant to be really long. They're just meant to establish some rapport, have fun, and either move on to a different game or move on to an intention. I might do this right before, if I was gonna read a book or something, I would do a game before and after the book. [00:31:17] Kate Grandbois:  I love this. I have one final question for you. Um, well, two final questions I guess. But the first is, when you are planning for therapy and you are interested in using improv in your therapy, and you obviously have a maybe more of a bank of games that you, that you pull from, do you have any strategies for how you match the game to maybe the targets or goals that you've, or objectives that you've written for the clients in your therapy room? How do you go about that process in terms of planning to use improv in therapy?  [00:31:52] Ali Arena:  Yeah, you know, I think it's kind of similar to the trajectory that you take as a clinician, right? You're at a point where you're like, oh, this game works for this, a[00:32:00] board game, right. Um, I definitely have started to create my own little list. Um, the book, I'll have you reference the book Maya wrote with all of these games, she does a pretty good job of saying, I would use this for this goal. So you can start to pair it that way. Um, I also try to think about it too, what games work for my certain types of kiddos. So, um, that helps me too, if I really have a lot of perspective taking kiddos, I might use certain games. Um, that for that age group, that's a little tough at times. And then, but perspective taking for a younger kid, that doesn't work. So I try to think about it with age too.  [00:32:40] Kate Grandbois:  That makes a lot of sense. For anybody who is listening, who is wanting to learn more about improv or would like to begin integrating improv into their therapy, what additional resources, I know you mentioned a book that, um, your friend Maya wrote. Can you tell us a little bit about the [00:33:00] book or maybe point us in some directions for where our listeners can learn? [00:33:04] Ali Arena:  Absolutely. So, um, again, that book was, she researched a bunch of social skills and improv groups and kind of looked at what games work. So there's that. Her and I run classes together a lot. Anyone is more than welcome to come observe and see kind of how that works. Um, and, you know, improv really is everywhere.  You were saying. There's Second City, there's Groundlings in LA um, there's groups all over. I would almost just say, take an improv class for yourself. Um, there's a lot online now because of Covid and just see, you know, what that experience is like for you.  [00:33:44] Kate Grandbois:  That's such a great suggestion. Thank you so much for joining us. I feel like we covered so much information in a short period of time. Thank you. But I think for me, having no experience with improv, even just thinking about it as a therapy tool, [00:34:00] that focuses on, you know, these core components, but also that there is no wrong answer that you can use it to improve. To have more fun when you're addressing some of these skills is a really powerful message and we really appreciate your time. Thank you so much for joining us.  [00:34:18] Ali Arena:  Of course. Thank you. Outro [00:34:20] 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 February 27th, 2023. The podcast episode is offered for .05 ASHA CEUs. 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 . This is a transcript from our podcast episode published February 27th, 2023. The podcast episode is offered for .05 ASHA CEUs. This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  [00:00:09] Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  [00:00:16] Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . [00:00:41] Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  [00:00:53] Kate Grandbois:  specified. We hope you enjoy  [00:00:55] Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes. [00:01:43] Kate Grandbois:  Welcome everyone to today's episode today, we had one of the most amazing conversations with a panel of guests who joined us. There were six of us, seven of us.  [00:01:56] Amy Wonkka:  It was the most people we've ever had on the, it was  [00:01:58] Kate Grandbois:  the, at the same time, it was [00:02:00] the most people we've ever had here on the show at the same. Um, and this panel of guests was here to discuss the client's perspective, um, when receiving gender aligning voice modification services. And we're just so grateful. Um, we left this conversation feeling. So warm and full and it was just awesome. So we are really excited to share it with you. We wanna get to the good stuff as quickly as possible. So I am going to read through our learning objectives and disclosures, and then we will cut right over to all the joy. Yes. Okay. Learning objective, number one, describe at least two ways. Clients find gender aligning voice modification to be beneficial to their daily. Learning objective, number two, describe at least two suggestions a client could make regarding how clinicians may demonstrate their cultural responsivity and learning. Objective number three, describe at least one way a client may work to maintain their voice strategies after [00:03:00] discharge disclosures ACS financial disclosures, AC Goldberg is the founder of transplanting and the credit Institute and received an honorarium for participating in this course, AC Goldberg's non-financial disclosures. AC is a founding member of the trans voice initiative and is a topic expert in gender for the informed SLP. He is a 2022 Asha convention planning committee member in health literacy, access communication, and. He is also on the community advisory board, overseeing research out a Boston university around the effects of exogenous testosterone therapy on communication and assigned female at birth speakers, AC is on the editorial board of the journal of communication disorders. Barb birth's financial disclosures. Barb is a clinical and academic instructor in communication, sciences, and disorders at Emerson college, she instructs students in the delivery of voice services to all populations. Barb received an honorarium for participating in this course, Barb Worth's non-financial disclosures.  