Leading Change in Continuing Education SLP NERDCAST We’re like a conference—in your car, gym, laundry room… wherever! Podcast Course: Screening and Progress Monitoring of Language This course is offered for .1 ASHA CEUs (Intermediate Level, Professional Area). "Thank you for making this excellent, research-based learning opportunity that is both extremely accessible and affordable. This is the best kind of PD: it’s one hour at a time so I can learn and then have time to synthesize and apply. It provides information I can apply to my practice immediately; and I can listen and learn while I drive, fold laundry, etc. thanks for the research and resources!" -Johanna H. Get this course and more with an SLP Nerdcast Membership MEMBERSHIP INCLUDES: Unlimited access to 100+ courses for ASHA CEUs: All SLP Nerdcast Memberships get you unlimited access to courses for ASHA CEUs that go in your ASHA Registry and can count towards an ACE Award. Access to conferences, live events and exclusive content All SLP Nerdcast Memberships get access to live events and exclusive content, including two annual conferences, SLP Linked and LEAHP. Unlimited Access to our Resource Library Upgrade to our All Access Membership and get unlimited access to our Resource Library that includes therapy materials, course handouts, and resources you need to save time. Intermediate 60 min Offered for .1 ASHA CEU (1 Hour of PD) Podcast Course Watch the course for free below or listen on your favorite podcast player Post-test included in SLP Nerdcast Membership This course meets ASHA's DEI requirement Course & Instructions Podcast Course & Instructions: Surprise! Science says more therapy isn’t always better… Post-Test Self Assessment, Course Evaluation, and Feedback Learning Objectives After participating in this session participants will be able to: List the purpose of assessment and identify those necessary for MTSS. Describe the characteristics of curriculum-based measures Explain how/why oral narrative retells are appropriate for screening and progress monitoring of language. Time Order Agenda: 10 MIN: Introduction and Disclosures 15 MIN: Descriptions of the purposes of assessment and identify those necessary for MTSS 15 MIN: Review of how student engagement relates to language outcomes 10 MIN: Review of strategies for implementing key findings from dosage and frequency research in your current practice 5 MIN: Summary and Closing What's Inside: 2 Lessons Course Description: You’re an awesome school-based speech-language pathologist (SLP), the resident language expert, the speech closet hostess with the mostest. You’re chugging along, doing your assessment thing, determining eligibility here, pushing into the classroom there, pulling kids out, chattin’ with the teacher- you’ve got this! Then BAM!! This episode comes out of nowhere and reveals an unknown blind spot in our educational system, putting a serious snag in your assessment status quo. No worries, the Nerds and their experts have your back! This week, Dr. Trina Spencer and Dr. Doug Peterson step up once again with an eye-opening follow-up to their previous episodes on dynamic assessment (DA) and Multi-Tiered Systems of Supports (MTSS) for language assessment and intervention in schools. Tune in to go the extra MTSS and DA mile and learn about your essential role in the screening and prevention domain, an area of SLP not often explored, but so essential to a student’s academic success. You’ll drive away with a better understanding of the roles of language assessment beyond eligibility determination, along with (free but fabulous) tools you’ll need to adjust for that screening blindspot and to help your education team set students up for language (and therein, academic) success. There’s free stuff, witty banter, soap boxes, and MacGyvering. Don’t miss out! Related Free handouts & downloads Choose the Membership that's Right for You Options that save you time and fit your budget Learn More Basic Unlimited Access to Courses & Content Experts All Access Unlimited Courses, Content Experts, & Therapy Resources Business Great for groups, departments, and organizations Looking for a freebie? Check out our Resource Library with free resources, handouts, downloads related to this course! Go to the Resource Library Meet Your Instructors Trina Spencer, Ph.D., BCBA-D Dr. Spencer is an Associate Professor at the Rightpath Research & Innovation Center at University of South Florida. She earned a specialist degree in School Psychology and a PhD in Disability Disciplines with emphases in language and literacy and early childhood special education. Her publications and editorial service span a number of disciplines including applied behavior analysis, speech-language pathology, early childhood education, special education, applied linguistics, and school psychology. Benefitting from strong collaborations with practitioners and other researchers, Dr. Spencer maintains a spirited research agenda to improve the academic and social outcomes of the nation's most vulnerable students. SLP/BCBA; SLP Kate Grandbois (she/her) & Amy Wonkka (she/her) Kate and Amy are co-founders of SLP Nerdcast. Kate is a dually certified SLP/BCBA who works primarily as an "AAC Specialist". She owns a private practice with a focus on interdisciplinary collaboration, argumentative alternative communication intervention and assessment, and consultation. Amy is an SLP who also works as an "AAC Specialist" in a public school setting. Amy's primary interests are AAC, typical language development, motor speech, phonology, data collection, collaboration, coaching, and communication partner training and support. Doug Petersen, Ph.D., CCC-SLP Douglas Petersen is a Professor in the Department of Communication Disorders at Brigham Young University. His research focuses on child language and literacy, with a particular emphasis on learning potential. His psychometric research examines the validity and reliability of dynamic assessments and progress monitoring procedures for language and literacy. His intervention research is focused on examining the efficacy, effectiveness, and implementation of multi-tiered systems of language support. Speaker Disclosures Kate Grandbois Financial Disclosures Kate is the owner / founder of Grandbois Therapy + Consulting, LLC and co-founder of SLP Nerdcast. Amy Wonkka Financial Disclosures Amy is an employee of a public school system and co-founder for SLP Nerdcast Dr. Petersen Financial Disclosures Dr. Petersen is a co-authors of the Story Champs curriculum and PEARL dynamic assessment. They receive royalties from the sales of those items. Dr. Spencer Financial Disclosures Dr. Spencer is a co-authors of the Story Champs curriculum and PEARL dynamic assessment. They receive royalties from the sales of those items. Kate Grandbois Non-Financial Disclosures Kate is a member of ASHA, SIG 12, and serves on the AAC Advisory Group for Massachusetts Advocates for Children. She is also a member of the Berkshire Association for Behavior Analysis and Therapy (BABAT), MassABA, the Association for Behavior Analysis International (ABAI) and the corresponding Speech Pathology and Applied Behavior Analysis SIG. Amy Wonkka Non-Financial Disclosures Amy is a member of ASHA, SIG 12, and serves on the AAC Advisory Group for Massachusetts Advocates for Children. Dr. Petersen Non-Financial Disclosures Dr. Petersen has no non-financial relationships to disclose. Dr. Spencer Non-Financial Disclosures Dr. Spencer has no non-financial relationships to disclose. References & Resources Petersen, D. B., Spencer, T. D., Konishi, A., Sellars, T. P., Robertson, D., & Foster, M. E. (2020). Using parallel, narrative-based measures to examine the relationship between listening and reading comprehension. Language, Speech, and Hearing Services in Schools, 51(4), 1097-1111. https://doi.org/10.1044/2020_LSHSS-19-00036 Petersen, D. B., & Spencer, T. D. (2014). Narrative assessment and intervention: A clinical tutorial on extending explicit language instruction and progress monitoring to all students. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 21, 5-21. https://doi.org/10.1044/cds21.1.5 Petersen, D. B., & Spencer, T. D. (2012). The Narrative Language Measures: Tools for language screening, progress monitoring, and intervention planning. Perspectives on Language Learning and Education, 19(4), 119-129. https://doi.org/10.1044/lle19.4.119 Course Details Where Listen to this course on your favorite podcast player, on our YouTube channel, or using the video above. Course Number ABJE0054 Transcript Available A transcript may be available for this course. Click here to visit our blog and read the transcript. Email ceu@slpnerdcast.com for transcript help or accessibility needs. Available on demand When Course Disclosure Financial and In-Kind support was not provided for this course. Learn more about corporate sponsorship opportunities at www.slpnerdcast.com/corporate-sponsorship Disclaimer The contents of this course are not meant to replace clinical advice. SLP Nerdcast hosts and guests do not endorse specific products or procedures unless otherwise specified. READ MORE COURSE POLICIES Additional Information All certificates of attendance and course completion dates are processed using Coordinated Universal Time (UTC). UTC is 5 hours ahead of Eastern Standard Time (EST) and 8 hours ahead of Pacific Time (PT). If you are using SLP Nerdcast courses to meet a deadline (such as the ASHA Certification Maintenance deadline) please be aware of this time difference. Your certificates and course completion dates will reflect UTC not your personal time zone. Closed captioning and transcripts are available for all courses. If you need additional course accommodations please email ceu@slpnerdcast.com Refunds are not offered for digital products, downloads, or services Certificates of attendance are only awarded to participants who complete course requirements Please email ceu@slpnerdcast.com for course complaints Thank you to our Contributing Editors Episode Summary provided by Tanna Neufeld, MS, CCC-SLP, Contributing Editor Audio File Editing provided by Caitlin Akier, MA, CCC-SLP/L, Contributing Editor Promotional Contribution provided by Paige Biglin, MS, CCC-SLP, Contributing Editor Web Editing provided by Sinead Rogazzo, MS, CCC-SLP, Contributing Editor

Explore language development courses at SLP Nerdcast. Gain insights into supporting language growth and development in your clients effectively. LANGUAGE DEVELOPMENT Courses Expand Language Development Skills for SLPs. Deepen your expertise with courses focused on enhancing language acquisition and intervention strategies in speech-language pathology. Category Courses Language Skills in Youth Offenders Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Language Development & AAC: Back to Basics Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Research to Practice in 2023: Addressing Complex Syntax Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Member Only Access Unlocking the Mystery of Selective Mutism with Dr. Aimee Kotrba Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Differentiating Difference from Disability: The DYMOND Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Bringing it all together: Aided Language Modeling Type: Podcast Level: Intermediate Length: 60 Min Credits: 0.1 ASHA CEUs Learn for Free. Snag the ASHA CEUs for only $9. The Language and Literacy Connection: A Beginner's Guide for Pediatric SLPs Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Trauma and Communication Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Meeting Families in the Middle: Working with Deaf and Hard of Hearing Children Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Bringing it all together: Chaining Procedures in AAC Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Improv: Your New Favorite Therapy Technique Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Adapting Materials for Language and Literacy Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Member Only Access AAC Narrative Intervention Type: Podcast Level: Introductory Length: 60 Min Credits: 0.1 ASHA CEUs Learn for free. Snag the ASHA CEUs for only $9. Choose the Membership that's Right for You Options that save you time and fit your budget Basic Unlimited Access to Courses & Content Experts All Access Unlimited Courses, Content Experts, & Therapy Resources Business Great for groups, departments, and organizations Basic 99 /year $ Get Basic Now Billed Once Per Year. Instant Access To Over 100 Courses for ASHA CEUs Unlimited ASHA CE Processing Unlimited Access to Certificates of Completion Private Community with Content Expert and Guest Speaker Access All Access /year Billed Once Per Year. Instant Access To Over 100 Courses for ASHA CEUs Unlimited ASHA CE Processing Unlimited Access to Certificates of Completion Access to all future Live Events & Conferences for the lifetime of your Membership 10% off Graduate Credit Courses Private Community and Speaker Access Members Only Monthly Peer Mentoring Unlimited access to over 50 course handouts Unlimited access to our Resource Library, including: 1 Free Year of Vooks digital books for you and your clients (valued at $49.99) Digital therapy materials and downloads (donated from 5 community partners and growing!) 10 Themed Language Bundles from The Speech Therapy Store (valued at $70) 5 Mini Language Lessons for Middle and High School Students (valued at $25) Discounts and Perks (valued at $25 and growing) 149 GET ALL ACCESS NOW $ Business Up to 15% OFF Get Business Now Discounts of up to 15% when you purchase 5 or more Memberships. A great option for departments, schools, or groups. We accept purchase orders, can provide detailed user reports and receipts. Pick the Membership that's right for your group and contact us to get up to 15% off . Click the link above to request a quote, or email us at info@slpnerdcast.com .

Leading Change in Continuing Education SLP NERDCAST We’re like a conference—in your car, gym, laundry room… wherever! Recorded Webinar: The Value of Visibility in DEI: Efforts from Multicultural Constituency Groups This is a recorded playback of a live course that took place on May 9th, 2023 as part of our LEAHP series. ASHA CEUs are available for SLP Nerdcast Members. "Thank you for making this excellent, research-based learning opportunity that is both extremely accessible and affordable. This is the best kind of PD: it’s one hour at a time so I can learn and then have time to synthesize and apply. It provides information I can apply to my practice immediately; and I can listen and learn while I drive, fold laundry, etc. thanks for the research and resources!" -Johanna H. Get this course and more with an SLP Nerdcast Membership MEMBERSHIP INCLUDES: Unlimited access to 100+ courses for ASHA CEUs: All SLP Nerdcast Memberships get you unlimited access to courses for ASHA CEUs that go in your ASHA Registry and can count towards an ACE Award. Access to conferences, live events and exclusive content All SLP Nerdcast Memberships get access to live events and exclusive content, including two annual conferences, SLP Linked and LEAHP. Unlimited Access to our Resource Library Upgrade to our All Access Membership and get unlimited access to our Resource Library that includes therapy materials, course handouts, and resources you need to save time. Introductory Offered for .1 ASHA CEU (1 Hour of PD) Recorded Webinar Post-test included in SLP Nerdcast Membership Meets ASHA's Ethics Requirement Recorded Playback & Handout Recorded Playback & Handout: The Value of Visibility in DEI: Efforts from Multicultural Constituency Groups Post-Test Post-Test Course Feedback Self Assessment, Course Evaluation, and Feedback Learning Objectives After participating in this session participants will be able to: Identify the mission of the Multicultural Constituency Groups (MCCGs) of ASHA. Describe two action steps to become involved with the MCCGs of ASHA. Discuss at least two challenges and the advocacy work led by the different MCCGs. Time Order Agenda: 10 MIN: Review of MCCG Missions 15 MIN: Review of Barriers to MCCG Missions 25 MIN: Review of MCCG Advocacy Tasks 10 MIN: Review of Action Steps to become involved with the MCCGs of ASHA What's Inside: 3 Lessons Who This Course Is For: Any professional that works clinically in the field of communication sciences and disorders Any professional who is not familiar with the multicultural constituency groups (MCCGs) Any speech language pathologist or related professional who is interested in increasing their knowledge base of action steps related to multicultural constituency groups Course Description: The multicultural constituency groups (MCCGs) will present the advocacy work through the collected effort across Asian Pacific Islander Speech-Language-Hearing Caucus, Disability Caucus, Haitian Caucus, Hispanic Caucus, L’GASP: The LGBTQIA+ Caucus, Middle East and North Africa Caucus, National Black Association for Speech-Language and Hearing, Native American Caucus, and South Asian Caucus. The panel will provide action steps to promote diversity and inclusion of our profession through MCCGs lens. Choose the Membership that's Right for You Options that save you time and fit your budget Learn More Basic Unlimited Access to Courses & Content Experts All Access Unlimited Courses, Content Experts, & Therapy Resources Business Great for groups, departments, and organizations Meet Your Instructors Brittani Hightower, M.S. CCC-SLP Brittani Hightower, M.S. CCC-SLP is currently a Lead Speech-Language Pathologist in Aldine Independent School District in Houston, Texas. She recieved her Bachelor of Science in Communication Sciences and Disorders and Master of Science in Speech Pathology from Howard University. Ms. Hightower has gained clinical experience in the private practice, outpatient rehabilitation and school settings, providing speech therapy services to students and patients ages 3 to adult. In 2020, she was awarded the ASHA Distinguished Early Career Professional Certificate. Currently, Ms. Hightower serves on the Board of Directors for the National Black Association for Speech Language and Hearing (NBASLH) and holds the offices of Parliamentarian, Bylaws Committee Chair, and NBASLH Cares Co-Chair. Ms. Hightower was recently elected to be the Chair Elect of the Board of Directors. H Sheen Chiou, Ph.D. CCC-SLP Hsinhuei Sheen Chiou (she/her/ ) is a professor and distinguished faculty scholar in the Department of Speech, Hearing and Rehabilitation Services at Minnesota State University, Mankato. She teaches academic and clinical courses in adult neurogenic disrders including aphasia and acquired conginative disorders, runs a brain injury research lab, creates patient-centered programs for adults with neurogenic disorders, and promotes equity, inclusion and diversity in speech-language and hearing sciences. She currently serves as co-president of the Asain Pacific Islander Speech-Language-Hearing-Caucus. GC Robinson, Ph.D. CCC-SLP GC Robinson, Ph.D. CCC-SLP (she/they) is an Associate Professor at the University of Arkansas for Medical Sciences. They are the chair of L'GASP: The LGBTQIA+ Caucus of ASHA, the Director of the Ph.D. Program in Communication Sciences and Disorders, the founder and director of the TLC: Gender Affirming Communication Group at UAMS, and the SLP Discipline Coordinator for the Arkansas Leadership Education in Neurodevelopmental Disabilities Grant. They also provide contract private voice therapy for Prismatic Speech Services. They've published research in the areas of Diversity, Equity, and Inclusion in Speech-Language Pathology. Archie Soelaeman Archie Soelaeman is a Co-President of the Asian Pacific Islander Speech-Language-Hearing Caucus. She graduated from Northwestern University with her master's in speech-language pathology and a professional educator license with speech-language pathologist teaching endorsement. She is the Manager of School Speech Language Services and a speech-language pathologist at Helping Hand in Countryside, Illinois. She has over 14 years of experience providing services to K-12 students with a primary diagnosis of autism and collaborates with multidisciplinary team on a daily basis. Her clinical interests include autism spectrum disorders, augmentative and alternative communication, and apraxia. Sofa Carias, M.S. CC-SLP Sofia Carias, M.S. CCC-SLP is a practicing bilingual speech pathologist in the Los Angeles area. She completed her undergraduate work at New Mexico State University in Las Cruces, and earned a Master's Degree from Arizona State University in Tempe. She has worked in several states as a school based speech pathologist, delivering services in both English and Spanish through various therapy models, while also supervising clinical fellows and speech therapy aides. Sofia is a past president of the Hispanic Caucus, a Multicultural Constituency Group, and has also served as a site visitor for the Council on Academic Accreditation. Her areas of interest include language disorders in school aged populations, autism spectum disorders in bilingual speakers, and the use of technology to improve therapy outcomes and access to services. Speaker Disclosures H Sheen Chiou Financial Disclosures The presenter is a full time employee at Minnesota State University, Mankato. Sheen is receiving an honorarium for participating in the conference. Sofia Carias Financial Disclosures Sofia has no financial relationships to disclose. Sofia is receiving an honorarium for participating in this conference. Shine Burnette Financial Disclosures Shine has no financial relationships to disclose. Shine is receiving an honorarium for participating in this conference. Gregory C. Robinson Financial Disclosures Gregory is receiving an honorarium from SLP Nerdcast, and I am a full time Associate Professor at the University of Arkansas for Medical Sciences and a contract employee for Prismatic Speech Services. Archie Soelaeman Financial Disclosures Archie is receiving an honorarium from SLP Nerdcast. Brittani Hightower Financial Disclosures Brittani has no financial relationships to disclose. Brittani is receiving a honorarium for participating in this conference. Kate Grandbois Financial Disclosures Kate is the owner / founder of Grandbois Therapy + Consulting, LLC and co-founder of SLP Nerdcast. H Sheen Chiou Non-Financial Disclosures The presenter has professional affiliation with: Academy of Neurologic Communication Disorders and Sciences (Finance Committee) Asian Pacific Islander Speech-Language-Hearing Caucus (Co-president) ASHA, ASHA SIG2, SIG14, SIG15, SIG17 ASHA Diversity Enhancement Community Aphasia Access, Mankato/North Mankato Act on Alzheimer’s Action Team (member) Minnesota Connect Aphasia Now (Speech-Language Pathologist/Clinical Supervisor) Minnesota Speech-Language-Hearing Association (VP for Professional Development) Sofia Carias Non-Financial Disclosures Sofia has no non-financial relationships to disclose. Shine Burnette Non-Financial Disclosures Shine has no non-financial relationships to disclose. Gregory C. Robinson Non-Financial Disclosures I am Chair of L'GASP: The LGBTQ+ Caucus of ASHA Archie Soelaeman Non-Financial Disclosures Archie is the Co-President of Asian Pacific Islander Speech-Language-Hearing Caucus Brittani Hightower Non-Financial Disclosures Brittany has no non-financial relationships to disclose. Kate Grandbois Non-Financial Disclosures Kate is the owner / founder of Grandbois Therapy + Consulting, LLC and co-founder of SLP Nerdcast. Course Details Where Access to this course is available exclusively to SLP Nerdcast members only. The recording can only be accessed through this learning platform and will not be found on our YouTube channel or wherever you typically get our podcast episodes. Course Number ABJE0110 Description The multicultural constituency groups (MCCGs) will present the advocacy work through the collected effort across Asian Pacific Islander Speech-Language-Hearing Caucus, Disability Caucus, Haitian Caucus, Hispanic Caucus, L’GASP: The LGBTQIA+ Caucus, Middle East and North Africa Caucus, National Black Association for Speech-Language and Hearing, Native American Caucus, and South Asian Caucus. The panel will provide action steps to promote diversity and inclusion of our profession through MCCGs lens. Available on demand When Course Disclosure Financial and In-Kind support was not provided for this course. Disclaimer The contents of this course are not meant to replace clinical advice. SLP Nerdcast hosts and guests do not endorse specific products or procedures unless otherwise specified. READ MORE COURSE POLICIES Additional Information All certificates of attendance and course completion dates are processed using Coordinated Universal Time (UTC). UTC is 5 hours ahead of Eastern Standard Time (EST) and 8 hours ahead of Pacific Time (PT). If you are using SLP Nerdcast courses to meet a deadline (such as the ASHA Certification Maintenance deadline) please be aware of this time difference. Your certificates and course completion dates will reflect UTC not your personal time zone. Closed captioning and transcripts are available for all courses. If you need additional course accommodations please email ceu@slpnerdcast.com Refunds are not offered for digital products, downloads, or services Certificates of attendance are only awarded to participants who complete course requirements Please email ceu@slpnerdcast.com for course complaints