Barb has a [00:04:00] decade of experience working with the transgender and nonconforming population. Kate's financial disclosures. That's me. I am the owner and founder of grand bought therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ashes, take 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 in the corresponding speech pathology and applied behavior analysis. Special interest. [00:04:27] 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 am a member of Asha I'm in special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. [00:04:45] Kate Grandbois:  Okay, now that that's behind us, we are so thrilled to welcome our panel of guests. We hope everyone enjoys. Welcome everybody. We are so excited to have this amazing panel of guests. Thank you so [00:05:00] much for joining us. We're so thrilled to listen to what you have to share and, and  [00:05:06] Barb Worth:  learn from you. [00:05:09] Kate Grandbois:  I'm Kate. Uh, it's lovely to meet you. My pronouns are she her? And I'm a speech language pathologist I've been practicing for over 10 years. Um, and I'm really, really excited to learn from you all today. [00:05:25] Barb Worth:  My name is Amy. I'm  [00:05:26] Guest 2:  also a speech language pathologist. My pronouns are she her? I've been a speech language pathologist for over 15 years, which sounds like a  [00:05:34] Barb Worth:  long time when I say it out loud. Uh, thank you  [00:05:37] Guest 2:  so much for joining us. And I'm so excited to having a conversation  [00:05:41] Barb Worth:  with you all today. My name. So now I'm gonna  [00:05:44] AC Goldberg:  make, I'm sorry, go ahead. Oh, no, this is great. No, I was gonna say, you know, um, we should go in order of speech seniority here. So, oh. Um, my name, um, is AC Goldberg, my pronouns, or he, him and his, I am a speech pathologist. Um, and I am also a transgender person. [00:06:00] Um, and I have been a speech language pathologist now for almost 20 years. [00:06:05] Barb Worth:  And I am Barb worth. I use she, her pronouns and this spring, it will be 30 years that I am a speech language pathologist. So why don't we start with April may.  [00:06:19] Guest 2:  Hi, uh, I'm April, may I use she, her pronouns? Um, I've been doing, um, uh, I guess gender framing, voice therapy for. Uh, I, since last spring, right? Yeah. So less than a year. Um, and yeah, I'm, I'm trans F um, that's my intro. Yay, Eddie. Nice to meet  [00:06:42] Guest 1:  you. Hey there. Uh, my name's Eddie, um, uh, my pronouns are he hang and, uh, I'm a trans guy and, uh, I'm a visual artist and a singer, uh, musician. So yeah, I'm, I'm excited to be here. Thanks for having me.  Fantastic.  [00:06:59] Barb Worth:  And Julia, [00:07:00]  [00:07:01] Guest 3:  hello everyone. I'm Julia. Um, I go by, she, her, um, I am a transgender woman. I went to Barb's program at Emerson, uh, in 20 18, 20 19, and really loved it. It was my happy space. Um, so, um, yeah, so I use those techniques. I learned there every day in my job as a software developer, happy to meet everybody.  [00:07:26] Barb Worth:  Beautiful. Well, let's start with what brought all of you to, um, receive gender affirming or gender aligning, voice modification. And whoever wants to go first,  [00:07:44] Guest 3:  um, I can start off. Yeah, so I, um, I started my gender affirmation, uh, like, uh, hormone. Uh, treatment for myself, uh, in June of 2019. And, uh, I, I had some family [00:08:00] stuff going on and I, it was a big interruption in my life, got back home and the COVID hit. So I was, uh, I basically, my voice started changing basically during, uh, like COVID lockdowns when I wasn't no longer. Talking to people regularly, just like, you know, not didn't have those everyday situations to go out and, and practice my new voice. So I, I looked up, but I, I thought, you know, I should, I should really be working on this. I can't just let it go. Um, you know, it's a little bit, when you go through such a personal change with something as personal as your voice, Like drastically changing, you know, it's, uh, it's emotional you when, when, when you lose your voice. So, um, I, I did some Googling and I found AC and I was super excited because it was like one of the first pages I found was, um, you know, it was a blog article that he wrote and I was as a trans, uh, person. I, [00:09:00] I didn't know if there'd be anything that would be inclusive. I thought it would maybe be very. I don't know, retrograde or something. I don't know. I was still a little pessimistic. So when I found C's article, I was, I was filled with hope and so I like contacted him right away. So, yeah. It's good.  [00:09:18] Guest 2:  Beautiful.  [00:09:20] AC Goldberg:  That me so happy DY. I'm just so happy to see you. And so happy that you're here working with you is so much fun.  [00:09:27] Guest 3:  awesome. Yeah, no, I, I really enjoyed our sessions together and, uh, it was just really helpful. Like at first I thought it was just gonna be. You know, I've come from a music background. So I thought a lot of it would be, you know, pitch and intonation and, and things like that. Like something from that, but just having that, your, your specialty and just, uh, you know, you really taught me a lot about, you know, like habituated voice. That was very important for me, cuz I had this general sense that, you know, a lot of psychology goes behind. Gender, you [00:10:00] know, gendered ways that we speak in our various cultures. Um, things like that, but I didn't really know. I didn't have, you know, the foundational knowledge. So it was really cool how you taught MEAC about that. And it helped, you know, even though I was, I, I still felt like I was really at the beginning of. Of my, my progress, cuz it, you know, it takes a while to process everything you learn, even in those individual sessions. And then, you know, I still society was still kind of shut down. So I mean, talking to my cat or talking to my partner. You know, I was, uh, mimicking David from shits Creek for a while. We had that, oh  [00:10:37] AC Goldberg:  my gosh, that was the best. Oh my gosh. That was the absolute best. you not wanting to lose? I remember you not wanting to lose your, your posity because, um, you wanted to have that expression in your voice, but you felt like in order to stay in the range that made you feel affirmed in your gender, that you had to not have those peaks. I remember that that was so much fun. [00:11:00] Um,  [00:11:00] Guest 3:  Yeah. Yeah, exactly. I mean, I, uh, I didn't realize how in my mind, like, um, a certain way of speaking, like to me, felt more masculine, but then it didn't sound expressive and I've done a lot of work since like it that's still sinking in for me. And I'm still, it's still something like the foundation you gave me. I was still something I work on every day. Now that I'm out working, I've got. You know, I've got other, um, friends who are identify as trans-masculine trans male and like seeing how they pitch their voice. It's just like that what you taught me, plus having now these experiences of like living day to day with this new voice, it's, it's still changing a bit, but. You know, having that knowledge has really increased my confidence a lot. And it's like, I, I, I, I went from feeling like, oh no, like, am I ever gonna be able to like, speak like, this is it's a little bit scary to like feeling empowered and you know, it's a really good thing. So. [00:12:00] Yeah, thanks again for I'm glad I found you. oh God. I'm so glad  [00:12:05] AC Goldberg:  that you're here. Um, I, we have so many more questions and maybe we'll circle, um, back to you, but, um, Barb, can I ask one of your clients to answer a question? Um, uh, just be in order of arrival, I'm gonna ask April may, um, what brought you to sort of seek out this type of service? Like, what was your. How did you initiate the process? Like what was it in you that wanted that?  [00:12:31] Guest 2:  Uh, yeah, I was actually, uh, off of a lot of things that Eddie said, cause I really did a lot to that. Um, there was originally, I started off by myself, like going online and like on YouTube. Um, and. It's rough, um, doing that alone. Um, because I think, I mean, inherently speaking is a very like two person thing. Uh, and it's to nowhere there to hear it, it, it can feel very hopeless. And, um, [00:13:00] so I, I ended up seeking out, um, Something more, uh, professional because, uh, I was originally a very extroverted person and I was finding that, um, I was becoming less, I was becoming like an introvert, um, just because I was afraid to speak, um, and, and be perceived in a way. That was not how I wanted to be perceived, especially because, um, I, I started college last year. Um, so it was like coming into a new environment and being like, seen as a person. Um, and it was, that was my, um, my decision was like, as I, I came to school was like, I'm just gonna be like the person I am for the first time socially transitioning and then medically transitioning. But. I, I was feeling really unmotivated. Um, cuz I think there's a lot of, a lot of things that can really, um, [00:14:00] bring you down when you. Don't feel like your voice aligns? Um, simply because I think, um, when you're dysphoric and you're transitioning and you're trying to be a different way, it's easy to forget how you look and, um, kind of block that out, but it's very, very hard to not hear how you sound when you speak. Um, so I ended up actually. Um, Googling like, um, voice, um, therapy, gender affirming care. And, um, one of the first things that came up was, uh, my college website, cuz I, I actually go to Emerson and I was very confused. Found out was a, um, whole. Um, program that was, uh, one block away from me. and, uh, yeah, that's how I ended up getting into it. And I'm really, really glad that I did  [00:14:55] Guest 1:  well. We're so happy to have  [00:14:56] Barb Worth:  you. Yeah. And April may, [00:15:00] um, received both individual and then also group work, right?  [00:15:04] Guest 2:  Yeah. I was originally just, um, solo, um, and that was all online. And then, um, this last, uh, summer session I was doing though in a.  [00:15:14] Barb Worth:  Great. Well, we, we love having you and Julia. So Julia also, um, was with our program for a while and received, um, individual and group therapy. And I don't remember how you initially found us and I don't remember, you know, what initially tell us, you know, kind of the same question. What, what were you thinking about your voice? Why did you want to modify it? [00:15:37] Guest 3:  Okay. So, um, so I was a pretty late transitioner and, uh, yeah, I've been speaking a certain way my whole life, you know, for decades. And, um, you know, when you're transitioning, it's a lot, um, you know, I couldn't look really BA you know, beyond two weeks, um, without just having so much anxiety. So I pushed really my. [00:16:00] I always knew. I wanted to try to, you know, um, have a different voice. Um, but I really, I couldn't deal with it at all. Um, you know, during the first part of my transition, so it all kind of came to a head as I, I went to New York city once by myself. Um, during that year I was transitioning and, um, I took the bus there. And came back the same bus the next day. And, you know, I was trying, so the, the bus, there was some confusion about the schedule. So the buses were not leaving from the station. They were leaving from like a block, you know, this other place that had to walk to myself. And I didn't know which bus was mine, and I was scared to speak to anybody. I just, you know, I just didn't want to be visible because of my voice. Um, it was a scary experience. Like I, you know, I didn't know who to trust and like who I could talk to and like, you know, out myself as trans and you know, it just, it was really scary. And eventually I, I [00:17:00] found my boss and I just got on the bus and I broke down crying and I'm like, I have to do something about this, you know? Um, so I did, I put it on my list and, um, actually. I didn't find out about, um, the Emerson program, my wife actually Googled around and found it and said, Hey, this looks like a good program. Um, I had just also like looked at YouTube videos and I also, I bought like a DVD of, you know, techniques and things like that, but it was really hard, like April may said to, to do those yourself, um, cuz you're like highly technical, you know, in the exercises. And you know, I was just trying to see if. A professional could really help me. And yeah, so that, um, so that's what led me to em,  [00:17:48] Barb Worth:  Beautiful. And I'm curious, and this is a question for you, Julian, for everybody. Um, you know, did you enter into it sort of with this very clear idea of what you were looking for or [00:18:00] was this something that evolved along the way? And that's really a question for anybody. Yeah. Julia.  [00:18:06] Guest 3:  Yeah. Yeah. So, no, I had, no, I didn't know what I was capable of. You know, like Uhhuh , I didn't know what voice I was capable of. And I remember, um, somebody asking me like, well, what, what's kind of your voice model? And I'm like, I don't know. Like, I, I don't know if I can sail like her or, you know, or her mm-hmm Um, I just wanna sound like me. Um, so it, it was very hard to know, you know, what I was capable of and yeah. So I, I didn't, you know, I didn't have anything specific in mind. I just wanted to, what I really wanted was to be gendered correctly without where a she, her button on my chest. So, yeah.  [00:18:46] Guest 1:  Yeah. Beautiful. [00:18:48] Guest 2:  Anybody else? Yeah. April a. Yeah. You might know Barb. Um, from watching my sessions, I, I have gone through a million variations of my voice. Um, [00:19:00] and honestly personally change it, um, almost daily mm-hmm um, I, I identify as gender fluid specifically. Um, so some days I am feeling a more, um, Usually like a more masculine, fem voice versus like a very fem found voice. But, um, yeah, like going in initially, um, just like Julia said, uh, you don't really know what's there, you know, like, like you don't know what you don't know. Right. And, um, it's like, it's honestly to like learning a whole. Skill whole new like language, essentially with like learning how to modulate and like seeing where that can take you. Um, and then like learning the different aspects. Um, modulation and playing with like, oh, I want to be like breathy. And like, my resonance is forward today. Or like, I want my resonance to be like back more, but like, I [00:20:00] want my pitch to still be high or it like all these different, like variations of, of the, those things can like make different voices. And, um, I don't know. I've I had a wonderful time explor.  [00:20:12] Barb Worth:  Well, and I also know April, may you also do some online work and you, and you do some D and D right? So, yeah. So it's important for you to have a lot of versatility in your voice,  [00:20:23] Guest 2:  correct? Yeah. I, um, I do like. A little bit of voice acting. Um, I play Dungeons and dragons, uh, and do like other role play games. And I usually, uh, run that. So I like to, um, well, I honestly just like to use my, my transness as like a boon in that situation because, um, I, I, a lot of, um, People, I mean, a lot of DMS, can't just be like, oh, hi, how are you doing? And then in the next like, voice go like, hello? Like, how are you? it's [00:21:00] I don't know. I think it's a, it's a skill and it, uh, can catch people off guard and, um, I like to utilize it and I feel comfortable doing so. So, um, it's, it's fun. I love, I love it.  [00:21:12] Barb Worth:  Exploration is what it's all about. We use that, that term constantly in our clinic. Don't we? April, may . Yeah, that's great. And you embrace that and I really  [00:21:20] Guest 3:  appreciate that. Yeah, it can  [00:21:22] Guest 2:  definitely be scary. I think until I got to this, um, like group work vocal group, um, the idea of going outside of. What was expected of me, cuz I even like when you're like in a, like a, a session trying to like change your voice, there's like this expectation specifically like myself as a trans feminist that like, I want to like move my voice in a feminine way. And, and to an extent I really do, but um, to another extent, like sometimes I'm not feeling that way and yeah. Um, I think it's a really, it's a really. Tool to be able to, [00:22:00] um, change so fluidly because, um, it really just allows like versatility and your presentation. Um, and makes me feel good. So,  [00:22:11] Barb Worth:  and you're good at it. so Eddie, I'm thinking you could probably relate to this  [00:22:17] Guest 3:  conversation. Yeah, for sure. Like, I think, uh, some of the expectations that changed for me was just, uh, AC went over, you know, just like analyzing different, um, voices in terms of gender. Like I'm, I'm good at analyzing singing voices. But, um, when it comes to speaking voices, it's just interesting to I'm after the sessions, I I'm paying attention more to people's everyday speaking voices, how I would gender them just based off of sound alone. It's, it's, it's difficult, right? When you always have a visual and to break things down. And I didn't really realize how narrow my own sort of, um, I guess [00:23:00] biases towards voices and gender, just like the actual technical, um, makeup of a voice and, um, with ity and, and pitch and Tomber and things, and, uh, sort of expectations I'd put on myself. And, uh, yeah, so I, and I feel like I was sort of in a place where I always just push my voice down, um, to speak and say things and. It was hard on my voice. And I was like, oh, low, you know, I wanna be masculine or whatever, but it's like, it was difficult cuz I was having a hard time expressing my personality fully. So I think that's the expectation I wasn't expecting to, um, Uproot a lot of internalized biases in terms of gender. I thought I was a little more open minded, so it's a really good learning experience. And it's actually taught me things now that I'm working on my singing voice more, the sessions with AC has helped me increase that. Sort of, uh, you know, [00:24:00] that analytical ability with singing voices as well, because, because it was such an internalized bias, um, you know, Yeah, I'm, I'm able to use it in other ways to explore and experiment with my singing voice as well. So that was, that was really unexpected. And that's just been in the past few weeks that I really have done some, some different things with a certain range, um, with my, like a higher, um, sort of breathy singing voice that I was like, oh, All these, there's all these male singers out there, or however they identify. Um, and I, I was thinking about their voice voices in a very specific way. And now that I've had this, uh, you know, these sessions, I'm able to sort of be more analytical in a way that's like really helpful. And it's, uh, I don't know. It's, it's made me more expansive. So I really appreciate that, uh, sort of, uh, personal insight and upgrading. Of my own knowledge with it. So yeah, hopefully that makes sense. that's  [00:24:59] AC Goldberg:  so cool. [00:25:00] Yeah, that's so cool. I just, the fact that you are a singer and a performer and that you're able to take this and, you know, carry it into that space is really awesome. And the fact that it makes you feel I. Empowered to explore like a head voice or whatever it is that you're talking about at the top of your range. Um, I've recently started doing that as well as someone who's a singer who has been actively kind of not singing, um, because of sort of discomfort around the fact that my voice changed and you know, how do I get my vibe in my singing? With my new voice. And I know that I'm not gonna center my own voice experiences in this podcast, but, um, I think it's really important for people to know that there's a component of, you know, Some people who are very attached to their singing voice, regardless of, you know, um, whether they're an actual performer, um, might experience a tremendous amount of grief when, um, you know, when trying to align their voice with their gender, that they can no longer [00:26:00] sing, um, in a certain way, or that they want to be able to sing and express themselves in a certain way. And, um, it's hard for them to figure out how to explore that and still feel aligned with their gender. And I'm so happy that you're doing that. And Julia, I saw your like brow raise a few times during, um, while Eddie was talking. Did you have thoughts that you wanted to add? Um, well, just  [00:26:23] Guest 3:  about the singing, I, I totally get that. Um, I used to, you know, like doing karaoke and stuff like that, but I've, I've avoided it, um, since transitioning my voice. Um, and, um, you know, I'm getting to the point now where I think, you know, I'm singing in the shower a lot. Um, and I haven't actually, I I've been meaning to record myself singing, to see, you know, really how it sounds. Um, but I think I'm getting close to, you know, that breakthrough. I mean, it takes a while, you know, you have to develop confidence in it. Um, but yeah, I, I, I took completely feel. Yeah, Julia, one of the things I [00:27:00] don't know if this is helpful at all, but recording yourself is a wonderful tool. That's I've done that throughout my whole life with singing, just recording and playing back. I do it ad nauseum. Like , I, I have hard drives full of just like singing practice because having that feedback