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes EpisodeSponsor 1 Kate Grandbois:  Welcome to SLP Nerdcast. We're so excited for today's episode. We are here with Amanda Sheriff Hobson. Welcome, Amanda.  Amanda Scheriff Hobson:  Thank you. I'm so glad to be here.  Amy Wonkka:  Amanda, we're excited for today because you are here to discuss developing [00:02:00] competency and self advocacy skills for complex communicators. Uh, so I'm super pumped to talk to you about this topic, but before we get started, can you please tell us a little bit about yourself? Amanda Scheriff Hobson:  Absolutely. I'm excited to be here and share about this topic. Um, I am a school based speech therapist. I work in a collaborative school in Massachusetts where I am a SLP, but I'm also the speech therapy department head. Um, I've primarily always worked with students with complex communication needs as young as three years old up until the age of 15, working on developing, um, communication strategies and robust communication systems so that these students have access to language. Um, so that has had me in private practice, home healthcare, um, and for the last nine years in the school setting.  Kate Grandbois:  So we're really excited for this, not only because it is of tremendous importance, but it also touches our personal clinical experience. And so it's, [00:03:00] I'm very excited for this conversation. It's going to be great. Um, we need, do need to read our learning objectives and financial disclosures before we get into the fun stuff. So I will do that as quickly as I can. Learning objective number one, identify at least three skills to target to develop communication competency. Learning objective number two, identify at least three activities or tools for students to learn and practice self advocacy skills. And learning objective number three, explain how to use coaching strategies to support communication partners. In utilizing skills explicitly taught during natural moments in the learning environment, disclosures, Amanda's financial disclosures, Amanda works for and receives a salary from a public school system. Amanda also received an honorarium for participating in this course. Amanda's non financial disclosures. Amanda is a member of ASHA SIG 12. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co [00:04:00] founder of SLP Nerdcast. My non financial disclosures. I am a member of ASHA SIG 12 and I serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy.  Amy Wonkka:  Amy, that's me. My financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I am a member of ASHA. I'm part of Special Interest Group 12, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, on to the good stuff. Amanda, why don't you start us off by just telling us a little bit about self advocacy? So what What is self advocacy and why is it so important? Amanda Scheriff Hobson:  Yeah. So I think this sort of started to become a focus area for me as I worked with more and more students with what again we're defining as these complex communication needs. Um, these students typically need a lot of interpretation around what their behavior means, what their communication styles [00:05:00] are. And sometimes it felt like we weren't doing enough to make sure that their needs were being known. Um, in my role as both a direct therapist, working with the students, but also supervising other SLPs, this just seemed to be a theme that came up a lot. How can we do better? How can we assure that There's full autonomy, even as they're continuing to learn how to use language more effectively and efficiently, and so it really started this conversation of what could we do? What kind of strategies can we use? What's out there in terms of self advocacy type curriculums? And of course, we quickly realized, That no big box curriculum is going to meet exactly what we're looking to teach. And so this is really combining a lot of different, uh, research pieces out there, different methodologies, different strategies. And again, we quickly realized we can't just do the teaching. We also need to think about the environment. So we need to think about where students are communicating, who they're communicating with, and how to make sure that the [00:06:00] people who are receiving these messages are just as prepared as those who are. And so when we're thinking about self advocacy, we're thinking about not just protesting and saying, if you don't want something, but we're thinking about how students can think about themselves and what they want to say and how to act on that. So we're really starting to think about what kind of changes to the environment need to happen. What kind of opportunities do we need? And we really started to highlight and go back to the Communication Bill of Rights, and how this is really a resource that a lot of clinicians have used, um, and referenced when they're thinking about presumption of competence and access to communication. But we started to think, why don't our students use this? Why aren't they learning about this resource just as we are? And how can we make that accessible? So sort of thinking about those 15 or 16 rights and saying, let's use this as our framework. Let's think about these things that we know our students should have access [00:07:00] to. And let's use that as our content and our skills that we're teaching, as well as what we're teaching the people who are working with our students. That sort of became the framework for how we're thinking about this. And so a lot of the things that I'll share today are. Coming from a classroom of middle school students who are all complex communicators, they are using alternative access. You see, like, two step switch scanning or auditory only scanning. They're also using direct selection. Um, some of them are very emergent in their communication skills, while some are more context dependent or transitional in their skills. Um, but there's still this constant need for interpretation from those who are working with them, and that's where we also start to think about the partner training to make sure that as we're teaching the skills to our students, we're also teaching skills to those around them. Kate Grandbois:  I know one of the first things that we want to do is have you talk to us a little bit about what self advocacy is by definition. Before we [00:08:00] get into that, I just want to make a quick comment, um, elaborating on something you said that I think is really important, is that out of the box curriculums, out of the box strategies are a slippery slope. And I love that you've kind of described them as not a, One size fits all approach, and I think in a lot of instances, these curriculums, these packages of therapy materials are marketed as a blanket, a pro as a blanket approach to your clients or your students, and that's never good practice, right? That's never a. Uh, an evidence based method of providing intervention, just taking, taking something straight out of the box and slapping it on or throwing it in the classroom, right? We always want to create customized interventions. Um, and I love that, that you've, you've set that up as a backdrop here for, for the important work that you're about to tell us. I just wanted to kind of make a comment about that.  Amanda Scheriff Hobson:  Yeah, I appreciate that. I think, too, we, we noticed that, you know, they're [00:09:00] great. They're great foundations. They just need a lot of adaptation or modification to them to make them accessible for all students or for specific students, individual needs. Um, and oftentimes they were very pigeonholed into a specific skill, and we really wanted to highlight that there's a lot of skills that go into self advocacy. Um, so, like, you might have a program that really just teaches access to IEPs and making sure they're a participant in their IEP process, and that's a wonderful thing, but there's a lot of, uh, self advocacy that happens. Every day around them, not just that one time annual meeting, um, or thinking about being able to protest again. That seems to be the first go to for a lot of, um, goal areas or focus areas. But it's also about acting on preferences and sharing opinions and making sure that students can do all of those skills. So really thinking more holistically about it.  Amy Wonkka:  Yeah, I, uh, I'm excited. I have the I have the good fortune of seeing the notes ahead of me. So I know some of the topics that we're going to cover. I'm [00:10:00] excited to talk about those as well. But I do think it would be helpful for us to just talk a little bit like Amanda, you've said, self advocacy is not just protesting. It's not just Requesting your basic needs. It's not just attending your IEP meeting. Um, so can you give us sort of a formal definition about what we're thinking about when we're thinking about this sort of all encompassing skill area?  Amanda Scheriff Hobson:  Yeah, absolutely. So we would define self advocacy as a set of skills and sub skills that engage that complex process of speaking on your own behalf, um, to share your needs, your beliefs, your opinions, your interests, desires, your protests, um, and you want to be thinking about also this concept of self determination within self advocacy. So in order to do all of those things, you also need to know about yourself, um, and what kind of motivates you and interests you and drives you during the day. Um, so they kind of go hand in hand. The [00:11:00] self advocacy doesn't really exist without self determination, um, and so that really means it's like a metacognition. task, right? You're doing this internal thinking about yourself. Um, you're learning about what you need, what your strengths are, what the areas you need support in, um, and also teaching value of who you are as an individual, um, so that you can engage in more of these meaningful tasks and motivating and within motivating context, um, to be able to self advocate. Kate Grandbois:  I loved when I was reading, um, your talking points, I loved reading that this was very much a metacognitive skill, meta, a metacognitive task. I'd never thought of it that way before, but you're absolutely right. And I think that's a really important lens to, to look at this through.  Amanda Scheriff Hobson:  Yeah, absolutely. And I think, you know, again, they go hand in hand. We want our students to understand why they're saying no to something. We want them to understand why they're asking for something, why they are trying to engage with the people around them, and when and where they want to do that. [00:12:00] And in order to do that, they need to understand it. the, you know, we're going to get into skills here, but thinking about what are their communication strategies? How do they communicate? Um, also including disability awareness, understanding who they are as learners and who their other classmates are as learners. And it's how it's okay to have differences. Um, thinking about accommodations that they need so that they can ask for them. They don't know what to ask for if they're not really aware of what their accommodations and learning needs. are. Um, also understanding who these people are that are surrounding them, these teachers, these aides, these therapists, um, and how they are support people and not actually the people who are doing the speaking for them or they shouldn't be. Um, also going into things like personal preferences and motivation, um, thinking about this concept of public and private information, um, and how they have a right to say no to that, um, if they don't want to share certain pieces of information. So we get into a lot of these like Big knowledge skills, right? Then we've talked about [00:13:00] disability awareness, accommodations, public and private. But then we also start to think about what do they do with that, right? Um, how do they use, um, a set of words, whether it's a pre stored phrase or an independent phrase to let somebody. know that they don't know a thing, or that they want that word added into their device, um, or that they want to engage with a new peer in their classroom. Um, these are the things that we're thinking about for the knowledge and content, but then also how to use that knowledge and content to act on their skills. Kate Grandbois:  I think another really important, um, delineation for me reading through this is thinking about these things as skills. And I, I know conceptually we, you know, Oh, well, a student should have knowledge of their rights. A student should have knowledge of self and individual needs, but that's very different than, you know, having that conceptual framework of what we should be focusing on is very different than. Well, let's actually target it as a skill, which I assume, [00:14:00] in your experience, translates into goals and targets and those kinds of things. That's very different than a philosophical framework of what we should be doing as therapists. Do you agree?  Amanda Scheriff Hobson:  Absolutely. I like that you're using that word should because this also challenges people to be a little bit, I guess, open and comfortable with the fact that we're asking them to do something different, right? We kind of all come to the table with our own agendas and teachers and teacher aides, they know that there's a schedule, we need to follow it. And so if someone comes out and says, wait, I'm not ready to do that. We have to be okay with saying, okay, we'll wait. Right. We need to change the environment, um, to be open to the, the, the, I guess the opportunities that our students are going to hopefully act on, right? If we're not willing to change, then some of these shoulds might not actually get those meaningful opportunities to happen. So that's why, again, that partner training is so important because they need to have the skills to act on. A student's advocacy in that [00:15:00] moment. And if we don't have that cause and effect, right, if we don't act on what they ask for, then they're not going to learn the power that self advocacy has. Amy Wonkka:  So just to say this back to you, and I think you'll talk more about the environment as we go through, but that implicit message that we're sending as communication partners and as staff in a school environment or some other environment, you know, when we don't listen and act on our students communication, when they are sharing these messages that are self advocacy, preference related, slash, you know, just Making their needs met. We are sending that message that okay It doesn't matter. We just we just want you to follow. We just want you to follow the program The program is doing what I want. Not what you want  Kate Grandbois:  um  Amy Wonkka:  So i'm i'm excited to hear more and more about that because I think that must be a really big Paradigm shift for a lot of places and I think there's also got to be a place in the middle, [00:16:00] which is finding the balance too. I mean, I, I work in schools as well. And there, you know, there is a schedule. So how do you help the communication partners to kind of find the times where, yes, you should definitely be mindful about supporting a student self advocacy versus, um, when you, when you really can't and what's the best way to do that. Um, maybe you can talk to us a little bit about what some of your Skill learning activities might look like.  Amanda Scheriff Hobson:  Absolutely. Yeah. So when we're thinking about this, we actually run a self advocacy group weekly in our classroom that we, you know, again, I talked about using the communication bill of rights, sort of as our framework for thinking about what content we want to teach, but we also think about what's happening around them. So for example,   A lot of our students, um, happen to have IEPs at the beginning of the school year. So we're going to use that maybe as a focus for the first four weeks or so, um, but what we're thinking about is what do we need our students to have in their, their [00:17:00] toolbox in order to participate in what's happening on their current schedule? Um, we want to move away from hypothetical and we want to really move into realistic. Um, and so we're thinking about. Content teaching and so content teaching can be really challenging. Um, it could be boring. Um, but we want to really try to make it as, um, functional as possible. So one thing that we'll do is when we set our, our main topic is we'll think about creating some type of custom. Um, this way we can really pull in realistic scenarios that our students will be part of, and this is used to provide examples of the skill that we're going to be teaching, provide vocabulary that we're going to be targeting, um, trying to use real pictures of the students, maybe in the settings that they're going to be practicing their skill in, examples we've had, let's go to an IEP meeting and we're going through that process in that building, um, my accessible school and we're walking around and looking at pictures of them. Things that are in the school that make it accessible for students to participate and learn in. [00:18:00] Um, and so once we have that type of narrative to introduce the topic, we're using a lot of explicit vocabulary instruction routines to really make sure that our students are learning about these higher level vocabulary, um, in a meaningful way. And using the words that they have access to. So, like I said earlier, a lot of our students are at various levels of learning to use a robust language system, but they all have access to robust language systems. And so we want to use the words that are in their devices to be able to identify, define, understand these higher level. Tier two and three words that we're targeting. Um, so for example, um, we looked, um, at the word accessible. And so that is probably a tier two or three word. They probably don't have it in their devices, but they do need to understand what it means to have something be accessible to them. And so we've used core words like accessible. It means to get what you need. It means to help you to go into this place. Um, and those are [00:19:00] words that live in their device, help, go, get, need. Um, and we really emphasize that as we're teaching the definition. Um, we do other activities that fall under these explicit vocabulary instruction routines, such as examples and non examples. Once we've understood that word accessible, we're going to look at some pictures of things that they've experienced and determine, is this an example of something that's accessible or is it not? So we might see a big staircase walking up to the building. Is that accessible for you if you're in a wheelchair? No. Um, is this elevator something that makes the school accessible? Yes. Um, we'll also generate situations, right? What kind of places are you going to be? to be accessible, um, and kind of go through and make lists that way. Um, we'll also do some word associations, reading aloud different sentences, um, such as, Amanda went to the bathroom with just one aide to change their clothes. Is that an example of something that's private or public? Right? As we're getting into different [00:20:00] vocabulary words. Um, I went to a busy mall. Is that a private place or is that a public place? Right? So again, we're thinking about these different ways to go through these routines to make sure that students are understanding the words that we're teaching before we're asking them to act on it. Kate Grandbois:  I also love, uh, one, just want to comment. I love the way you're describing these activities. It sounds like some of them are really experiential learning. So going with the student into the hallway. To the stairs and having a conversation about the accessibility or inaccessibility of of that physical environment, which is a very different learning experience than just conceptually learning about in the in the classroom. And I have to imagine that that is a really powerful learning experience.  Amanda Scheriff Hobson:  Absolutely. They recently did a scavenger hunt to go through the building, sort of like what you're talking about to find and they had, they had a list of all these places that are on their schedule. Go find something that's accessible. Go find something that's not. Take a picture of it. [00:21:00] But we're also putting language on that with their, their aid. So tell your aid when you're ready to take the picture. the picture, tell them yes or no, if this is the place that you want to take the picture of. So there's so much language opportunity on top of these content pieces, um, and again, to provide the autonomy around, um, being able to say, yes, I want to do this. No, I don't. Um, and it's a really good practice opportunity for the aides that are working with the students.  Amy Wonkka:  And I just want to reiterate for the listeners that you just gave such a nice example of some of that environmental difference, right? So in. Instead of going somewhere, finding that it's private, having the aide tell you to take a picture, you're having the student direct the adult. And I think also for so many of our learners, they're going to have a paid caregiver who's supporting them, um, throughout mo most of their life, all of their life. So being able to give those directions to other people is not only a self-advocacy skill, but it's a, it's a long life skill. Um, so that's just one nice example of how. [00:22:00] That environmental piece might look a little different. It's not a huge change. It's easily doable. Um, but building in those opportunities for students to give directions to adults.  Amanda Scheriff Hobson:  Yeah, absolutely. We really want to, again, make it functional and make it meaningful, right? Learning to give these directions is not something that's just going to happen in isolation in this activity. We're hoping that with repetitive practice, this is something that they can learn to do with a variety of communication partners.  Amy Wonkka:  I know you had a couple of more activities. Yeah, absolutely. You let it  Amanda Scheriff Hobson:  go through. Um, so yeah, after we get through some of these explicit vocabulary instruction routines, um, we're thinking about looking at, okay, so you have this comprehension. Now what are we going to do with it? We'll use this tool, Talking Maths, which is another way to look at Students being able to have autonomy when they're sharing their preferences. Um, TalkingMats could be a low tech or a high tech tool, um, they have an app now that you can use. A lot of our students need things that are large to accommodate for a CVI, um, so we'll often do these on large poster [00:23:00] boards where they can have symbols representing the words that we're talking about. But when you're using a tool like this, you really want to set the topic of what you're about to ask opinions around. And then again, thinking about the function of it after they share all these opinions. what are you going to do with it? Um, so, for example, um, last summer, we got ready for field trips, and the teacher committed to the students sharing their opinions about different field trip options, and based on the results of the classroom, those were the field trips they were going to go on. So they did some virtual field trips of looking at different field trips. Things in the Boston area that they could go to, um, she made sure they were realistic options. Um, and after, you know, all the students got to say, I like it, I don't like it, or a very popular phrase for the middle schoolers is whatever. I don't care. Um, and that's kind of our center column. So you have it. That's amazing. Yeah, it's very, uh, very into the age group, um, and a lot of them really like that word, um, so we hear that a lot, um, but [00:24:00] it's a good way to know, you know, sometimes we don't have opinions either way on something, so we want to, we don't want to pigeonhole into either the I like it or don't like it. So after these virtual field trips and these, um, ways to watch videos and think about what they were about to share their opinion on, they sorted those field trip options into those three categories. Um, they looked at which one had the majority and that's where they went. Um, so again, it kind of ties in building up the idea of that was the unit around preference. We all have preferences. We understood what that word meant. Then we got to practice acting on it. And the environment followed through, right? There was a cause and effect to completing that activity. Um, similarly, we've used this tool for IEP participation. Um, so looking at our schedules and thinking about the different classes that we attend, and we know that there are classes you just have to attend when you're a student, um, but you still can have an opinion about them. Um, so being able to sort that and then present it at an IEP meeting, um, share it with the families and the team members [00:25:00] so that they can see what your preferences are. And I think a tool like this is going to be very helpful. Um, Massachusetts recently changed their IEP format, and I think all schools will be rolling that out next year. Um, and there is a new section around student, um, student, uh, vision students, uh, what they want to learn about and what they like and their future goals at major transitions. Elementary, middle school and high school, and there's feedback around. How do we get somebody with maybe complex communication needs or an emergent communication level? How will they do this? How are we going to integrate that in? And I think it's important to think about some of these tools that can help meet a student where they are, but still give them the autonomy to share their opinion. Amy Wonkka:  I was so excited to read this whole piece about Talking Mats because I think that it's such a helpful tool for people, for listeners who may not be familiar with Talking Mats. It actually comes to us out of Scotland. Is that right, Amanda? Scotland? I think you're right. Yes. Yeah. [00:26:00] And I heard that this year they may be offering online trainings. At times that are USA friendly, um, so I'm pretty excited about that. I love the idea of using it for the new IEP, um, because I do think that is a challenge, um, for getting authentic participation. And I, I had a question for you just about using TalkingMaths as a tool. How, how early are you introducing something like this with your students? How young are you introducing the idea of sharing preferences like this and kind of grading your preferences between not just like, I want this, and I don't want this, but this is something I like, this is something, whatever, I don't care, and this is something I don't like.  Amanda Scheriff Hobson:  So I recently started thinking about this at even as my young as my preschool classes, right, because it's one of the early things that I'm hearing our aides model when they're introducing robust language, [00:27:00] because verbal referencing or being able to say what you see when you're noticing a student communicate and maybe what we would consider an unconventional way. Um, it's very easy to notice. Sometimes attach meaning to that, right? If someone's laying on the floor and they didn't like that fidget tool that they just selected, you can say, Oh, it looks like you don't like that one. But now to add another level to that, being able to maybe make a chart of fidget tools for students and saying, you know, every time you grab that brush, you seem to end up on the floor, right? It doesn't seem to be something that you like. So maybe we put it here for now. You could always change it. Um, it's not a permanent board by any means, um, that you could be able to think about Providing them some concrete visual that shows what they like and what they don't like. And it also then becomes a tool for the classroom. Um, you might have subs coming in every once in a while or every day. Um, and they might be able to look at a tool like that and say, Oh, okay, when I'm working with this kid, now I understand those things that they like or don't like. Um, music is very big in the younger classrooms, and I feel like we often [00:28:00] jump to nursery rhymes. Um, but nursery rhymes are not the only thing that we listen to. I have a two and a half year old who loves to listen to Mamma Mia the soundtrack, right? But that's not typically something that you would introduce until you knew. And so as you're doing a lot of experiencing and thinking about, Oh, okay, I'm noticing that they're getting very excited when they hear this. We can add that into their I like column. And I think that again, it's, it's not permanent by any means, but it does. Provide an Understanding where, um, the students are at.  Kate Grandbois:  And I, I think everybody listening, presuming most of our audience is speech language pathologists, most of us are familiar with the concept that visuals are a really powerful teaching tool for language. But, one of, another really important thing that you've brought up here is the power of visuals for the culture of your classroom. The power of visuals for the culture of your workplace environment and for communication partners because when you have that permanent product, like you said, you know, you have a sub coming in or you have a new aid or there are [00:29:00] other kids in the classroom that might, you know, really benefit from this kind of approach. You've, you're, you're tying it all together with this visual. I just, I just love that suggestion. I love it.  Amanda Scheriff Hobson:  Yeah, and we've used it in general education classrooms as well. So we have our students who are being pushed into their same age peers, seventh grade social studies, seventh grade math, things like that. And we recently had students, um, in those levels, um, the general education students fill out a survey telling us about the words they're using. Um, because again, we, the, that word, you know, uh, whatever really comes from what we're hearing other seventh grade students saying. Um, and it also seemed to be the most, uh, kosher, I guess, you know, we could use that word, um, but, you know, when we're thinking about it, we wanted to make sure that we're thinking about, okay, these are the words that other seventh grade students are using. That doesn't automatically mean those are the words that are seventh grade. Students should use, but we want them to know about them. So after we had the general ed students fill out the [00:30:00] survey about, you know, what are the words you can't live without? Or when you're turning on your iPhone, what's the first app you're going into? Um, trying to get a survey about what, you know, we're, we're old, we're, we don't know what's happening, . Um, so when we got that feedback, we went through and we said, okay, here's some slang words that you know, some of your peers are using. That's sick. Drip row, no cap. Yeah. That's what my son always says. I don't even know what it  Kate Grandbois:  means. Amanda Scheriff Hobson:  Exactly. We did have to do some looking up to understand what some of these words meant, but once we got them, we did some of those explicit vocabulary routines to teach them what the words meant, and then they got to decide, yes, I like that word. I should add it to my device. No, I don't like that word because. Who knows what it means or I'm never going to use it. I'm not, I don't want that in my device. And we showed it to the peers. We said, thanks so much for filling this out. Look what we did with it. And now it's another like, uh, socialization, social communication opportunity for our students to connect with their same age peers. Amy Wonkka:  Love it.  Amanda Scheriff Hobson:  And so that jumps [00:31:00] into, you know, thinking about phrasing phrases that we're teaching and programming. We're really shifting to including our students in that opportunity. So as we're learning those new phrases for self advocacy, right, we're balancing having students be able to use words to make their own. You know, snug, spontaneous novel utterance generation, being able to say exactly what they want to say, but sometimes self advocacy has to happen really fast, and so we also want to teach them that there's a fast way to use a phrase. Or I don't like that, or that's private information. We want to have that as a pre programmed phrase so that they can have the ability to say that quickly. Um, when there's like an urgency involved into the self, uh, self advocacy. Um, but again, you know, Historically, and I still have them, you know, we have a lot of sheets around the classrooms of aides and teachers writing down programming needs, but we're also including our students in that we want them to tell us what they want added to their device. So almost all of them have buttons that say, [00:32:00] add that word to my device in their chat words or quick, quick words folder. Um, in the case that, you know, we're in a classroom and they hear somebody say something, then we could add that in. So they're learning to advocate for that. But we'll do explicit teaching of that while we're learning new words. So in a unit around public and private information, when we're learning, that's private, or don't talk about me, or let's change the topic, we'll go through and say, which of these phrases do you want us to add to your device? And where? Um, a lot of them have a self advocacy quickfire. Folder page in their device where they can access it pretty quickly with the least amount of navigational demands. But sometimes they want it something in a different place. I've had students say, I want that under, something's wrong because they feel like maybe that it is a, something's wrong phrase when someone's talking about me, um, and so we give them the autonomy to think about that and that is where we program it and then aids know where it's living so that they can model as time goes on. Amy Wonkka:  I think it's really great because it's a good [00:33:00] example of how you're making these small changes in your environment that aren't impossible, don't feel super daunting, but are still sending that message about Both you and the student being equal partners, uh, in the communication exchange. Um, and I think it's also, it's, it's really great to think about similar to directing other people's behavior. Just thinking about if you're somebody who's using a high tech tool, you are likely going to continue using that high tech tool, at least in some capacity for many years to come. And so being able to take ownership and direct other people to make that tool the way that you need it to be is just such an important. Not only immediate self advocacy scale, but such an important, like, long term life skill. It's, it's really great.  Amanda Scheriff Hobson:  Yeah, absolutely. And I think that leads into, like, one more activity, but also kind of ties into the environment piece of thinking about communication planning tools. Again, historically, you'll often see speech therapists making them with a team, um, so [00:34:00] that, you know, you've heard communication passports, so communication passports has been historically something that, you know, speech therapists will make to share with a team or make with a team. Um, and it's a great. tool to have so that everybody knows how somebody communicates, what their communication strategies are, um, and how to support them as a communication aid. But we're starting to pull that back into using the, having the student be part of that team conversation, um, so that they can co plan or co construct some of the narrative around it. Thank you. Why they're communicating, how they're communicating, and how somebody can help them. We'll also shift that into, like, I need, I do, you can charts. So, you know, if we're thinking about, you know, in the summer, we go swimming. A high tech device doesn't really mesh with being in the swimming pool. So, what do you need when you're in an environment like this? that and we'll talk through some low tech options and why low tech is the better solution in that scenario, um, what that person [00:35:00] might do, that student might do when they need access to it. So what are their unaided communication strategies? I yell, I move my hands, I start shaking my head, um, and then what you can do as the communication partner, you can. Get my device. You can model some phrases for me. Um, and that's been really helpful because again, uh, summertime, especially you meet a lot of different communication partners, you see some lifeguards, some swim instructors, instructors, that's something that you can do and show to them, but it was co created by the student. They sort of signed off on what they want to be able to share with those partners who are reading those tools.  Kate Grandbois:  I just love the word co constructed. I think that's a great theme of almost everything you've said so far is just this underlying, um, just centering the student throughout every single decision that is made and not just in concept, but in participation. I just think it's so great.  Amanda Scheriff Hobson:  Yeah, and I, it's really, it goes [00:36:00] into then that environmental piece of working with the partners, the partners are part of it, they're not the ones who are thinking about what they think is important, it's sort of, um, you know, important to, important for conversations, um, is it important to the student or for them? And, and it's both, right? We know that communication tools are important for them, but what's important to them to share? Um, and so we want to make sure that that's being, um, included, um, in that con kind of conversation. Similarly, we're thinking about when I do, it means, so when I shake my head, that means no, that means I don't like it, right? They get to decide what they're trying to communicate in that moment. Um, and again, we're working with students with a variety of communication skills and a variety of communi So we're thinking about how we're presenting those choices to them. There might be a closed set of choices of, you know, if I'm shaking my head, here are three options of what I could be saying. But there's also always a way out of that. Um, usually it's a symbol for, I have [00:37:00] something different to say, or a symbol for their device that says, get my device, I have something different to say. Um, because again, we don't want to lead them to an answer, but we do want to work with the level of support that they need. Kate Grandbois:  So, throughout everything that you've mentioned, it sounds like not only is the student participating and being centered in, in each decision, but we've already talked about the importance of the environment, but we've danced around this very important role of communication partners and communication partner training. And I wonder if you could, just in our last section of the episode, just talk to us about The role of the communication partner, how important it is and how we might refocus our lens to train communication partners.  Amanda Scheriff Hobson:  Yeah, absolutely. We, um, use and, uh, the teacher I work with coined this, this phrase of communication ally. We really shift to, from partner to ally. Um, she'll often say things like, be the microphone, not the actual speaker. Um, right? We want to make our [00:38:00] students voices louder so that everybody's hearing them but not do the speaking for them. And so this idea of communication ally looks at more of like this partnership and this companionship as opposed to like a helper or someone who's there to guide you to what you should be doing. And so when we thought about self advocacy at the beginning, we really said that we know we can teach content and skills. But in order for it to stick and to generalize and to be understood at an even higher level, we need those things around the student to change too. Um, and so we also know that with the varying levels of communication strategies in a complex communicator, that there is a large need for interpretation of what students are saying or trying to say. And that could be really risky because you want to be able to interpret. So that you can understand and attach meaning, but you don't want to cause harm by [00:39:00] interpreting it in the wrong way. So we really need to support communication partners and feeling, um, confident and having a really strong set of tools in their toolbox so that they can follow through on these skills with fidelity. Um, and it, it means that there's a lot of time that is needed. for this training that I will say in those schools, you don't always have. And so when we thought about running this group, we really thought about doing it with all of our aides. It's not a break time for the classroom. It's for everybody to be part of the group so that we are. So it's not just doing the content teaching for students, but it's really also content teaching for staff, and then providing some of these opportunities that are more hands on and practice in a safe space, so when they go out into the larger setting of the school or in the community, they're carrying the skills with them.  Amy Wonkka:  I love that. I think that, you know, you, you make such a good point in terms of, you know, the interpretation [00:40:00] piece is not necessarily easy. And even if you're someone who's been working with a student for a long time, there's a lot of, um, risk, like you said, in. Potentially misinterpreting or putting words in their mouth. And that, you know, also isn't what we want to be doing. We don't want to be telling the student what their message is, um, and, and interpreting it incorrectly. Um, so I think the, the scaffolding and the support that you talked about providing to the communication allies, um, I also really like that term is, is really a helpful, like sort of emotional piece underneath it. Um, in terms of the skills, when you're Doing your self advocacy groups, and that's a, sounds like it's a great opportunity, like you said, to teach the skills to the student, but also the partners. How explicit do you get with supporting the partners in that environment, where you're sort of doing that skills instruction? What does that look like?  Amanda Scheriff Hobson:  Yeah, [00:41:00] we usually are pretty explicit, right? We want to know exactly, um, what we're teaching our students and what exactly we're trying to teach the staff and we want them to know on the receiving end as well. Um, and so we'll use a lot of repetitive skills, I would say that really are just going to help with all communication. So we're really emphasizing. presentation skills. What does it mean to be partner assisted scanning? Um, to just be the scanner, not the questioner. Um, we're really thinking about what is wait time and how do we do that and start to feel comfortable with it. So we'll do a lot of explicit coaching of I'm going to ask a question and I'm going to wait silently for 10 seconds. And then based on that time, I'm going to do this because I'm noticing this. Um, so a lot of that, like, uh, self talk and self modeling, um, during the opportunity to practice. Um, we're also just recognizing then, like, some of those higher level skills of thinking about different response strategies and variation of response. [00:42:00] Um, I talked a little bit earlier about verbal referencing, um, thinking about being able to say what we see to attach meaning to that for the student, but we're really also teaching the power of maybe. Right? Again, we're doing interpreting in that scenario, but we want to be cautious about telling a student that that's what they are doing. So instead of saying, I'm noticing you're, um, you're laughing during this comment, you might think that what your student or your classmate just said is funny. Um, we might be saying things like, maybe you think they're funny, or maybe you thought that was a good joke, or maybe you just liked it. Um, but maybe you're thinking about something else. Right. We don't know. Um, so rather than saying you think it's funny, we're changing that to maybe you think it's funny. Um, so that we're not telling the students exactly how they feel. Um, and we're thinking about, like, again, going back to some of those general strategies, least to most prompting, um, but one that has been really nice, um, this is from somebody who put out in a thesis, [00:43:00] um, and it's in print, um, but it's called SNAP, um, and it stands for Stop Stop. Notify, await, acknowledge, and proceed, and it really does a nice job of encompassing, like, a lot of different partner, um, strategies that are out there, um, but it's, we've been using it a lot for making sure that there's autonomy for our students as well. even on the things that are scheduled. So we talked about schedules earlier, but for example, a lot of our students receive g tube feeds, uh, medication. Um, they need to, they hear the bell ring, they need to go to their next class. These are things that we know have to happen, but we can still go through the snap process by letting them know what's happening. So we're stopping and notifying. Um, we're waiting to see if they respond. So that might be unconventional strategies, like Looking up and making eye contact, um, it might be looking away and shaking your head no, right, to indicate you're not ready, um, it may be using symbolic communication that's a little bit more clear, [00:44:00] like, okay, thanks for telling me, right, um, and then once you get that acknowledgement from the student, whether you're ready to do it or not, then you can proceed, um, but what has been a shift on that is when What happens when a student says no, what happens when they're like, no, I'm not ready for that YouTube feed or I don't want to go to social studies today. And so we've been allowing teaching and providing tools for these communication allies to be able to say, okay, I'm going to set a two minute timer and then I can come back. And then we will unfortunately have to do that feed because it has to happen within this window, but I'm okay waiting a few minutes or okay, I'll go let your social studies teacher know that you're going to be a little late today. Come back. Make sure you have what you need. And then we can go to class. Um, if it's something that's optional. You know, sometimes they have allied arts classes or things that they're just not feeling that day, we can say, okay, let's look at a different part of your schedule that we can do right now. That might help you get back to the schedule for your day. [00:45:00] Um, but that's a shift, that's a big change for teachers and staff to feel comfortable with just because it seems like they're deviating from that expectation that they should be following.  Kate Grandbois:  I was just about to say this is a really important nuanced shift because, and I think it touches on something you mentioned earlier, which is just, you know, as the professional in the classroom who might be focused on student rights and self advocacy, working with an aid or working with a teacher or working with another individual in the classroom who is maybe new to this concept or reframing things for the first time, I can only imagine when they are Encounter an activity that is mandatory, like social studies or, you know, a J tube feed for nutrition. You know, these are really important things. And I think this is, I guess, maybe just a cultural thing of this note. Well, sorry, too bad. You got to go. You know, that's kind of how we treat children in general. Um, but making space for some [00:46:00] flexibility, creating, seeing it as a learning opportunity for those self advocacy sales and that wiggle room. So important. So nuanced, and I have to imagine that this is going to intersect with the relationships that you have with the other people in the classroom, the professional culture that you're in, in your workplace in general, um, the groundwork that you've put in with these other professionals in terms of Explaining the importance of these things, taking the time to, I don't know, Amy and I have talked about this on the podcast a lot before, just creating a nice professional relationship of kindness so that when you remind them, Hey, you know, they did, they did say that they didn't want to go. Would you mind just shifting your perspective? It's not perceived as harsh criticism or direction. You know, you have that nice collaborative relationship to begin with. It's just so important.  