of your own voice is just for me, it's been a technique that's I've been able. Fully like changed my voice in so many ways by doing that. Um, and I just really appreciated AC what you said about like grief and, and voice changes. Because I don't know, as a trans guy, when I had what would be considered a more feminine, uh, singing voice, like I was a high soprano, a very soaring notes and. To sort of deal with that. Psychologically, that person, that voice sort of had to become a character for me. And it represented sort of, I don't know, almost like a Sonic shield for like my emotions. Cause I was like, this person, this voice is not what I would've chosen, but this is the voice that I have to express myself. [00:28:00] And when you get to a certain place with singing, when you're able to sing from your heart and it's technically, you know, it sounds good and people you're able to connect. With people with your voice, losing that after so many years was definitely an emotional process, but also being, feeling more affirmed when I went through my vocal changes was great. And, um, You know, Julia speaking about like safety issues, like, you know, as a trans person being gendered properly is like everything being safe in, in public spaces, in relationships, things like that. And so to have that sort of, it's like, you know, to sort of profound things, intention, you're like, you're becoming, you're sounding more like yourself, but you're also losing something. And I feel like I'm sort of always working through. Um, but then what April said about also having fun with just like being able to experiment, cuz you've had so many voice [00:29:00] now I've had so many voices in my life, you know, you can have a lot of fun with it too. So it's uh, I'm really appreciating this discussion. It's like, yeah, it's really good. So,  [00:29:10] Barb Worth:  you know, we're, we're sort of talking about all the ways that you U you all use your voice, um, all the different settings context, and I'm wondering, you know, how do you work on your voice outside of formal training? You know, so all of you have received formal training from either AC or I, or, and, and maybe elsewhere as well, but, you know, do you have. Program a warmup. Are there things specifically that you do when you are, um, when you're not with us and you've talked a little bit about that, but I'd like to hear more.  [00:29:47] Guest 3:  Um, yeah, for me, I, I hope it's okay. That I'm speaking again. I don't wanna take up too much, but, um, yeah, I this keyboard I, uh, having a keyboard, even if it's not a full ranged [00:30:00] piano or whatever, for me, um, having a, um, an instrument where you can work on pitch and, uh, you know, yeah. I feel like without. There's no anchor of like notes and I mean, I'm a musician, so that's my background, uh, piano, especially, um, I find with a confidence thing with, um, like resonance and tone. If you're not having, like, for me, if I'm having a tired voice day, it can be a little bit, you know, it can affect confidence a little bit having that, like a keyboard or, or a instrument that you're sort of resonating with. It's um, You know, your vocal chords are vibrating as so as the instrument and having that sound buffer, you know, and sort of helping you, it's almost like a, a sound friend there, you know, all the notes mm-hmm and you can kind of match that. So it's, uh, you have something to sing with or, or to even just, you can use it with your, I can use it with my speaking [00:31:00] voices. Well, and check where my range is, so sure. That's that's, what's been helpful to me, so beautiful.  [00:31:07] Guest 2:  I I think for me, um, I, I just have this, I, and I'm so thankful for this incredible support system with my friends right now. Um, where essentially, um, like most of my friends have been the chance that start. Of my transition. Um, and so they understand that like, essentially I'm a work in progress , um, which is okay. It's like, it's okay to be, um, finding yourself and like, not, not know who, like you are quite yet, or to not to, to know who you are, but to not be there yet. Um, and I think, I think most of it for me is like, is just this mental barrier that comes with, um, Right. I guess, practicing, um, and over exploring your voice, um, in social settings. Right? [00:32:00] And so, cause, cause I think, um, you know, you can sit down for an hour a day and, and practice a voice, but you're not gonna get nearly as much as if you, you know, you go out to dinner with a friend and you just, um, You just, you just explore. Um, and sometimes I tell my friends like, oh, my voice is probably gonna change a lot. Um, like, and, and they know that as like, if, if in one like sentence, I sound one way I want sentence said another way. And it's because, you know, in my head I'm, I'm thinking about it and I'm trying new things. Or, or sometimes I. Um, these, um, I'm trying to think of the word for them. The, the, the words you say to get you back to your voice. Um, if that makes sense, I'm not sure if there's any anchor words. I like anchor words. Yeah. Yeah. And so just like telling your friends, like, yeah, sometimes I'm gonna go 1, 2, 3, 4, and like, just ignore it. cause it's, it's just gonna happen. But [00:33:00] yeah, uh, that and something I've been enjoying recently as like a, a warmup, um, for me to kind of find my, my like voice of the day, if you will, um, is I will say hi in like every different voice I have going up and down, um, at one is a warmup, um, to kind of get my voice like going. Um, and also I find that if you. Work out the, like your whole vocal range. It makes it easier to then like choose a specific one and like set to it. But, um, yeah, that's, that's kind of my, my process. Um,  [00:33:34] Barb Worth:  Beautiful. So, you know, so it sounds like we've talked a little bit about warmups. We've talked a little bit about the, the, the importance of having social support of having places to practice. You talked about anchor words, which are fantastic. So little, little things that we can interject to kind of reset the voice. Um, we talked about use of the piano. Um, Julia, I'm wondering, can you add to that list? Just ?  [00:33:57] Guest 3:  Sure. Um, so, so pre COVID I used [00:34:00] to commute to work and Uhhuh used to go to this thing called an. Um, um, yeah, so, um, I used to, uh, so I would take the bus to his place and I would have like a 15 minute walk from there. So I would walk down the street alone and I would be doing my pitch. Whoops. Um, ah, You know, I would try to make sure nobody was around me cause I I'm sure I sounded crazy doing on them, but like, you know, they were kind of like woo, like that, you know, and going up and down. Um, and then I would have my AirPods in and I would, I would bring up voice analysts on my phone and ah, I would just talk. I would talk about my day, what I was gonna do. And then I would listen, listen back to it. Um, and you know, that's how I would commute to work. So I'd get kind of like ready before I went into the office, um, to do that. Um, so then, you know, then we all, you know, came home to work and you know what, that, that did. I found a really good advantage of [00:35:00] that and that's that I could bring my iPad right here by my computer. And I could record myself during meetings, um, because we all know that like, so I, I still bring up, like to gets secure in the rainbow package. And, and I, I read those, but like, I'm performing kind of, but like when you're, when you're talking like in a meeting like this, it's totally different, like you're not. Thinking about every word you're giving, you're giving the, um, your speech, like only like 10 or 20% of your cognitive, you know, load. And, uh, as opposed to like, when you're practic, when you're doing, you know, reading it specifically, your all your mind is focused on that. Um, so, so, yeah, so that was really illuminating, like taking myself during meetings and I would then listen back to it and. The things I was very unhappy with. I would just say them again and again, and felt like I got it. Right. And, um, that was really helpful because it's, cuz those moments when you're not focused completely on your speech, when you know what I found that I [00:36:00] let myself down a lot during those moments. So, you know, really that, that drilling of those common things that you say really helped. Yeah, the,  [00:36:11] AC Goldberg:  the everyday the everyday words. Um, I have a question. I know we're, we're about to run out of time, but, um, I, I want, um, to ask you all sort of how this process and how, um, you know, the clinical relationship that you had, um, with, you know, myself with Barb, uh, with anyone that you may have worked with at Emerson, how that compares to. Other types of healthcare services that you've received, um, you know, relating to, or not relating to gender. Um, you know, what, what that sort of felt like to you? Um, similarities, differences, um, you know, um, I want our listeners to be able to, you know, understand a little bit of, um, a little bit of what that felt like to you. [00:36:58] Guest 2:  I [00:37:00] specifically with the Robin center, I've felt like they've been great. Um, I think when, when it comes to like transcare, or just like how, like going into a hospital in general as a trans person, um, I think like no event is good. If that makes any sense. I think there's a lot of. Um, specifically me in the past, going into a hospital and being like, oh, my name is this, but my legal name is this or them coming in and like asking questions about, you know, transness and it's like a. Maybe, um, I don't know, you're my doctor. Maybe you should have known that going in, but, um, I don't know. I've always felt like none of that is like up for questioning when I'm, um, specifically going into the, the Robin center. So like that that's honestly been a, a big deal for. For comfort. It's just like, [00:38:00] um, not even just feeling seen, but like feeling that like being accepted within the space was never in question. You know what I mean? Like, um, it's almost like, um, like when you, when you see people putting an effort to make you feel comfortable, that's great. But, um, just. Effortless comfort is I think the same, the amazing thing as a trans person to experience, cuz it's not something you get to experience a lot. So I, I think it's a really big deal  [00:38:34] Barb Worth:  that that makes me just feel so happy. I can't even tell you. I'm actually  [00:38:38] AC Goldberg:  tearing up. I'm here. I'm tearing up and I don't work there because it just, I know what it's like to experience that it's really genuine. [00:38:50] Guest 3:  I, I would just second that like, um, you know, I, I, all, all my experiences, like outside of Robin center, like you, you have to be on guard, you know, you have to like [00:39:00] really watch out for yourself and like, let everybody know who you are. Um, and. You know, still then things go wrong. Uh, and it hurts. It really hurts. So, um, I never felt that at the Robinson, I think that's one of the reasons why it was my happy place. Um, you know, cuz it was just, it was, I was having fun. I was in a group experience. Um, you know, it was students teaching me, you know, so it was like, you know, being around a lot of young, enthusiastic people and like other trans people. And I just, I, I, it was just a really positive experience among my other trans health that I, that I sought out. It was not the best.  [00:39:41] Barb Worth:  Thank you, Julia. I'm curious too. Um, and for this is for you, Eddie, um, what specifically do you think our listeners should be paying attention to? You know, let's sort of take it the next step of  [00:39:59] Guest 1:  what  [00:39:59] Barb Worth:  [00:40:00] advice, what would you say? Like when people are thinking about offering these, uh, sorts of services,  [00:40:07] Guest 1:  what do we, what do we need to do better? Eddie  [00:40:13] Guest 3:  I dunno, I had, I had had a really good experience with AC. I mean, I was yeah. Isolated at home and feeling alone, and then I've got AC and again, like, yeah. What, uh, Julia was saying about it, you know, kind of feeling like effortless, acceptance and feeling. You know, I belonged it was a zoom window, but you know, when you're, when you go out into the world as a trans person and yeah, you have to be in guard, you have to any room you're in any space, you know, you just have to, I don't know. That's how I feel. You're always in a defensive posture. So, um, I just think, you know, any healthcare practitioner, whether it's in your field or, you know, otherwise it's, uh, paying attention to content like AC puts out on transplanting, [00:41:00] things like that. Just really being open, continuing to in the conversation. And yeah, like, I, I feel like this, like, what you're doing is, is great. Just this session is exactly just more of this mm-hmm .  [00:41:17] Guest 1:  Yeah, beautiful.  [00:41:19] Guest 2:  April may. Yeah, I was just gonna add onto something. I think you actually said earlier about, um, implicit bias and, um, specifically like the idea of, um, like, I guess maybe even like internalized transphobia. Yeah. And like perceptions of gender that we have. Um, and I think my most important thing in the thing I tell people, um, when they're like coming into contact with trans people, working with trans people, and maybe there's just maybe their gender group as well. Um, I think either way, um, I think, uh, implicit bias and, um, checking those implicit biases has to be something that's active.[00:42:00]  Um, I don't think it's something, you know, you do, and then it's done, um, as, as amazing as that would be. I think, um, you have to continue to, um, the send to those people. Um, Who are experiencing, um, I guess like different levels of privilege than you. Um, and just like, keep, I guess, updating your internal map of, um, just, just the ways you, you treat others in regards to their identity, especially with something as like sensitive as, um, you know, voice care. Um, An active assessment of Biase is a, a huge deal. And it goes a long way.  [00:42:48] Guest 1:  Yes. Yes. Thank you for that.  [00:42:51] Barb Worth:  Great. And I think that it's a good message that we need to continue. That it isn't something you just check the box, right? It has to be something that we [00:43:00] do on a daily basis on an ongoing basis.  [00:43:03] Guest 2:  What is something you learn as like a trans person, cuz um, I, I think being trans and transitioning a big part of that is mental because, um, just like anyone else you're socialized. In a certain way towards gender, uh, and you're raised into a society that treats it a certain way. And, um, you, you can find this dissonance in your own sense of self because you were raised one way, but, um, you feel a different way in, in those clash. And so, yeah, it's, I think it's a big deal.  [00:43:34] Guest 1:  Yeah. Thank you  [00:43:36] Barb Worth:  for. [00:43:36] AC Goldberg:  thank you all so much for, for just being here and holding the space with us. I know that we're, you know, kind of coming to a close and, um, thank you so much for being willing to come on here. And like your ongoing, just vulnerability in this conversation is really appreciated because you know, the listener, the people who will listen to this podcast, you know, they're going to be faced with [00:44:00] potentially serving the trans population. Um, and. I think that, you know, it's at the utmost importance that they understand how vulnerable we are in clinical spaces. Um, and you know, how important it is to engage in culturally responsive practices. Um, because we do come with so much, we do bring so much baggage from other clinical interactions, um, into these spaces. And I just I've had such a wonderful. Time, listening to your voices and listening to your stories. And I know Barb is doing such amazing work, um, and Eddie, it is so wonderful to see you, Kate and Amy, thank you so much for holding this space for us here today. Thank you  [00:44:38] Kate Grandbois:  all so much for all of this. I have enjoyed this conversation so much, and I'm so grateful for your time and vulnerability and, and sharing your stories with our audience. Really. So.  [00:44:50] Guest 2:  Agreed. Thank you all so very much. And it was, it was lovely to virtually meet you all too. Thank you  [00:44:56] AC Goldberg:  so much trans joy. I just agree so much [00:45:00] trans joy right now. Like, like so much of it. It's just like overflow. Um, and if I didn't  [00:45:06] 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.