Amanda Scheriff Hobson:  Yeah, and, and like you said, the foundation had to be built, right? This didn't happen overnight. The first time it happened, it was like, wait, what, what do you mean I [00:47:00] have to wait to give a g tube feed? That's my job. I'm the classroom nurse. Um, and that's, they're right. That is their job. They have an order. They need to do it. Um, and so that's like opening up that conversation of, okay, let's talk about it. Is there any flexibility? What is this window where it has to happen? Um, we know you have other kids that you need to feed or give meds to, like really, truly, what is our window here? We want to be realistic about it, but if there is a window. We want to be able to honor that piece. Um, and I think once we had some of those collaborative conversations, the foundation just got stronger to be able to do that. And a lot of this, the snap, this stop, notify, wait, acknowledge, proceed. That's something that carries and goes through so many different advocacy skills, but it was taught in our like, ask me first unit, right? Rather than just. moving my chair, or moving my body, or bringing me to the next part of my schedule, or putting me in a place that I'm not really sure about, make sure you're asking me. Um, and it's as little as simple things like, do you want to [00:48:00] read this book right now during your choice time, up into the big things of, do you want to go to this class? Um, or do you want your G tube feed right now? But we felt like it was important to make sure that we taught the skills to the staff and taught them why. Right? Um, as well as then give the skills to our students who now love to remind us to ask me first, um, constantly. And, and we call it out when it happens too, right? Um, as a speech therapist, I'm doing programming on devices. Sometimes I'm removing a device and I, I forgot to ask first. And so, you know, we acknowledge, oh man, you're right. I forgot to ask you first. Let's go back and do this because that modeling from me as that person who is a leader in the classroom, Also helps the aides who are learning this to realize I'm not just setting an expectation for them. It's really just a whole classroom, um, expectation. And then thinking about other activities too, right? These are all practiced in role play scenarios. So, again, I feel silly. We're asking people to be on the spot. Um, But it is really important for [00:49:00] staff to practice this in a safe space before they go do it in a more, I guess, uncontrolled space, right? When they're in larger community settings, there's a lot of more unpredictability around what's going to happen. Um, and so now that we do it regularly, I would say that people are more engaged with it. Um, but we'll have, you know, a role play where we go back to those co constructed scripts. So we might set a scenario, um, where we say, okay, um, you're in class and you hear somebody say to your teacher, Oh, why are they using that device? Or what's that thing hanging out of their belly? Um, and we want to think, okay, what are you going to say? And so we have the teacher kind of act it out, the teacher aid act out that scenario and the student thinks about some of their self advocacy phrases that they learned that they could say, and then they come up and practice it in front of the class. We'll sometimes tie that into a you be the judge activity where they. purposefully choose maybe something that we wouldn't expect to happen or that we [00:50:00] wouldn't want to happen, um, for thinking back to those explicit instruction routines of examples and non examples so that they're not always practicing it the perfect way. They're also practicing it when it might happen. Um, and sometimes it's also like a more of a communication ally focus thing, right? Like what if, um, somebody comes up to you and speaks to you in a baby voice? What would you do, um, as a communication ally, how would you be the microphone for that student to really amplify, um, what they are trying to communicate? If their face is grimacing because they don't really like it, rather than speaking for them as the communication ally, what kind of strategy could you use? to help that person understand why maybe that's not working for the student. Um, and so a lot of these activities allow it to be a safe space to practice, um, and to think about, okay, when I, I experience this now in the real world, I'll have a better, um, idea of how to respond. Kate Grandbois:  I'm wondering if you have any suggestions for any professionals who are listening [00:51:00] who are really inspired by everything that you're saying, but also looking at their current work environment, their current classroom, their current collaborators feeling a little overwhelmed or realizing how much work there actually is to do to shift this balance and work on some of these nuanced perspective shifts. What would be, do you have any suggestions for just a good place to start?  Amanda Scheriff Hobson:  Yeah, I would start by thinking about your environment and thinking about what you're noticing and seeing happening around you and what would be one thing you might want to change, whether it's small or big, starting with one explicit area, and maybe thinking about Tying it back to that content piece of the Communication Bill of Rights, which right may or may not be violated, um, which area should you do more education around for students and staff so that there is this, uh, this foundation set of why we're doing this. I think when our staff really understood why we [00:52:00] were doing this. It's not just to be those annoying professionals who are trying to embark on a change journey, um, but that, oh, wow, this thing really exists and it says this and it's a human right. And now I understand why we're doing it. Um, and then once you learn about it. and have the skills to do it. A lot of it is confidence building. Um, and so something too that we do that's pretty simple is we do self advocacy shout outs. Um, at the start of every self advocacy group, we have a little jar that we can add post its to during the week of like noticing when somebody is doing a really great. Job self advocating, whether it's a student, but oftentimes it's staff that we're writing down exactly what staff did. Um, and then we're calling it out, um, at the start of group and applauding really their, their change, um, their action that had a better benefit. then maybe doing the alternative prior to self advocacy group. Um, so, you know, you'll see things like, oh, uh, Ms. So and so did a really nice job asking first [00:53:00] before she went and took the student to the bathroom, or, um, the student did a nice job saying, don't talk about me when they heard somebody talking about them in social studies. Um, so it's student and staff alike, and I think it's built a really nice camaraderie because now staff are writing about each other, um, positive things, obviously, um, but they're trying to reward and really call out that positivity. And I think that helps with the culture piece and is also helped with the, the confidence piece and the overwhelmingness, right? We're noticing when people are doing things and we want to tell them about it.  Amy Wonkka:  Yeah, I think that's super, um, That's a, that's a super helpful example and something that feels actionable and like you could start it and do it and, and move forward from there. I know I had a question just about some of your actual units that you teach in your group. So I know one of the units you referenced was ask me first, are there any other kind of core units that might be a [00:54:00] good starting point? For people who might be listening and feeling very excited about wanting to go back and do this. Are there other units similar to Ask Me First that might be a good starting point?  Amanda Scheriff Hobson:  Yeah, so we've done Ask Me First, which again was wonderful for just like being able to say yes or no to things. Um, but we're also this summer doing, we're actually going back to do it again. We have some new students coming in. We're doing a whole unit on preferences and choice making. And choice making being beyond just saying what book you want to read or what song you want to do, but meaningful choices that happen during the day. Um, and so, you know, we have. Students to prepare. We had our older students, um, take pictures of the choices they make during their day. So we did a predictable chart of I can make choices about and they wrote down things that they make choices about during their day, like, um, where they want to sit. During independent work time, what fidget or sensory tool they need access to, which teachers they want to work with during individual work time, and then they went to those meaningful [00:55:00] places, took the picture with the tool, and now they've made a book to introduce to the new students who are coming in this summer, um, and that will go into teaching the word. preference. Um, this idea of being able to make a choice or say what you want is sort of our core word definition. It will go into the different types of choices that we can make, and then how we make choices, like the communication tools that we use to make choices, and then what staff should do when there are choices to be made, um, and what staff should do to provide more opportunities for choice making during the day. Um, we also this year did a big unit on respect, um, to talk about how people talk to us, um, what kind of information. So this tied in public and private information, um, and how that addresses respect and dignity. Um, and it also tied in, um, thinking about, like, how people communicate with us too. tone of voice, um, and being able to think about baby voices or talking to us in a respectful tone, especially at that middle school [00:56:00] level. Um, it went into body autonomy, not touching just because I'm in a chair. You shouldn't touch my chair. That's actually an extension of me. Um, and Even devices, right? I gave an example earlier about ask me first before you take a device to program. Um, so all of those pieces were tied in, um, and we ended that with like an acceptance unit, um, doing a little bit of disability awareness, watching videos of other AAC users. I believe this was during April when we had like Neurodiversity Awareness Month and Autism Acceptance Month. And so they ended the unit by co constructing a script, uh, a narrative around what acceptance means to them. Um, and so we had a narrative that we heard somebody say, we took and filled in some blanks and they use some of their vocabulary to fill in those blanks or their devices. to create this their own narrative around acceptance, which was nice. We try to end all the units with like a very permanent product or something that kind of ties it all together. So again, there's meaning to what we did. [00:57:00] Um, so like for summer that I just Talk about for preferences and choice making. They're going to be working towards making sure choice making boards are available in the classroom or tools are available in spots that you often make choices, um, and get to practice those and have a say of where they go, um, to again, get their classroom ready for the traditional school year. Amy Wonkka:  I love that. I was hoping you could talk to us just a little bit. You did at the end. But just for people listening, when you're talking about your units that you're running with your students, this is not like a, like a one, we did one 50 minute block and then it's done and we move on to another unit. This is something that's stretching multiple weeks, right?  Amanda Scheriff Hobson:  Yes, this is, um, I'll, uh, thank the teacher that I work with on this who has the organizational skills of what a really nice lesson plan looks like, not that we're not lesson planners or speech therapists, but I think this goes into the more academic level. We usually try to complete those when we're thinking about the unit. We've identified either the problem or the thing we want our students to do, [00:58:00] and then we name that unit. Um, we'll identify what vocabulary words that, that tier two or tier three level, um, what words we're targeting, and then think about our core word definition so that it's consistent across all weeks. Um, we'll jump into the different activities that we want to do to explicitly teach the vocabulary, have them practice the vocabulary, do more of those hands on activities. We're also thinking about the goal for this. The communication allies. What do we want them to leave the unit with? Um, and then usually we're trying to identify some type of permanent product, which sometimes is a little bit more concrete than others. Um, so like I said, that acceptance narrative at the end that they got to videotape and send home to families. Um, maybe it's a communication passport that they're figuring out to share with, um, you know, other communication partners. And sometimes it's a little bit more abstract, like getting the environment ready for the next school year. Um, but that kind of gives us a flow so that we are typically doing a unit anywhere from four to nine weeks, right? It might be a [00:59:00] whole quarter. Respect was a large majority of the year because there were so many different areas that we can go into. We're also tying it into the Communication Bill of Rights that kind of fits into that unit. Um, we have a dictionary of the Communication Bill of Rights. that has all of the pictures representing the rights. Um, we use a lot of Boardmaker symbols, but we've identified which, uh, PCS Boardmaker symbol to represent that right, what core words are used to define the more abstract right or the abstract definition, and then this can get referenced as well. So we try to have some continuity and things that are set up in advance, but there's a lot of planning unit to unit too.  Kate Grandbois:  Everything that you've just described is so robust and well thought out and planned. I, I am very inspired. I don't even have a classroom to go to, but I, I just feel like. This is a really critically important and I have to assume somewhat overlooked and missing piece of curriculum. Um, [01:00:00] particularly when it comes to the nuance of some of this and the staff relationships. I wonder if in our last couple of minutes you have any final parting words of wisdom or, you know, action steps that we haven't gone over that you want to share with our audience.  Amanda Scheriff Hobson:  Yeah, I think I would be to highlight sort of what Amy brought up around if you're overwhelmed and you don't know where to start, what should you do? Um, and I think it's really to just do an environmental observation. Think about what you're noticing in the spaces that your students are spending the most time in. in, and is there this tangible change that you're looking for? Is there something that you think you're doing, but it's not working or it's not generalizing? And start from there. And really thinking about self advocacy with that self determination lens. Thinking about how to teach the student to act on it because they understand themselves and their desires and their motivation. And trying to empower them to [01:01:00] learn this skill, um, is definitely going to be, I think, your key in, um, and also recognizing that doing change is hard and it doesn't happen overnight. I'm talking through a lens of we've done this now for two full school years, and we still have areas where we're like, we could make this better, we can make a lot of change in this area. Um, and so it doesn't happen overnight and it's hard. It's not instant gratification, but I will say thinking back to two years ago before we did this, it's hard to even imagine because our students didn't have some of these skills or they weren't even being highlighted. And I think again, going back to the school setting, training partners is hard, mostly from those time restraints as a barrier. So thinking about a way to make that inclusive into some of the student teaching will help maybe going back to that original overwhelm.  Kate Grandbois:  Thank you so much for sharing all of this. This was so eye opening, so inspiring, really [01:02:00] just a wonderful in depth insight into the quality of this work and how it could be done. You've given us so many action steps, so many ideas. We really appreciate your time. Thank you so much for being here with us today. Of  Amanda Scheriff Hobson:  course. I'm so happy to be here and share just a little insight into what we're doing. Thank you so much.  Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes EpisodeSponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here today welcoming a guest that we've had on the show multiple times before, but we were, before we hit the record button, kind of flabbergasted by the fact that we haven't seen you since 2001. [00:02:00] No, no. That was way too long ago. We haven't seen you since 2021, which was years and years ago. Uh, we're very excited to welcome you back to the show. We are here with Dr. Trina Spencer to talk about narrative language intervention and AAC, which is a topic we don't get to talk much about. Welcome back to the Nerdcast. Oh, thank you so much. Nice to be here.  Amy Wonkka:  Yeah, it's you guys. It's really nice to see you. I'm glad we got in the time machine and got to see one another again. Um, no, it's good. Time does fly. The older you get, the faster time goes. That's a real thing. I swear. Um, Trina, you're here to discuss this time, um, to discuss AAC and story champs. But before we get started, can you just tell us a little bit about yourself? Trina Spencer:  Yeah, sure. Um, I don't know. Currently, I'm the director of Juniper Gardens Children's Project, which is a 60 year old [00:03:00] community based, community engaged research center as part of University of Kansas and Like, I'm really proud to be affiliated with Juniper Gardens Children's Project because in the 90s when I was just a, uh, you know, like a hopeful researcher, I read a lot of cool stuff out of here, and now I'm here. It's like, really, really amazing. Um, yeah. And that's what I do now. I am, let's say, originally, I was trained as a behavior analyst. Um, I am also a school psychologist, and I worked as a preschool teacher and a special education teacher. And when I was done doing all those things, I decided to study language. And yeah, that's language and communication. And I don't know, I, I consider myself an intervention scientist and an intervention designer. So like I design interventions and I, and of course I have to develop a lot of assessment [00:04:00] tools when you're doing that kind of work because oftentimes you develop things in spaces where there's no good assessment tools. So I do those things too.  Kate Grandbois:  One of the things I love about your background is that you bring so many different perspectives and expertise to the work that you do, having experience as a school psychologist, a classroom teacher. a researcher, a behavior analyst. You've also, a lot of the other episodes you've done with us, um, were with Dr. Doug Peterson, who is a speech pathologist, researcher, and the two of you have collaborated across multiple, um, projects producing the cubed assessment, the pearl assessment, Uh, let's see a story chance, which is the non AEC version of what we're going to talk about today. So I'm very excited to kind of unpack all of this with you from your many, many lenses and areas of expertise, which is really exciting. Before we get into the really fun stuff, we do need to read aloud our learning objectives and disclosures. I will try to get through that as quickly as I can. [00:05:00] Learning objective number one, describe the benefits of narrative intervention for AAC users. And learning objective number two, describe the active ingredients of story champs that leads to generative repertoires. Disclosures. Dr. Trina Spencer's financial disclosures. Trina is the author of Story Champs AAC and is entitled to financial benefits related to its sale. Trina is also the director of the Juniper Gardens Children's Project at the University of Kansas. Trina has no non financial relationships to disclose. Kate, that's me. I am the owner and founder of Grand Voie Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka:  Amy, that's me. My financial disclosures are that I am an employee of a public school system and co founder of SLP Nerdcast, and my non [00:06:00] financial disclosures are that I'm a member of ASHA, Special Interest Group 12, which is AAC, um, and I participate in the AAC advisory group for Massachusetts Advocates for Children. All right. Now, Trina, before we hit record, we were talking a little bit about AAC and how, you know, we've had, I mean, Kate and I both work as quote unquote AAC specialists. Uh, we've had a number of episodes in this podcast and we talk, I feel like we've focused a lot on kind of earlier communicators or like those early communication skills in AAC. So I'm super excited to talk more about narrative intervention. Um, You just tell us a little bit about that first learning objective. What, what are the components of narrative intervention? Why is it so important? All of those good bits.  Trina Spencer:  All right. I've, I should first say I am not an AAC expert. Okay. You guys are the experts, right? I'm an instructional designer who designs with colleagues and partners and community people who tell me what they need and want. Right. Okay. [00:07:00] So, but that way I'm going to tell you a narrative intervention. Is, I mean, it's been defined differently in the, in the research, but, um, in 2021, Doug and I published a paper, Narrative Intervention Principles to Practice, and we kind of just like, okay, this is how we're going to define it because it was kind of getting out of control, like people defining it however they wanted to. So the way we defined it was the, the active ingredient or the definitional feature was the use of storytelling. As the key teaching procedure, so storytelling, so the children or the recipients of the therapy, of the intervention, the instruction are either telling or retelling stories. And they can do that using speech, gestures, AAC, written, you know, spoken, all sorts of modalities. But there are some form of storytelling and retelling as the key. Active ingredient. So that's a narrative [00:08:00] intervention. Um, now there are other kinds of interventions that use narratives as the base for teaching language and those are closely related. It just depends on whether or not they're actually doing some sort of active storytelling within the intervention or not. Um,  Kate Grandbois:  and I have to assume that working on narrative intervention is important for language development. I mean, this is a dumb question. I know the answer to this question, but I'm asking it anyway because I'm halfway through and I'm going to double down. Working on narrative intervention is important for all language learners. I know we're here talking about AAC, but to kind of Set the, set the stage and talk about, can you tell us a little bit about why this is important for all language learners? Yes.  Trina Spencer:  Okay. It's okay that we talk a little bit about verbal behavior, right?  Kate Grandbois:  I don't think I'm gonna get a rash. Amy, are you gonna get a rash if we talk about verbal behavior? Amy Wonkka:  I am a rashy person, but I have a cream for that.[00:09:00]  Kate Grandbois:  This is so good. It's gonna be so good. Science and humor, right? This is why we're  Trina Spencer:  here. And why not? Exactly, exactly. So I guess I, I can answer that question because I understand that there are kind of like, there's a spectrum of complexity of skills, right? In, in terms of communication and language. And oftentimes when we're like SLPs or in communication therapies of some sort, we're looking at things at the level of a word or an utterance. Right? But narratives are discourse level. And, and so, when you're doing things at a word level, you can do something like, I'm making a request. Right? Or I make, I'm labeling this item. Okay, I'm expressively identifying it. Um, you can also answer WH questions. Those are like common early language and early communication kind of things. But you often don't get [00:10:00] spontaneous. Fully generative, meaning like not practiced, but they are able to combine and recombine things that they've learned at the word and utterance level into a larger sentence or discourse level, right? So it's like a higher order in terms of the size of the unit, a narrative or a story. Right, that requires, at the discourse level, you require sentences, and sentences have utterances or clauses, and utterances and clauses have words, and words have morphemes, or, you know, components, um. So, in doing narrative intervention, you get all this other stuff. Do you see that's like nested communication within that and with you, if you can, if you can work at that fire level, you actually get a lot of that other stuff for free. So it's not like you have to start with the word and build another word into it and build a, a, a, An increased MLU [00:11:00] before you can do a sentence, before you can do a story. Now, to some degree, there's some logic in that, but it's not always necessary. And so I am always, after. As an instructional designer, I would say I'm always after the most efficient means of producing functional, like not, not, I'm gonna say that word again. I'm gonna use a different word. 'cause that has many, many means, like purposeful, meaningful, generative communication. Right, not something that's been rote memorized, not something that's been like trained over and over, like what's the answer to this question, right? That's not what I'm talking about. I'm talking about how do we get real generative language and communication. And the narrative, because of its higher order size, the unit of that analysis, you get a lot of stuff for free.  Kate Grandbois:  Well, with that as a backdrop, I'm already looking back at my own clinical decisions with regret, that, you know, narratives. Possibly should have been a larger target in even my more emergent [00:12:00] communicators. Um, I have, I would love to hear how we're connecting this to fundamentals for why narrative intervention for AAC users is a specific area of need. Yeah.  Trina Spencer:  Okay. So kind of with that same theme, um, when I, okay, there's, there's a lot of starts to this story, so I'm just going to plug in at different places. All right. But in this one, when I would look at the AAC literature, so often they're talking about like vocabulary and I would go, yeah, but vocabulary for what? Like, like, do they know this word when they need to request it or do they need it to label a preferred item? Um, Or a person or to to ask a question or for social interaction for protest and you see what I mean all of a sudden you go of word or a symbol that doesn't mean that they know how to use it for all of the the Functional, um, you know, [00:13:00] verbal purposes, the communicative functions, right? And so, and oftentimes, the literature wouldn't really explain very carefully what function they were actually teaching. And in fact, they are always teaching a particular purpose or communicative function. They just don't describe it that way. And so, oftentimes, you can't pull them apart. Okay, so we, we would say that these communicative functions, speaking to an SLP audience, are actually functionally independent. Meaning if you teach somebody to label something, they don't automatically request that thing when they want it. Or if you're, if you're teaching requests, they don't automatically then be able to like, label it or answer a question about it. You have to actually teach them. somewhat separately. Now, our typical language learners are going to cross those communicative functions quite easily. They generalize quickly. Um, they don't need much kind of, um, programming to be able to make that, those, uh, cross between those communicative functions. [00:14:00] But in AAC, we're talking about children who have much more complex communication needs and maybe have more difficulty generalizing, especially because it's so pictorial based. Or iconic base, like it's not as, um, they're symbolic, but you don't have the same variety as you might in a, in a word or an utterance or whatnot. So you get kind of like, I don't know, what am I trying to say guys? I'm trying to say something that it's like a  Kate Grandbois:  more more discreet.  Trina Spencer:  Yeah, so often it is and we start really simple You know, and I'm not saying that Starting simple is bad, you know, like there is like pre symbolic, you know phases symbolic phases and whatnot but even one of the surprises that came up is that We thought that the StoryChamps AAC would be for kids who were already proficient with their devices in these other [00:15:00] communicative functions. We actually did not find that to be true. As a matter of fact, the kids who learned the most were the ones who had least proficiency with their devices. So that puts you thinking, Oh my gosh, it's not just for those people who are already proficient in their AAC, right? And then you think, what else can you do with this? So what, what stories don't do is teach requesting, but the majority of the research, something like 60 to 80 percent of the AAC interventions reported in, um, In research are to teach requesting  Amy Wonkka:  and and not to minimize the importance of requesting right like I we all want to get what we want when we want it as much as possible, right? And like, that is an important piece. But I do, you know, as you were speaking, I was just thinking about how Often narrative comes into play with those more social exchanges with [00:16:00] people, right? I mean, just thinking about, we hadn't seen one, we got on the zoom call, we haven't seen each other for years. And what are we doing? We're sharing personal stories. It's been a  Kate Grandbois:  really long time,  Amy Wonkka:  so long stories  Kate Grandbois:  to tell,  Amy Wonkka:  but we're all sharing, you know, these bits of like our personal narrative or other things that we've seen. So I think that this narrative piece also has a really Um, it's, it, there's like so much utility beyond just, you know, as somebody who's school based, I'm thinking about curriculum access. And yes, of course, that's important. And we're asking people to like read a narrative, retell a story and all of these other components that like tie in with the curriculum access. Uh, but it's also, there's such a huge social component there too.  Trina Spencer:  100%. And like, I also don't want to minimize requesting because if a child can't get their wants and needs met or an individual, not just a child, if they cannot get their wants and needs met. Like we should not be working on like, let's talk about some stuff, you know, like, we've got to get that but As soon [00:17:00] as the, the basic skill of like, hey, I do this to get something I want or need once that's established, oftentimes our, our AAC users aren't moved on because we go, I don't know what else to do. How do I link them to this social stuff? I want to build, I want this kid to be able to interact with their friends. I want them to be able to do, you know, like, uh, curriculum related content. The whole reason why I started in the narrative space was because of their utility, right? They're academically relevant. Narrative language abilities is one of the best predictors of academic achievement, especially around reading comprehension and writing, which is where Doug and I spend a lot of our time, right? Um, But they're also socially important. Like you said, we talk about stories all the time. Well, so, what's to stop us from using this incredibly meaningful, you know, academically relevant, socially important context for teaching [00:18:00] better, or teaching AAC use? Right.  Amy Wonkka:  So talk to us a little bit about, about story champs. Cause I think as, as some, I haven't used story champs, I'm excited to learn more about story champs. Um, one thing that I'm trying to conceptualize as you're talking to us right now is like, what, what do the activities look like? Like, what are we, are we working on personal narrative? Am I telling the student a story? Are we looking at a book together? Like what, what does, what, what components are involved in this intervention?  Trina Spencer:  Right. So, Doug and I have been working on StoryChamp's research for now, I think, 15, 16 years, and I'm going to say what it is today. I would say it is more than just a curriculum, just more than just an intervention. It's a whole approach, and it has three key ingredients. Okay. One is that we have carefully constructed stories. It is not storybook reading. And I love storybook reading. I'm not saying don't do that. I'm saying it is [00:19:00] not for, um, intensive effects of an intervention, right? It's like casual, low dose, low intensity kind of thing. You want real intervention, you got to construct the story. So our stories are carefully constructed. Number two, we use strategic visual materials. So that we can teach properly and get generalization independence. Um, and we do that through the fading of, the intentional fading of visual materials. So we have illustrations and icons that we use in all of our programs. So, and all StoryChamps has those kind of visual supports. And the third piece is very explicit. Um, teaching procedures that come from a very large research base and there are some teaching procedures that are really key and one of them is multiple exemplar training. So we've talked about this whole like generative repertoire just a little bit, but I want to talk more about it because especially with you, like, [00:20:00] uh, kiddos or individuals or clients that seem to have, you know, um, intellectual, Considerations and challenges with generalization. We often do a lot of rote teaching until they say exactly what we tell them to say in response to the stimulus that we taught them to respond to. And that is not generative, right? But we want to build a generative repertoire. We just don't know how to do that with such with learners with such complex needs and high support needs. Right? And so, um, if we approach it, not as like, Okay. Um, drill or like intent like you might see an intensive teaching session session. Um, you know, I'm a behavior analyst. So we we see a lot of discrete trial teaching. And that is not what I'm talking about. I'm talking about the opposite of that. All right. So I in when you're talking about communication and language, some other types of really strong teaching procedures are better suited and multiple exemplar training [00:21:00] requires that you have multiple examples involved. Of the construct you're trying to teach or the concept you're trying to teach and a single story is not the goal, right? We do not want kids to retell this story or to memorize this story. We want them to have the language to be able to retell or generate their own story. That they have never, like a story they've never heard before, generatively, right, putting words together that they may have heard, but in some sort of different sequence, in different things, or maybe using synonyms instead. It's about meaning, and it's about constructing something unique, spontaneous, and expressionable, not wrote. Right, and that really requires multiple exemplars of stories, right, and, and a controlled exemplars. That's the reason why we write the stories ourselves is because storybooks, they're great, but they don't have all the patterns that we're looking for. And by the way, patterns are a big thing too. [00:22:00] So I would argue, and people who hear me talk, I'm doing a lot of this, um, that we're actually teaching the patterns of language. And if we teach the patterns of language in Also, to our AAC users, we're going to get generative repertoires. But when you teach patterns, you can't repeat the same thing over and over again. Because otherwise, you're just teaching content. But if you teach patterns, and you do that through exposing them to multiple stories over time, And it to your question, sorry, I'm like rambling, but I'm getting getting there like in in every intervention session, a new story is presented and we practice retelling the story, but tomorrow or next week, you get a totally different story. So, the memory of that content is gone, but guess what stays. It's the patterns of the story and the patterns of the language used to tell that story. So I, I started with this like word, uh, word parts, words, utterances, sentences, and discourse because each one of those have patterns [00:23:00] and that is what grammar and syntax is. And that's also the reason why stories are, uh, stories at the discourse level are analyzed by story grammar. It's the rules. and um, rules and I don't know, organization of how to put the pieces together so that you can have a generative repertoire. That's what grammar does for you.  Kate Grandbois:  Okay, this, this all makes a lot of sense. This all makes, I feel like I'm, I've entered the stadium, I see the ballpark, I see the relationship between narrative intervention, why it's important for all language learners, all of the, everything you said about multiple exemplars, not teaching in a silo, right? Not teaching the, the rote scripts. We, we know this. We, we know that that's bad practice, it's not how you teach language. You mentioned earlier that. The research that you've done shows that individuals who don't have AAC proficiency are the [00:24:00] ones who are learning the most. What, tell me, tell us about this research. What does, so now that we know that this is really important theoretically, what does, what does the science so far tell us about this as an intervention strategy? Trina Spencer:  Well, I'm going to just clarify and caveat here that this wasn't our research question, but we didn't know what the inclusion criteria were because we hadn't, you know, we didn't have any experience with it. We assumed that the inclusion criteria to be able to do Story Champs AAC would be that they had, you know, like a tact repertoire, or they could label quite a bit, like that they could say, you know, cop, you know, book, whatever. We thought that that was a need. Uh, a prerequisite, would you mind you? Okay, but we had difficulties actually recruiting and, you know, in the chaos of all of, you know, moving and whatever. I'm building new community partnerships. And so we were like, okay, well, we got these 3 kiddos, but these 2  they only [00:25:00] know about 4. Preferred items on their and I can't even remember the lamp or, you know, some sort of anyway, it doesn't really matter. That's that's actually another question. Like, it doesn't matter what, what kind of device or system that they're using. Um, and. We were nervous , but the one kid that had pretty good, like he would, he was able to like request proficiently and was able to label like maybe 30 or 40 items using his device. It took him the longest to make progress and the other kids were like, Oh my gosh, it's a whole new world. They were just like super exposed to lots and lots of different symbols and the way to navigate their device in a very intensive. Supportive 30 minutes 30 minutes a day, and they only got 9 and 10 sessions something like that 9 to 12 sessions That's it. We saw generative growth quite rapidly with those [00:26:00] kids who didn't have like a large Proficiency with their AAC device before so now though in the next research that's become a research question. What is Like what exactly, we need to unpack this a lot more, like what are these predictor variables, like at baseline, do any of these variables at baseline predict their growth in the intervention, right? That's a research question we don't have the answer to. But we were surprised that amongst these three kids, that didn't seem to be the, the case. That we hypothesized.  Kate Grandbois:  Tell us a little bit about what this intervention looks like. Is it parallel exactly to StoryChamps without the AAC piece? Is it, for those, if anyone's listening and they're familiar with StoryChamps, but not yet familiar with StoryChamps AAC, or maybe someone's listening and they have an AAC user and they're excited to try this approach, like me. Thinking back to all of the mistakes that I've made, that's what happens every single time I get [00:27:00] in, get in these recordings, is I learn all the things I've done terribly. What, what does this look like? What are some of the things that happen in an intervention session?  Trina Spencer:  Okay, so StoryChamps AAC is the same as StoryChamps, and that was three key ingredients. Carefully crafted stories, Right? Engaging visual materials and explicit teaching procedures. Very intentional. How they're different is the stories are crafted and simplified specifically for AAC symbols. Now, it, it, I don't think it can accommodate, and it doesn't accommodate everybody, right, and all AAC users, but let's say school aged children, okay, who use AAC, so we crafted stories, and we crafted them slightly differently, we, these stories have, like, the five main elements, they have a character, like, a setting, which kind of goes with the character, um, a problem, a feeling, an action, and an ending, You know, some sort of resolution. Um, so it has those basic story grammar, but the [00:28:00] sentences themselves are not super complex like we would have in StoryChamps, and some of the versions of the stories are really like complex sentences with multiple subordinate clauses. These don't have that because in an AAC, when we're talking about these emerging AAC users, they're using simple sentences. Okay, like maybe two or three, um, you know, symbols to say one thing. Um, okay, and each, what we did to create the stories is I reviewed several different software vocabulary lists and kind of put together a list that was very common. And I, I don't remember, 102, 108, I don't know, words. And I have a verb. Um, I have a noun, a verb, and an adjective, or a modifier, in every story. So, I clustered the words, wrote a story using those words. So, we, in the StoryChamps AAC, there is some vocabulary learning, [00:29:00] but what we're trying to do is expose them to the symbols on their device. That, if they don't have that particular one, then one that's very close, and it's easy to like swap out symbols and stuff like that. So, it's not a big deal if they don't have that exact thing. Um, So there is some intentionality around teaching this vocabulary, but we don't repeat that story so that they memorize that thing, right? The next session, they would get a new story and new set of words. So, in the Story Champs AAC, we only have two master lesson plans right now because that's all I think the research is telling us we can do, you know, I, I, I tread lightly, and the beauty of being involved with the, with commercialization is that I only can step two steps. Like, I can, I can gauge how far out of the research we can go. Um, and in this case, we have a, a lesson plan. It's very similar to the StoryChamp's regular lesson plans. And then we start with a retell. So the, [00:30:00] the steps are like this. We name the story grammar, sorry, name the story grammar parts. We display the illustrations that I forgot to mention. Sorry, let me go back to the illustrations. This is my, one of my favorite parts about the illustrations is the kids in our illustrations. Use AAC and have disabilities, and they're a very diverse group. So the representation is better. There's 36 stories too. Regular Story Champs has fewer. If you think about it, kids with high support needs, they actually need more exemplars, not fewer. And if you go fewer, they're going to likely repeat them or cycle around and then they're memorizing. So if listeners have used Story Champs, With kids with high support needs who are speakers. This is one of their complaints is that there's not enough stories  Amy Wonkka:  well You that sorry to interrupt you just really quickly though If you are like how firm are the boundaries if i'm somebody who has used story champs? Like the original story champs and I have a student who's not an AAC user But they're just a high [00:31:00] support needs learner and they need a lot of repetition and they use their oral speech like would it be appropriate for me to use some of the AAC materials with my Student who's using their oral speech instead of AAC? Trina Spencer:  The answer is yes, but I feel like I should like finish the answer to those other things and come back. Don't do it. I jumped in. I got hasty. I got hasty. It's okay. It's okay. I know you're going to remember the, the, the. I'll bring us back. The word is expansion pack. Okay. All right. I'll bring it  Announcer:  back.  Trina Spencer:  We're going to come back to that. Like, how do we expand regular story champs using the AAC stories? Okay. We'll come back to that. But in terms of like the, the, the way it's different. Yeah. Okay. So the stories are crafted differently. The illustrations feature, feature AAC users and the teaching procedures are actually drawn from the AAC intervention literature. Okay. And that's important because you teach AAC [00:32:00] communication slightly different. You know, the things that work are going to be different than what they do for speakers, and so that was a very important step, which is also the reason why it took me so long. I've actually been working on Story Champs AAC for probably, like, Seven years, seriously, seriously. Kate Grandbois:  That's impressive.  Trina Spencer:  I, uh, yeah, there's phases in how you like go through, like, you got to do like a research dive, you know what I mean? And when I first started this dive, there was so much debate about like core and fringe words. I was like, I cannot start a story unless I understand this. Right. And it required, it required a bit of, uh, time, you know, I don't know if you know this, but this was actually the reason why I went to South Africa. I applied to South Africa for my Fulbright scholarship to work at the Center for AAC. This is exactly the reason. It's because I was not getting enough time in my regular job in the U. S. to devote to [00:33:00] studying what needed to be done. I needed to dive into that research fully to understand what the teaching procedures were. You see, and I didn't, I had to clear my plate, so I went to South Africa and did that. I want to, I just want to point out, I had some really great, um, colleagues, um, in South Africa who were my AAC mentors, and I, you know, I was able to teach them a little bit more about those communicative functions and why it matters in terms of teaching stuff. So, great, and we actually have a systematic review on AAC interventions to teach commenting. Which is a precursor to this, right? I had to do that systematic review to find out, because commenting is a, is a precursor to storytelling.  Kate Grandbois:  That makes a lot of sense. When does that systematic review come out? Do you know yet? Well,  Trina Spencer:  I just resubmitted it. We got some feedback. So  Kate Grandbois:  2025.  Trina Spencer:  Yeah. Yeah. I think that's what I'm hoping for. 2025. Yeah. [00:34:00] For sure. Excellent. Probably by the time this, uh, this podcast gets released. Yeah, that's what I was going to say. So if it's,  Kate Grandbois:  if it's available, we'll link it in the show notes. We'll link all of the research that you're reviewing in the show notes. Trina Spencer:  Yeah. Okay. So where was I? In terms of like the T, so those were the three major differences between Story Chams Classic and Blitz. With Story Champs AAC, um, which I think are appropriate. Yeah, it took me a long time, but it's not that it really took that long time, because by the what's really funny is Doug is constantly going, How did you make Story Champs AAC so fast? And I said, I didn't. It's just the part you saw didn't take much time. I mean, seriously, think about seven years of reading research, uh, working with community, you know, partners, SLPs all over the country who were using regular Story Champs, To teach with their AAC users. And as a matter of fact, a long time ago, I was invited into the Chicago area [00:35:00] and some really great SLPs there. I want to say shout out to Bobby, Eileen, and Sue from the Chicago area, from the LaGrange, um, um, school district there, because they were showing me how they were using StoryChamps with their AAC users, like seven, I don't know, maybe even more than that, I didn't count properly, but anyway, and I was like, oh my gosh, sweetie, I could do that better for you, because I didn't write those stories using the symbols that are likely to be on those devices, and I didn't design those teaching procedures based on the literature for AAC interventions, so I had to do it right. So that's what got me going and like, listen, this clearly is a need they're like, but we love it. The kids love it. You know, we need more stories, though, because we're talking about high support needs. So anyway,  Kate Grandbois:  This is great. And I just want to point out one thing that I appreciate so much, which is, you know, the, the SLP. product landscape is wide, right? I'm not going to get on my soapbox about this, I swear. But there are many, many, many products [00:36:00] and services available to us as clinicians to, to purchase, to use in our, in our therapy rooms. Um, not all of those products that are available for purchase are science based. or rooted in evidence. And I just want to take a second to point out and appreciate that what you're talking about is putting science first and moving and creating products and services that are following the science instead of creating something that sells really well and then asking somebody to research it to see if it works. And so I say that because I think it's a very important and very under discussed distinction, um, everywhere in medicine and intervention. And, but. particularly in our field. That's all I will say about it. I just want to point it out that anybody listening who's getting excited is because this is bound. This is backed by evident by by research, which is great.  Trina Spencer:  Okay. But I have to say something too .  Kate Grandbois:  I knew I was gonna, did I, [00:37:00] did I open Pandora's box so much?  Trina Spencer:  So much? Oh, no. No. What did I, I'm gonna be quick. I'm gonna be, I'm gonna be quick because I, I am right there with you. Okay? Like I am a clinician at heart. I'm an interventionist a heart. I see kids who could communicate better, and I wanna teach 'em. That's what I wanna do, but. As a researcher, my audience, my users are the SLPs and teachers who are teaching these kids. And I don't start with, here's the science, I'm going to do this for you. I start with, what do you guys need? What do you want? What's going to be useful in your context? And I design based on what they tell me they want and need and what's going to be good for their kids. And it's, so it's not just based on science, it's based on community, um, identified Problems of practice and, um, I did say this at the beginning. Juniper Gardens is a community based community engaged research center. And this idea of doing this kind of [00:38:00] work is it. First of all, it's very difficult. To do takes a long time and a lot of scientists don't do it because it's so much easier to just go to their university clinic or this lab school or, you know, whatever, but to actually be in the trenches with these people, like, it's so satisfying. So, so satisfying. And I'm going to be talking about the community partners that helped me along the way. So, so Bobby, Eileen, and Sue were the original ones that said, hey, this is what good idea. I picked Bobby's brain several more times after that. Well, how would you do it? How do you, you know, how would you do this? I mean, here's some of these things going, having these conversations, right? And then when, when I had a prototype, I had some more colleagues in, or partners, I don't know, There are SLPs in schools, um, in the Michigan area, Oakland County schools in Michigan, who piloted, field tested, gave real feedback, right? Real feedback. [00:39:00] So, yes, I applied to science, but it wouldn't be nearly as good as it is, and it would not be, it would not be what it needs to be to solve the clinical problems if the clinicians weren't the ones telling me this is what you need. Or, this is how to do it. And you see this, you know, I'm not the ones out there trying it out. They are.  Amy Wonkka:  I mean, we've talked so many times on this podcast too, just about, I mean, I think there's, there's all the things at play, right? So, it is, when we can find the sweet spot as something that's actually an evidence based intervention that you could then use as a curriculum in your session is like, ah, like that's wonderful. There's also this crazy research to practice practice gap. Um, and I feel like in, I don't know if it's because we do this podcast, so I get to talk to all of these smart people who are doing the research or because it's like a bigger, I mean, I would like to think it's a bigger shift in the field too, but the idea that there are more of these researcher and clinician partnerships is just. So exciting as somebody who is not in the research world at all other [00:40:00] than like reading it and trying to be like, well, I don't know what that means exactly, but I'll try. Um, so I think, you know, all of those pieces intersect and are really exciting for people who are practicing clinicians. Um, I want to, I want to, I want to weasel us back toward the story champ, because I have specific questions. I know, and they're selfish. We get on the tangent. I'll get to it. No, it's good.  Trina Spencer:  That tangent was my  Kate Grandbois:  fault. I take full responsibility.  Trina Spencer:  It's okay. It's alright. But that is clearly something I care a lot about, is finding that sweet spot. You know what I mean? Like that's how you get real impact and I'm always promoting the interlocking relationships between practitioners and researchers, right? It's so  Amy Wonkka:  important. It's, it's really like, because in fact, like you can have something that's like a really tight, great clinical intervention in a lab, but that is, Impossible most of the time to translate, um, exactly into a school [00:41:00] environment. So, and I think for people who are practicing in schools, we're used to curriculum, like I've had so many conversations with special education teachers about, you know, just the, the difference between, we, we never expect like third grade teachers to share curriculum, right? Like we just buy them curriculum, like we being the schools, I don't actually buy anybody curriculum. Um, But just, you know, I think that part of that is because there's not as much curriculum available for special education. And again, like that is changing. Um, for my higher support need learners who are using AAC as like all are part of their communication system. What are, like, can you walk us through like what a story champs? Um, what do you think the next intervention might look like? Like, like, am I reading this story to them? Am I modeling on their system? And like, what, what does that look  Trina Spencer:  like? I started on those steps, but I didn't get very far. So let me pick up. I think it's because I [00:42:00] interrupted you. Step one. So illustrations, some visual materials. Um, they're just like five panels. And then there's icons for character problem, filling action, ending that correspond to each of those panels of illustrations. Um, we model a story. And in Story Champs AAC, there are actually two versions of the story. One is what you might hear in a Story Champs regular, so it has the more complex language. Not super complex, right? But some. It's more complex than what they likely are doing in, you know, some beginner AAC use. Um, so we can textualize it. So they're hearing the story. All right. And then, then the next step, the, um, the interventionist is using an aided modeling with the child's device and using a simplified story. Okay, and the simplified story importantly, it's not telegraphic [00:43:00] speech. So they're still voicing it. as complex like, you know, um, the boy was at home, right? But that might not be what the kid is doing on their device. It might be like boy home, right? So there's a simplified story, a regular story, a simplified story. Um, there is a little bit of Instruction on the parts of the story like character problem filling action ending, which is in the original and it's mostly because we want to make the pattern salient. Okay. And, um, then after there's been an aided model of that story there, then the child. Or the individual retells that story using their device and there is a, uh, customized least to most prompt hierarchy that gets used. And so we have some guidance about how to go about selecting. The, the levels in the prompt [00:44:00] hierarchy and some cautions against things like physical touch and using things like questions when many of our kids with high support needs don't answer questions readily. It's not really a prompt. So like these kinds of things. Um, so there's a customized least to most prompting. And so they are getting support in Retelling that story using their own device, and then it's faded again, they get another trial with just the icons so that they move from maybe relying more on the pictures, the illustrations, which provide more content information, and the icons only tell you kind of like the category of what you're supposed to be talking about here. Okay,  Amy Wonkka:  meaning like character  Trina Spencer:  or like selling exactly. It only gives you information like describe the character. And now you have to like, rely on the previous steps of them going. Okay. It was the boy was at home. Right? Um, so, I mean, that's pretty much it. That takes about 30 minutes. And they're just [00:45:00] practicing with their device and remember the next day or the next intervention session the story changes And so those three target words were planted, but they get a lot more than just those three target words Online we have this really cool like I don't know. I think it's really cool I like anything that's pretty and like helpful, but it's basically a list of words that The stories were designed around, and it's not just those three, like a noun, verb, and adjective, but there's also a variety of people. So I'm looking at the list. There's like mother, family, teacher, grandpa, dad, mom, sister, tutor, kid, lunch lady, aunt, brother, cousin, you see, grandma, like, We've intentionally made sure that kids are getting exposed to any kind of family member they might have on their device. And what's really, I mentioned this kind of before, if like there's a story but the child doesn't have like a grandma on their device, it doesn't matter, you make it another female character, [00:46:00] you know, that they do have. And then there's also settings, so you have like home, kitchen, school, house, classroom, park, gym, class, closet, study hall. You know, all sorts of different locations that would also be on their devices. And then we use a variety of emotions as well. So there's a lot of emotion training in kind of the stories. And these are kind of incidental. So they might not have been the words that we. Well, we did. We identified words that we constructed stories about, around, I guess, so that there would be lots of variety, but they're in these kind of like categorical bins. And there's lots of actions, like, everything is an action, like, the attempt to solve the problem is always some sort of action. Um, things like, Eat, draw, help, carry, fix, drive, run, forget, you know, these are kind of words that you would see in, um, vocabulary lists on devices. So, there's a [00:47:00] lot of practicing of getting to a category for a certain bin in the pattern, right? Are you guys following me there? So like, if there's a character problem, filling, action, ending, they kind of know what categories they have to go to in order to talk about that, but they're not memorizing the specific. Symbols or words.  Amy Wonkka:  And I feel like when you're talking about the patterns repeating, it is not so explicit as like book one is the boy was at home. He lost his book. And book two is not the horse was at home. He lost his frog. Right? Like, so pattern in the sense, in the sense that it's like pattern in  Trina Spencer:  the, in the structure, not in the content.  Amy Wonkka:  Right. And I think that that is also, as somebody who's worked in a lot of programs that do a lot of repetitive instruction and practice, I think that that's a helpful distinction to make too, that it's not, it's not a, just a tiny shift. [00:48:00] It's like a, it's like a fundamental, you're not showing like almost the exact same picture every day. You're showing like completely different things that like have a similar.  Trina Spencer:  Yeah, and the teaching procedures that are, like, in there, I already talked about multiple exemplar training, but we also train loosely. This is kind of a tricky one. People go, wait, what? Yeah,  Kate Grandbois:  I was going to say, explain this. Yeah.  Trina Spencer:  Okay, so, I don't know how or why, but somehow there's this idea that if we've got a kid with high support needs, we need to be more rigid in our instruction. That just isn't true. It's the opposite. We actually have to be more intentional about variety. Otherwise, we build rigidity and rote learning. Okay, so the strategy here is to not train too tight, not train too mastery. Uh, by the way, a lot of people, I might even be criticized for this sometimes, but that's okay. Um, I'm old and I've been doing this a long time and it works really well. The criticism is that I [00:49:00] will not use a mastery criterion before I make a change. I will not, because it is the antithesis to generalization and generative language repertoires. We're here. So, I won't do it. But, that is the, what's the right word? That's the, that there's this some sort of like, I don't know, unspoken agreement that we all have to go, like, This prompt then made a mastery criteria and then we go to this thing and meet some other mastery criterion and then we go to this thing, right? Well, I did that once and it backfired and it sent me on a rabbit's hole to figure out why I came out of that rabbit's hole. So in love with SLP and behavior analysts who works, SLPs and behavior analysts that work together to create spontaneous language. And that, that's what I learned is you've got to train these things loosely so that the kids will learn, will use the current stimulus conditions and [00:50:00] environment to choose the right words when they need it. And let me give you an example for this. And remember I talked about you don't really get a lot of transfer without intentionally teaching it well. So in the study that we did, um, and I should also mention my doctoral student, Nora Amnubark, she was the lead, um, investigator on this, and she just had a baby, um, she lives in Saudi Arabia, she's amazing,  Kate Grandbois:  congratulations,  Trina Spencer:  yeah, so, so good, and let me tell you how many times she freaked out that she was not going to finish her dissertation, I said, no, no, we got this, she's like, but I got no participants, recruitment is so hard, I said, don't worry about it, this is going to happen. Literally she started her study the next week and had all those three participants. So anyway things work out. But anyway, what was I saying? Oh, yes. I'm gonna give you some examples about how the train loosely works. Okay, so we only had one story On I think the story is about somebody who got food from mom or something and it was cold [00:51:00] and they wanted their food to be warm, so warm food. I can't remember what the other target word of the story was, but warm and food are very important to this, right? So, one story, one session about these words, okay? And remember, it's more like commenting and discourse level talking about something, not requesting we parents. Had written down, they kept a log of what the kids were saying and doing outside of our sessions and two parents recorded that their kids had asked for, or clarified, or described food and the word warm in the same multi symbol utterance spontaneously without anybody prompting them to do it. One of the kids said, said, um, um, I want warm food. So, there you go. You got, you, we just got like a four symbol request and we taught a story about how the kid wanted to warm up his food, [00:52:00] right? So, that's what I mean by the stimulus environment that's immediate. That's going to help control what words, what symbols those kids need, when they need it, if you trained loose enough. for the correct stimulus condition to take over.  Amy Wonkka:  And when you say, sorry, Kate, you're unmuted. No, I've, I've got words in my  Kate Grandbois:  brain, but I can hold onto them.  Amy Wonkka:  Okay. I'm, I'm trying to clarify the trained loosely. So it was trained loosely about also in that moment, what you're accepting from the learner as like a correct response. Yes. Some of that. So it's some of that. It's also some of like, I'm not reading this story a hundred times. We're not like focusing on the warm food story. We're just focusing on like the components of stories. This one's about incorporate some warm food. Is there anything else in that that that would make you say, ah, that's training loosely? Was there anything else that you're [00:53:00] doing or in the way that you're teaching or responding or like what your criteria is for your learner? I mean, yeah,  Trina Spencer:  kind of like all of those things, right? We, we shuffle stories, we, we change stories quickly, right? So we don't over teach anything. Um, and then we accept and model, like, we will keep modeling those three target words, but if they, if it was warm and he said hot instead of warm, we'd be like, Great. Let it go. We're going to reinforce the independence and the spontaneity of the variety, right? Like it's a, it's a recombinative, um, utterance. That's more important than correcting him and saying, no, no, it's warm food. Like who  Kate Grandbois:  the  Trina Spencer:  hell cares? I  Kate Grandbois:  can't communicate. I, I want to say this back to you as another point of clarification for Amy. But that like what Amy said, um, when I think of training loosely, the word variety really comes to mind. So variety of [00:54:00] materials, variety of people teaching in a variety of places. Um, I see a lot of, you know, when we're talking about complex learners, I see a lot of teaching at the desk, teaching at the desk, teaching at the desk, using Mayor Johnson symbols, using Mayor Johnson symbols, you know, a lot of repetition of the same flavor, not a lot of variety. And is, would you agree? Yeah,  Trina Spencer:  yeah, 100%. But variety should be intentional and strategic and systematic. And when I first got into this field and I worked with some SLPs, one of the things that I, I, you know, I was a behavior analyst, I was probably too much on the rigid side. And I would be like, okay, so what were you trying to teach there? And the SLP would be like, I don't know, just playing. I'm like, oh. You see what I mean? I don't mean that. I don't mean just like going in there without a plan, without any idea what you're going to do, because the more intentional you are about that variety, the better outcome and the faster it's going to happen, right? So [00:55:00] there is a balance between that, you know, and that's why it's so important to understand the different communicative functions, okay? Now, I want to tell you about one, another kid. Um, one of the kids that was not, never really used his AAC device in our study, okay, remember he only got like 9 or 10 sessions, 30 minute sessions, and remember there are 36 stories, we only got through 10 with this kid. Um, we did these, um, intervention sessions at home, um, it was like easier than to go into their schools. Anyway, but of course, the kids were using their AAC device so much more just a result of the exposure that we were giving them. And this one day. The SLP at school says to the mom when he, when she came to pick him up from, uh, from school, she said, Hey, did you guys ride a bus and go to a swimming pool over the weekend? And, um, the mom says, yeah, we did. [00:56:00] And she goes, okay, he just told me a story about that using his device. Oh my God. I know. That's so cool. A personal story with multi syllable utterances about something that actually happened to him that was real, right? Using words that we had not taught him for more than one exposure. That's amazing. Yeah. And personal stories, by the way, are really the ultimate goal, right? We want them to be able to talk about things that are important to their lives. We teach in the retail format primarily to start the exposure to the layers of their device, the navigation, and the, the breadth of vocabulary and categories. But what, as we're doing that, those become useful in their everyday. Which is the reason why we were tracking with the parents and, you know, we had really good details from two out of the three parents and that's the kind of thing that showed up and we're talking about kids who would never use their device before, hardly even to make [00:57:00] requests. So the second type of Master lesson plan is a version of a personal story because we want to be able to, like, build the retell transferred over to personal generation. Now, I, that we did not use in our, in our study this, this 1, but I know it from the clinicians that helped me design that. And I, there are some other studies of generating personal stories using photos of real events. So, basically, once you teach patterns and the. Variety of symbols that they got at their disposal, transferring it over to a personal story is, I think, easier than we think it is. That's  Kate Grandbois:  amazing. I, I want to make a comment just to anybody listening who's, I don't know, feeling excited about this, the outcomes that you're seeing, the early phases of this research and, and all of the, all of the positive patient outcomes that you're describing. But also looking at their professional workplace [00:58:00] and thinking, you know, how can I make this change? I, and I say that because when you talk about the rigidity of instruction and some phenomenon that happens when we have someone who's a complex learner and something happens where we get very rigid and we, we need to like do things in steps. I, my opinion here is I feel like that is very much a professional culture. And I think that it also in a lot of instances stems from workplace culture, or this is just the way we do things here, or how people are trained and expected to kind of go about their jobs.  Trina Spencer:  I think the origin was accountability. Kate Grandbois:  That too. I wonder if you could tell us a little bit about How to, if someone is experiencing those thoughts or thinking about how to shake things up and bring training loosely in and bringing multiple exemplars into their current intervention, what are some strategies that they can employ to [00:59:00] move that needle and kind of break some of that rigidity? Yeah.  Trina Spencer:  Oh, I, I, those, those are really good questions, ones I'm not necessarily, you know, prepared for, but I would happy to talk about them.  Kate Grandbois:  Just, you know, throwing you right under the, you know, in the hot seat, right at the end here. And totally,  Trina Spencer:  and totally fine, right? Because that is ultimately what I want. I don't, I don't necessarily want, like, a million, you know, Story Champs users. I want the, the technologies that we have been able to, to document their effects, I want them to be used. I want, to be honest, there's not a lot of literature that's going to tell you to train loosely. The literature that's out there is these stupid prompt hierarchies that say you got to do this and have a mastery criterion and da da da. And every single time I want to roll my eyes and go, Yeah, give me that, give me, give me those people, give me those people, I'll show you. We can do this better, faster, and have better impact, and no one's going to hate our services because we're so rigid if we just do it with some [01:00:00] intentionality. So, how to get there, sorry. So, I would plan on what's your ultimate goal, right? Is it to teach this phrase or is it to teach generative communication, right? And be, be thoughtful about what are the components. All right, the component skills and the patterns needed to be able to generate the, the language needed for something and, and I would argue it really is about patterns and we, uh, this is one of the things that SLPs are so much better at than behavior analysts because they're, they often focus on structure and all the behavior analysts are over here focused on function and think somehow that that's superior. Guess what? We need both. That's structure. Okay. is the pattern of language and we don't really understand how to teach that. So the way you teach that is give, once you've identified that's your generalizable strategy or your big idea that you're after, the pattern of something, right, you need to inventory a set of patterns that you're [01:01:00] teaching because you don't want to just teach one because otherwise you get like I want cookie, I want a cup, I want Choose you see you don't want that right you got to create a list of all the patterns that you want to teach and then Make sure that you're designing the instruction so that they're getting multiple opportunities to practice each of those But not in consecutive trials, right? So you have to like mix it up in a very Thoughtful, almost random way. It appears random, but it's not random, right? It's strategic variety. Um, so they're getting lots of exposures to them and you have to be very, very careful about your prompting. So you have to be able to fade your prompting. These are the key components of good instruction. Exemplars of the thing you're teaching. Strategic, intentional exposures to those in, in meaningful context. If Doug was here, he would have been, trih, contextualize, contextualize, contextualize. Meaningful context, right? Don't do it in, um, [01:02:00] sitting need a need a kids intensive. There's no need to drill. I have not drilled in 20 years. Right have not and the kids are learning how to talk. So, you know, you don't need it You don't need it and often the structure that's in place It's because we as the clinicians or the teachers we need it more and then there's accountability to it Okay, so so Identify your big ideas. I list all the different patterns and things that you're trying to teach in order to get to that big ideas. Uh, create some sort of structure or system to make sure you get that variety that's random but not random. It looks random but not random. And then, um, teach with intentionality to fade your prompts. Um, make sure you're identifying good prompts for that learner because A full physical prompt is not the best prompt for everybody and I would argue for very few people. Um, so we have to be very selective about how we customize prompts and then we have to have a [01:03:00] plan for fading and the fading needs to happen a lot more rapidly than you think it does and do not rely on mastery criteria. Right? And you have lots and lots of setting changes, context changes, you know, curriculum differences to practice all of those new patterns and generative repertoires in meaningful  Kate Grandbois:  contexts. Is that enough? That was beautiful. And now again, I'm just thinking about all of the things that I've done wrong, uh, in terms of, in terms of previously using mastery criteria and all kinds of things. I love the entire landscape that you've painted for us. And I'm wondering in our last couple minutes, if there are really important takeaways or other themes that you want to leave our audience with. Trina Spencer:  I want to make sure that I answer Amy's question about the expansion. Do you mind if I go there? You get so many [01:04:00] points for remembering my interrupting tangent. Good call. No, it's, it's important because we, we kind of were like. Well, is this a new Story Champs? What is this exactly? You know what I mean? We, we struggled with how you, how we can conceptualize this and how we communicate it with our, with the, you know, the clinicians out there using it. And we really want to say it's an expansion, right? And we call it an expansion pack. Kind of because it builds off of what we already know and do, especially the research. We already have a good, a very solid base of research. So we're expanding from that, um, expanding from the other research and the other clinical experiences that contribute to it, but also it adds more stories. Now, if you have high support learners who are speakers, even if they're just doing two word speaking, you know, spoken word utterances, the regular StoryChamps lesson plans would be [01:05:00] appropriate, but you can use these stories. Okay, the teaching procedures are really for AAC. Users specifically. So if you have a speaker, you can use these stories, but use the other story champs, story, uh, story champs, master lesson plans. Okay, because those are written with the research for the teaching procedures for speakers. And these are written, which is only, there's only two right now, but we believe that there's additional expansion coming. We got more research to do. So, yes, expansion, it works. And actually, Story Champs AAC is quite affordable, too. Like, that's another piece that we kind of, we want people to be able to be like, Oh, I have regular Story Champs and now I'm going to start collecting these expansions for different versions.  Kate Grandbois:  I love it. Thank you so much for sharing all of this. We're going to have all the research that you mentioned in the show notes, a link to [01:06:00] Story Champs for people to check it out. I so appreciate, I don't know, everything that you talked about from rigidity of instruction to, you know, how we need to think more, more robustly about the power of teaching narratives. It was, I, like I said, I have a lot of regrets, but that means that I learned a ton. Uh, so, you know. Glass half full and thank you so much for being here. This was awesome.  Trina Spencer:  Well, thanks for having me. I definitely think that narratives are underutilized and we could be a more efficient workforce with the people we serve. If we. Like, integrated some of these instructional design principles. Yeah,  Amy Wonkka:  this was awesome. Thank you. Trina. Thanks. Trina.  Kate Grandbois:  You're the best. Trina Spencer:  I just enjoyed it. It's fine. I'm sure you probably we have more problems, more clinicians and more teachers are like, okay, this is what we need. So I got other [01:07:00] things to work on now.  Kate Grandbois:  Excellent. Well, we'll be following along closely. And of course, we'll, we'll just beg you to come back. That's right.  Trina Spencer:  I appreciate you letting me come on and talk about it. It was, it was good fun. Thanks again. Yeah, you guys are awesome.   Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here today to talk about a topic that is very new to Amy and I, uh, we are here with Neshifa Hudamoman to talk about feeding in the ICU. Welcome [00:02:00]  Neshifa. Hi Kate and Amy. I am so thrilled to be chatting with you guys today. Thank you for having me on. Now Neshifa,  Amy Wonkka:  you are here to discuss early feeding and developmental care in a cardiac ICU, which is. a really specific topic, but as we were discussing before we hit the record button, actually applies to so many of us who are working in the field of speech language pathology. Um, before we get started, can you please tell us a little bit about yourself? Sure.  Nashifa Hooda Momin:  Um, so as you guys mentioned, my name is Nishifa, and I've been a practicing speech I've been a speech language pathologist for about 11 years. I currently work in an acute inpatient children's hospital and work primarily with pediatric feeding and swallowing and pediatric dysphagia. My passion is working with infants and children with congenital heart disease. More specifically, single ventricle physiology, and I work primarily in the cardiac intensive care unit and our step down unit, which is called the CACU. Um, and I recently stepped into a new role as [00:03:00]  an allied health research scientist, so I get to support, um, evidence based practice, quality improvement, and research in my institution. And then finally, I'm wrapping up my doctorate in speech language pathology from MGH Institute of Health Professions. We'll be finishing this August. So super excited about that. Outside of the realm of speech language pathology, I like to run and I like to read. And that's about me.  Kate Grandbois:  So many things. So that's very, that's very exciting. Um, your role sounds really interesting and I feel like I could talk to you for a thousand years about the doctorate, but that's not why we're here.  Let's move on to read our learning objectives and disclosures, and then we will jump right in to learn more about feeding in, uh, infants. Learning objective number one, participants will be able to identify three reasons for the importance of neurodevelopmental care in the cardiac ICU. Learning objective number two, participants will demonstrate the ability to accurately [00:04:00]  identify a minimum of three feeding problems commonly observed in infants with congenital heart disease. Learning objective number three, participants will be able to identify three strategies to improve culture and education on PO feeding in a cardiac unit. Disclosures, Neshifa's financial disclosures, Neshifa Neshifa is an employee of Children's Healthcare of Atlanta. Neshifa also received an honorarium for participating in this course. Nishifa's non financial disclosures, Nishifa has no non financial relationships to disclose. My financial disclosures, I'm Kate, I am the owner of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and I serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy.  Amy Wonkka:  Amy's disclosures. That's me. My financial disclosures are that I'm an employee of a public school system and co [00:05:00]  founder of SLP Nerdcast. And my non financial disclosures are that I am a member of ASHA Special Interest Group 12, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, let's get started. Uh, Neshifa, why don't you start us off just telling us a little bit about congenital heart disease? What What is it? What is the definition? Yeah,  Nashifa Hooda Momin:  absolutely. And I think that's a great place to start because before we dive into neurodevelopment, I think it's good to just understand our foundation. So when we talk about congenital heart disease, it's any type of structural abnormality in the heart that's present at birth. And these defects can widely vary based on their severity and impact in heart function. And the way that I like to Um, categorize them, or the easiest way to think about them is acyanotic defects and cyanotic defects. So when you have an acyanotic defect, it's often an abnormality in the structure, which may be like a hole between the chambers, like the ventricles or the atriums. And, um, some examples of this could be like a [00:06:00]  ventricular septal defect, which is essentially a hole between the two ventricles, or an atrial septal defect, which is a hole between the atriums. And what ends up happening is that, uh, When the blood is being circulated through the heart, what the blood that is already oxygenated goes back from the left side of the heart to the right side of the heart to re oxygenate. So these babies, clinically, will often be, have increased work of breathing, they'll have, um, endurance issues, they may, like I said, they'll have tachypnea. Um, but again, this is one of those things where it's like an inefficient system, um, and once they have surgery, they generally will do well. The other type of defect is a cyanotic defect. And what a cyanotic defect is when you have insufficient oxygenation going to the rest of your body. And this is, this is a little bit more serious, right? And so what ends up happening is that blood that's from the right side, that's not oxygenated yet. It hasn't gone to the lungs. will cross over to the left side and then that blood will get circulated to the rest of the body. So when we see these kids clinically [00:07:00]  before any type of repair, any type of surgical repair, you'll see that these babies often may have like blue fingers and toes because remember that our fingers and toes are the furthest away from our heart. So it's usually a telltale sign like when you see these infants, um, at bedside. Um, and then these kids are often similarly going to have work or breathing issues, endurance issues, um, and then they'll need some type of surgical repair. So congenital heart disease can impact one in 120 in the United States. It's a relatively and actually the most common birth defect that we often see with, um, infants. Kate Grandbois:  Okay. I have a follow up question. I, first of all, I feel like I need a refresher on the structures and function of the heart. Absolutely. , so I want to say something back to you to make sure I've understood it  and I'm going to use a word that prior to this recording, I'm not even sure I could pronounce. Essentially, what you're saying is infants who are born with congenital heart disease can fall generally into two [00:08:00]  categories. One is a cyanotic and the other is cyanotic.  Nashifa Hooda Momin:  Is that  Kate Grandbois:  correct? I'm getting, I'm giving myself all the A pluses for pronunciation. Um, and of, and of those two, of those two categories, the cyanotic category is um, Would you say more severe or has a larger impact on the child's body and oxygenation overall?  Nashifa Hooda Momin:  Absolutely. right on it.  Kate Grandbois:  Hooray. I'm so glad I got it.  Nashifa Hooda Momin:  You brought up a great point. I think we could talk a little bit, just very, very simplistically in terms of blood circulation, right? So when we have blood circulation in our body, we have deoxygenated blood that comes in from our, I'm not going to get too particular. It comes to the, right side of our heart, and it goes into our right atrium, and then it goes into a valve, and then it goes to our right ventricle. From there, it'll go in through, into our pulmonary artery, and then it'll [00:09:00]  go into our lungs to get oxygenated. Then that oxygenated blood will return through our pulmonary vein, and go to the left side of the heart, so now we have oxygenated blood. blood and it'll go to the left atrium through a valve through the left ventricle and then that left ventricle will send it to the aorta for systemic blood flow. So that's why when you have blood that goes from the right to the left side without any oxygenation without it all going to the lungs, um, That's when we can have a cyanotic defect. Now I will say as a disclaimer, it's not that the whole full 100 percent of the blood is going from the right side to the left side with no oxygenation. Um, we could talk more about structural, um, anatomy and that would take us, uh, onto a different path, but I, I, there are mechanisms in place in terms of the structure of the heart to have a little bit of that blood flow going to the lungs. It's not just like a one way street.  Kate Grandbois:  What's amazing about this is that you're a speech pathologist. Yeah, and we are here to talk about speech pathology, and I can't wait to make [00:10:00]  this connection. So, so keep keep going. Tell us more.  Nashifa Hooda Momin:  So, so to then kind of switch into neurodevelopment, right? So we were just talking about cyanotic defects, right? When, think about when the baby is in utero. So when the baby is in utero, the same thing is happening at that point. If they have a cyanotic defect, then oftentimes that blood that is being passed is not all of that is not going to be going to our brain. So when these babies are born, especially with critical CHD, and we can talk about some of the diagnoses that you see as critical CHD being like Tetralogy of Low, Transposition of the Great Artery, Hypoplastic Left Heart Syndrome, Hypoplastic Right Heart Syndrome. Those are more synodic defects. We often see a lot of neurodevelopmental issues. So that's kind of what I wanted to talk a lot about today, is that you know, why is this such a hot topic for infants with congenital heart disease? It's, and it's often because it's something that we're not always thinking about. Um, now I will say a lot of the research and we'll talk through a lot of the research, [00:11:00]  um, is now this is at the forefront. Um, but yeah, is that, yeah, that's, that's just a little bit about, you know, congenital heart disease and neurodevelopment.  Amy Wonkka:  And just, just to go back to the, what you were saying about having a cyanotic, um, form of congenital heart disease and the fact that that is also happening in utero, um, I wonder if you can, and I know you're going to talk about neurodevelopment, but just talk about the importance of oxygen when we're thinking about, um, the development of a brain. Nashifa Hooda Momin:  Yeah, exactly. So imagine, um, well, when, when we'll talk a little bit about this later, when we talk about like neurological insults and whatnot that happened, it perioperatively postoperatively, even what we see preoperatively, but when you aren't getting adequate oxygenation to the brain. That's obviously going to cause changes in your brain function, but also the brain is what controls the rest of our body. So there's just a lot, uh, we need to have a hundred percent oxygenation right now. If we were to go, [00:12:00]  um, to the doctor and they put a pulse ox on us, we would have a hundred percent oxygenation. The cyanotic babies. If we, right after birth, if we were to check their pulse ox, it would not be at 100%. It would be around 75 to 85%. Um, again, it'll depend on the type of structural abnormality, but that's not considered what we would say normal or typical, right? Um, so it's definitely a concern and definitely something that we have to address pretty quickly after they're born.  Kate Grandbois:  And for everyone listening who is kind of, you know, either working in a medical space or even in a school. And thinking this is, you know, the first time that we're the first time that they're hearing about congenital heart disease in its intersection with speech language pathology. You had mentioned before we hit the record button that this is a relatively new field. Is that true?  Nashifa Hooda Momin:  That is true. So that's the interesting thing about it, right? So, um, so much has changed in the field of congenital heart disease and the management of congenital heart disease. So much [00:13:00]  has even changed in, um, how we take care of kids in the ICU. There's been surgical advancements, there's been ICU advancements, there's just knowledge advancements. advancements in congenital heart disease. There's knowledge about neuro development at this point, and so with all of this information with specifically the surgical ICU advancements, the mortality rates among the Children with CHD born with CHD has decreased. But there's a lot At the same cost that we've seen an increase and, um, more neuro, uh, neurological abnormalities and neurodevelopmental impairments. Um, and so we have to remember that yes, cardiac intensive care is life saving. Um, and it's, it's so big for a caregiver who has an infant with congenital heart disease, but it does come with a lot of environmental and tactile stress, um, that is placed on the infant in an ICU setting. And that's why we're talking about neurodevelopment. Amy Wonkka:  And for those of us who haven't been in that environment, either, you know, in our personal life or in our professional life, can you, can you give us just a little window into [00:14:00]  what the cardiac NICU looks like, what that intensive care environment sounds like and looks like?  Nashifa Hooda Momin:  Yeah, absolutely. Um, so it's interesting cause I, um, I guess being in the field for now, I, 11 years, um, and working in the ICU, I have so many new graduate students. Students that when they, um, meet like a medical SLP, they their goal is I want to work in the NICU setting and I think that's fantastic because I, but I think that's because also many people don't know that you can work in a cardiac ICU and it's, um, equally fun, um, at least in my perspective. And so what a cardiac ICU is, essentially we can have babies that are, um, we can have neonates and we can also have full term babies. But it's any baby that, that, specifically in my institution will come to our institution when they likely need some type of intervention, whether that is a surgical intervention in the operating room or whether that could be a cath intervention or whether that's just, Hey, let's bring them in. Let's do a full workup and see if we can [00:15:00]  manage this as an outpatient, um, and then get them home and then bring them back when they're bigger and healthier to do that surgical intervention. But these are the kids that are going to likely need some type of cardiac intervention because Because of their congenital heart defect for me. Um, specifically, I work in an ICU setting and like I mentioned in a step down unit as well. And so A typical day is, um, oftentimes if a baby is transferred over into our unit, we'll all often do like a pre op or pre op feeding before they have any type of surgical intervention. I'll see them post operatively after any type of surgical intervention. And then especially these kids that may require multiple interventions, I'll follow them along and make sure that I'm supporting them in their feeding. Because keep in mind, You know, similar to a NICU baby when they're born, they're gonna need all that support to, to feed, right? But now add that component and then add the surgical component to it with them having surgery quite early on. Um, and it, it is a really stressful environment and they need [00:16:00]  all the support from a speech language pathologist, even a PT and an ot, really like a multidisciplinary team.  Kate Grandbois:  As you're talking, I'm making these frowny faces because I mean, it's just, you know, thinking about these tiny little human beings in this very experiencing this trauma. Um, and, and being in, I don't know, I'm imagining, I'm imagining an ICU. There's bright lights, lots of beeping. I mean, tell us a little bit about what these tiny little humans experience on a day in day out basis.  Nashifa Hooda Momin:  So if you think about, um, in an NICU setting or an ICU setting, specifically the cardiac, um, ICU setting, you have, say the baby is born, right? And say the baby has congenital heart disease. It's a cyanotic defect and say it's a single ventricle, um, defect. That patient is going to require pretty quick intervention and our hospital is not a birthing hospital. So the first thing that's going to happen is the baby is going to be separated from their mom [00:17:00]  quite early on and they're going to come into our ICU setting. At that point, They're going to likely get some type of echo. They're going to get lines placed. Um, they're going to have, um, the medical team is going to come and kind of look at their echo and look at, you know, kind of what their, like the, what their blood work is. Um, oftentimes we may initiate PO feeding, but the first couple of days, especially before any intervention for a high risk infant is pretty chaotic. There's a lot going on. There's a lot of, um, Healthcare providers trying to get in and kind of do their assessments prior to any type of intervention. So I hope that is that answering kind of generally what  Kate Grandbois:  it does and I you know, I'm just thinking about what impact These experiences will have on on the infant, uh, i'm just you know, looking at some of your talking points about about what they experience in terms of procedures, interactions. These are brand new babies been, who have been separated from their moms. I mean, this is like a, this is [00:18:00]  huge. This is very layered.  Nashifa Hooda Momin:  So it's interesting if you look at the, um, European research, um, based NICU studies, specifically NICU, not cardiac ICU. They have found that an infant can have in a day in the hospital can have anywhere between zero to 14 type of procedures. And another study by Cruz and colleagues that was done in 2016, they found that infants in a typical day were having anywhere between seven to 17 procedures. And these would include, um, He'll, um, like a heel touch to get blood, um, nasal endotracheal suctioning, any type of placement of peripheral venous catheters. And so the interesting part about all of this is that once a child reaches that threshold of pain, all non Non painful experiences will be perceived as pain, um, and the infant will often shut down. And interestingly, only 5 percent of the touch in a hospital setting is considered positive. All that 95 percent of the rest of that is considered either medical or, [00:19:00]  uh, or painful.  Just putting it into perspective of kind of like what an infant goes through.  Kate Grandbois:  I have to imagine that this has a massive impact on their nervous system.  Nashifa Hooda Momin:  Mm hmm.  Kate Grandbois:  And I wondered, what does it mean when an infant shuts down? Nashifa Hooda Momin:  So oftentimes you'll see like a baby, well, uh, I see this quite a bit with PO feeding. Um, and PO feeding, I mean by, is per oral specifically, so eating by mouth. Um, if I'm feeding a baby that is generally having like, uh, it's stressful for them. They're tachypneic. Um, it doesn't feel good. Potentially they aspirate or maybe they're just a, a preterm infant and they're just It's super overstimulated. Shutting down will often be that they look sleepy, right? Their eyes will close, they'll kind of disengage. Their body, their body like tone will change. Um, and you kind of, a lot of times it can be perceived as Oh, they got sleepy, right? Um, but they really truly just shut down. They're like, they can't take anymore. And so you'll see this kind of like, um, stagnant or no response. Um, and, and [00:20:00]  not in a. serious way, but in a way of like, Hey, I'm not going to engage in this activity. I'm not going to engage in this for the next step. I'm not going to PO feed. And so a lot of times, um, you'll often see that. And I feel like, I mean, outside of the world of NICU and babies, I think we're similar in the same way, right? When we're overstimulated to some level, we like to back down our nervous system. Well, like wants to get that. And so I, I, it makes sense, right?  Amy Wonkka:  Yeah. Sort of just having that self preservation mechanism to just be like, this is too much. Yeah. I've got to take a little break here. Yeah. Yeah. Yeah. In your talking points, you also had some information just about brain volume. And so thinking, thinking about all the things, right, thinking about the oxygenation piece that we talked about earlier with the cyanotic babies, thinking about nutrition and how much it might just be a struggle to get adequate nutrition. All of those things together are obviously important for development. Um, yeah. [00:21:00]  Can you talk to us just a little bit  Nashifa Hooda Momin:  about that piece? Absolutely. Um, so interestingly, there was a study done by Scotting in 2021, and they found that infants with CHD had smaller brain volumes than a typically developing infant. So what they looked at specifically was 10 infants with the postmenstrual age of, uh, 39 to 54 weeks, and then they compared it, um, and those were the typically developing infants with, um, 10 infants with CHD, um, and what they ended up finding was that the infants with CHD had a smaller, had smaller brain volumes, and so some of the inclusion inclusion criteria. And what I mean by, um, inclusion is that what types of infants we're talking about with CHD. These were the more critical CHD, so Tetralogy of Fallot, Transposition of the Great Arteries, Coarctation uh, uh, Hypoplastic Left Heart Ventricle, Hypoplastic Right, um, Ventricle. So again, are more, uh, critical CHD. And then in another study, um, by Litsch et al. in 2009, They also looked at infants [00:22:00]  with critical LCHD, and they looked at 29 infants with hypoplastic left heart syndrome and 13 with transposition of the great arteries. And they found a one month structural difference in brain development. And so then what does that mean? Right? And so I, I always, I love the study because it really puts into perspective as a healthcare provider on how, what does it mean? How do I, what do I take with this information? Right? So an infant, imagine an infant born at 38 weeks with hypoplastic left heart syndrome, their brain is going to be similar to that of a 34 weeker, right? So to take that one step further, how do you suppose that the infant's development and maturation is at that stage? Given that it says 38 weeks versus what our perception and actual development support the infant is actually getting, um, and so when we think about just to kind of think about in utero development and the milestones that the baby is kind of achieving in gestation around 34, um, To 36 weeks is when that non [00:23:00]  neutral to suck on a pacifier really matures. And that sucks while a breed coordination for PO feeding that matures around 37 to 44 weeks. So now if we add that layer on, then what, what are we, what are we expecting from the baby versus what? We should be expecting from the baby. Um, so I, I like to talk about this because it puts into perspective how we, when we work with this particular population, we really kind of have to take a step back, look at what their existing research. We have to look at the patient in general. We have to look at their cues. We have to put it all together before we just have these like unrealistic expectations and almost like push the baby too hard. And we're kind of heading in that wrong direction neurodevelopmentally. Kate Grandbois:  And I know we're going to get to this at some point, but I can't, I can't help but think about the long term implications of all of this across all the variables we've talked about the trauma and separation from the mom at birth, the lack of nutrition or risk of lower nutrition, the neurodevelopmental [00:24:00]  changes. I, I wonder if maybe this is a dumb question, but Are there guidelines for adjusted age when you're talking about brain volume like we do for preemies?  Nashifa Hooda Momin:  No, because I don't think it's consistent across all babies with CHD, right? I think, um, and I think this is still something that we're learning more and more. I think in general, we can all agree that infants with cyanotic lesions are just at a higher risk because we know in utero, they were also not getting the best oxygenation, right? But. Um, I don't think there's any guidelines in specific to be like, Hey, these particular infants, we're going to do it this way. I think in general, we know that critical CHD is just a higher risk population. Um, but it's interesting because, um, another point that I kind of wanted to bring up is really when we think about these kids and we think about, we were talking about interventions when a baby goes to, um, has any type of intervention, they get put on maybe Bypass, for [00:25:00]  example, cardiopulmonary bypass. And a lot of times as speech language pathologists, and I'll say I'm guilty of this, like, our assumption is that, oh, well, you know, now that we're kind of going under cardiopulmonary bypass, and then they're likely going to have any type of neurological insult on top of everything that's going on, and post operatively, we might see an insult. But interestingly, one thing that I also found, um, interesting about our specific population is that, um, There's actually preoperative concerns as well, like we've been talking about, right? And so in a study that they looked at in 2019, they looked at 70 newborn infants with critical or serious CHD, and they did an MRI prior to surgery. And what they ended up finding was that 39 percent had some type of cerebral lesions, with white matter injury being the most prominent lesion. Um, and there were a few cases of arterial ischemic stroke. And so again, like, why am I bringing this up? Because I think when we think about neurological insults with populations in general, with babies or adults, we always tend to think [00:26:00]  about, you know, During surgery, like perioperatively and postoperatively, and oftentimes we're not even thinking preoperatively. Um, and I, I can say that I've done that myself, and I still do, because I think it's when you don't see it, when you can't visualize, um, something, then it's hard for us to, like, take that into consideration.  Kate Grandbois:  And I have to assume, just as a clinician, Your consideration of where the patient is at baseline is a really important component of the interventions you choose post op, right? And what you're talking about is, is evidence related to what that baseline looks like in terms of potential lesions or, or other, of all the things, all the exposures, all of the, you know, traumatic experiences that this tiny little baby has gone through.  Nashifa Hooda Momin:  Yeah, absolutely. And we really, as a clinician, like you mentioned, we have to look at the whole continuum. We have to look at them [00:27:00]  from intrinsically when the baby was in utero. We have to look at it preoperatively, how clinically they present. perioperatively, postoperatively, and then to take it one step further, we also have to think about outpatient. I think one of the areas where I feel like the disconnect often happens is between a hospital setting and an outpatient because as a healthcare provider, I, and I'm, I'm trying to be better about this, but like, how do we make sure that caregivers realize that this is something that we need to be thinking about even as they get home? And even if the, the CHD may be repaired, That there are some other considerations we have to continue to think about and then how do we make sure that they get plugged into outpatient and they take it seriously because again, when you can't visualize something, it's hard to take it seriously. Sometimes it's hard to think about like, okay, well, you know, I had my Heart defect is done. And now, you know, the speech therapist might be saying or the, um, the healthcare provider is saying that I need to do all this outpatient testing and yada, yada, yada. And I have to go to the cardiologist appointment and I have a PCP appointment. I have three [00:28:00]  other kids. Like it sometimes becomes less important, but I think we have to emphasize the importance of it because there are, uh, considerations we need to be thinking as, as they, as these children start to grow. And to, to that point, um, the American Academy of Pediatrics found that infants who needed heart surgery, specifically cyanotic lesions, um, and those cyanotic lesions that had comorbidities such as prematurity or prolonged hospitalization were at a higher risk for developmental disabilities. And there's also research showing that, um, The more critical the CHD, the more, um, sorry, the more severe the cognitive impairment that we may, we may see with this particular populations and so a lot of these challenges that we see these in the challenges that these infants have won't often be seen. Um, and I think that's a of times kids are being seen or teased out to school age. And so is it? Is it that they develop in school age? Or is it just that they were missed until that moment, right? And I think it's because I think they're just missed until that moment because the child isn't going to be pushed. [00:29:00]   In a school setting until their school age, right? They may it may. They may just make it right by they may. It may not be concerned concern, but some of the challenges that we often see is exactly that. Decade of function challenges, attention, fine motor and gross motor, academic struggles and behavioral issues. But again, it's not that these issues just, you know, showed up at the age of five or six. I think it's just the fact that nothing, nobody was like really testing 'em. They might not have been pushed until they were integrated into a school setting.  Kate Grandbois:  So I am wondering now that I know this is a relatively new field, and it sounds like there's a lot of emerging evidence or a lot of, you know, in the last few years, a lot of evidence that these kids, these babies are at higher risk, are there any standard screening procedures in place or standard screening Um, protocols in place to catch some of these deficits so that we can provide the critical period of early [00:30:00]  intervention. Nashifa Hooda Momin:  Yeah, so, um, I can't speak 100 percent to how other institutions are doing this, but I will say at our institution, we do have a neuropsychologist who, um, will try to plug them in with the, with her, um, and she will often do these assessments, uh, to kind of see where they are in terms of, in terms of neuropsych, and she follows them up to the age of two, and I know she's looking specifically at our more high risk population again, um, but I think it's something that truly is needed everywhere. And I'm, I'm hoping that as we, you know, we're learning about all of this and I, I hope this then becomes like regular standard care practice for a lot of our critical CHD babies.  Amy Wonkka:  So, I mean, I don't want to lose the, the, the piece about this is life saving care for so many of these infants. So even though it is, you know, in a stressful environment and they're experiencing challenges and they may experience prolonged challenges, it's also, um, [00:31:00]  It's also potentially it's life saving. Um, are there, are there any, um, strategies or is there any research around things that can be done when they're still in the NICU or in the step down unit, um, that might just help facilitate  Nashifa Hooda Momin:  positive outcomes? Yeah. And I think that's a great point. So that's the thing, like we've talked about all this research, right? So then what, we know all of this, what are we doing about it? Right. So interestingly, there is now research about looking at neurodevelopment in CHD. And what they found is they thought there was a study by Peterson or a paper by Peterson in 2018. Um, and some of the strategies they talked about for specifically for our CHD babies that do kind of overlap with our NICU population is massage, uh, skin to skin kangaroo care, which, um, again, that's definitely something that we use in the NICU, developmentally supportive positioning. Now, um, I want to say this is more specific to, you know, when the patient is intubated or that when the [00:32:00]  patient is in ECMO, like, we can still do developmentally supportive positioning in these critical time periods. Q based feeding and PO feeding, and I'm, we'll talk a little bit about the importance of PO feeding and the PO feeding project that we did at our institution, pain management and procedural support, and what I mean by that is that We don't want to over sedate our population because then we're missing these developmental critical windows where we need to be involved and working with this particular population. Um, so yeah, that's kind of like what's going on currently.  Kate Grandbois:  I have to assume, I have to assume that there is a lot of coordination of care that is happening to be able to provide the supports that we know are going to try and counterbalance all of the negative experiences. So everything from educating other staff members, collaborating with parents, you've already mentioned collaborating with a neuropsych for follow up. This has to, I guess All of that collaboration really has to be built [00:33:00]  upon some foundation of infrastructure within your within your workplace. And I have to imagine that if that's not there, all of these pieces are not going to be executed well. Nashifa Hooda Momin:  Yes. So I agree. And I think that one of the great things I feel like at least what I at least what I feel at our institution, everyone there wants to be there. Everybody is so, uh, eager to support these infants, and I think that's what's making that difference. And I, and this isn't, this is, I'm sure, all across the United States, like, when you work with this particular population, you are passionate about change, you're passionate about patient outcomes. But at our, um, institution, there's a couple things that we're doing, um, structure, or like, I, I don't know if it's structurally, I don't know if that's the word, um, that we're doing, um, to help support neurodevelopmental care. One of them is, uh, neurodevelopmental rounds. And so neurodevelopmental rounds, it was actually created by our child psychologist. And, um, what it is is it's a what it's once a week rounds and we round on four patients. So about four patients for the hour. It has a [00:34:00]  physician champion. The primary nurse for that patient will be on the rounds. And then our rehabilitation staff, PT, OT, and speech will be in rounds. Um, This is currently being revamped with like, you know, COVID obviously kind of shifted a lot of things, but we're kind of revamping it at this point. But what we're talking about is these are the patients that often, um, we're not, we want to bring neurodevelopment into the lens, right? So we're like, Hey, This patient is a high risk patient that is going to be here for a long period of time because they're waiting for a heart, um, and, or this patient has a VAD and they're going to, they're waiting for a heart, or this patient is a single ventricle baby who is too, uh, fragile to go home, so they're going to stay here in the interstage period, or this patient sustains some type of neurological insult and they're going to be in this institution for a period of time. At that point, And it really at any point when the patient is there, we have to start thinking about development, right? Is the patient getting tummy time? Are we doing cycled lighting? Are we doing the things that you would be doing in a home setting that [00:35:00]  we don't do in a hospital setting? Because it is important for brain development. We know that if we took CHD in hospital out, we know there's all this research that this, these are the things that we need to be working on in a, for a typically developing infant. But sometimes that gets put on the back burner. And so we're trying to bring light to that when they're inpatient. Um, The second thing we have is a neuroprotective care council. Um, It was created in 2018. It's supported by a physician champion and the team includes a PTOT speech, a pediatric psychologist, um, and nursing. And we have quarterly meetings and quarterly goals. And so some of the things that we've worked on so far that have been, um, super interesting have been mobilizing patients. And I mean, intubated patients, intubated babies, like getting them out of the bed into the mom's arms for skin care. kangaroo care. And we've had kangaroo thons, um, neonatal temp management. So thinking about the importance of temp management, because that can really change our vitals and put the baby in a crisis, uh, promoting oral feeding. We'll [00:36:00]  talk more about that. And then, um, incorporating parent feedback into our practice. Cause what are we, if we aren't really putting the parent Um, giving them a chair, a seat at the table. Sorry, I said that wrong, a seat at the table. Um, because it is important. At the end of it, we can think we're doing all the right things, but we have to have that perspective from the caregiver as well. Amy Wonkka:  Can you talk to us a little bit more about the feeding piece? Just how many, how many of the babies in general are able to do PO feeds when they come to you? And what does that process look like as you're working with them over a prolonged period of time? Sure.  Nashifa Hooda Momin:  Yeah, absolutely. So, um, if we, if the patient comes to the hospital, um, and they are medically stable, we are going to try to PO feed the baby, uh, preoperatively. The only thing I would say we're probably not going to PO feed is if they're intubated, obviously. And, um, if they are, um, on ECMO or something, if they're really, truly stable. There is not an option to PO feed. Otherwise, we're going to have [00:37:00]  some type of involvement, whether that would be, um, offering a pacifier, pacifier dips or oral feeding, and we will try to oral feed as much as we can, and as, um, when the medical team says, says we get clearance for them. Um, so the project that we did to kind of emphasize this PO feeding was, um, in 2019, we had done an internal survey with our CICU nurses. Um. Just about neurodevelopmental care and interestingly, the knowledge deficit we found was all around feeding. Um, it was about how to feed a baby, like what position to use. There's so many nipples, what's appropriate. Um, what is like the speech therapist is always talking about signs of aspiration. What is the sign of aspiration? Like how, what feeding, feeding related deficits, right? Um, knowledge deficit. Um, so the purpose of our project really was to get CICU nurses, uh, you know, give them the strategies and kind of. address this deficit. Um, and so I will say it's so important because as [00:38:00]  a speech language pathologist, yes, if we're consulted, I'll go feed the patient, but I'm not feeding the patient around the clock. I'm not there at night. And so the nurses really, truly are the core of promoting feeding in a unit. Um, so knowing that is important. So what we ended up doing is two speech language pathologists, one of them being me, myself, um, educated two nurses that were our nurse champions for PO feeding. And then all four of us together kind of came up with, well, had this project. So two nurses, um, and specifically were kind of like the support when the nurses had any questions. And then as the speech language pathologist, we were involved in doing didactic teaching with the nurses and new nurses, and then also doing hands on teaching. So the purpose of the project was to educate CICU nurses on the strategies of bottle feeding, given the knowledge deficit, and the way that we set this up was that we had To speak to speech language pathologists that were primarily in the cardiac units, and we worked with two nurses that then became our P. O. Champions, [00:39:00]  and we educated them on strategies and everything that we would be telling the nurses. And then the speech language pathologist worked on a two part system. One was doing didactic education to the nurses. Um, and then the second part was a hands on course or hands on practice. So So the didactic part was where the nurses would come and new nurses would be on board and it was part of their onboarding education. They would meet with a speech language pathologist and we would talk about topics like CHD and medical complications, feeding difficulties in infants with CHD. Like what are, what do we anticipate with this particular population? What are the feeding strategies? When to appropriately use these strategies? And this included positioning the different types of nipples in the, um, in our system. the use of pacing, and then we talked about the importance of developmentally, developmental feeding, and signs of aspiration. Then, they had two to four weeks where they would be clinically practicing in the ICU or step down unit, and then we would meet again for hands on practice. And the reason I loved this kind of model was [00:40:00]  because they got to take the didactic teaching and apply it and then see if What, what wasn't making sense or where they needed more clarification. And then the hands on practice, they would come with the speech language pathologist and observe us feeding, like, two to three patients for an hour. Um, and then they would ask questions, and we would kind of have this, like, open dialogue of, Hey, like, this, I have a question about this nipple. Why did you do this? And it was great because I felt like you got the, the didactic education, then you have a little bit of hands on practice and you can fill in all the holes in the, in, in between. Um, and so. With that, the nurses that I mentioned that were educated, they were also there to support these nurses when we weren't even around. So, like, say you're clinically seeing a patient as a nurse, and then you're feeding a patient, and you're obviously not able to get the speech language pathologist. Obviously, we always tell them, call us if you have any questions. But say they see the PO Champion nurse, they can easily go to them and be like, hey, I have a question about this. And so there's a little bit of that support in the unit as well. And so what we ended up finding is that nurses [00:41:00]  reported an increased confidence in their ability to recognize early signs of aspiration and feel empowered to reach out to speech language pathologists. And we saw, um, an increase in speech consults within that unit, as well as appropriate use of swallow studies with that particular population. And then some other wins that we saw was that we kind of changed a little bit of that culture that I had mentioned in one of my learning objectives, and that we changed the supply. So in our unit, Previously we had standard flow nipples and slow flow nipples and realistically with our population and with the amount of infants that we see, we really weren't using standard flow nipples and having an inappropriate nipple for these for this population ends up causing the safety issue because what if you are unaware, then you're just going to grab it and use it. And we really didn't need that. Right. So we ended up Switching, taking the standard flow nipples out and then replacing them with preemie or extra slow flow nipples because that's usually our go to for this population. Um, we continued this [00:42:00]  education model where now every nurse that enters, um, into the ICU units has this like, um, hands on teaching or has the didactic teaching and the hands on with speech language pathologists. And this started a long time ago and we're still doing this. And, um, we've started, we've created some more feeding guidelines so that We're promoting PO feeding in our units and including collaboration with our providers. And then now we also have automatic orders for all infants under three months. And we're actually expanding that hopefully soon to include maybe up to six months or even up to a year. Um, so there's been a lot of wins out of this project. Um, Yeah, that's a little bit about the PO feeding project.  Amy Wonkka:  That sounds awesome. It does sound awesome on multiple levels. I think it's great that you incorporated like multiple stakeholders into the initial planning with the two champion nurses. Um, but then I feel like also just the fact that it was ongoing and multilayered, uh, how big were your trainings usually? How many nurses are you training at once?  Nashifa Hooda Momin:  So back, [00:43:00]  uh, like I guess a while ago, we would have about 10 to 15, but, um, our, we are transitioning to a new hospital. So recently we've had 15, 20 nurses at a time now. Um, and we've been doing them quite frequently, but yeah, this, it, I think it could vary. Sometimes we've had like five and sometimes we've had more. It just depends on who's being onboarded into our system.  Kate Grandbois:  It sounds like a tremendous win. I know you use the word win a couple of times, but just to not only make other stakeholders feel empowered and confident, but engaged and also elevate the evidence based practice in your, in the whole, within that department, within that unit, that is a tremendous win. That's a tremendous success. Um, and I am hoping that anyone listening who is working, maybe not even in a similar workplace environment, takes away those suggestions for how to really elevate and shift [00:44:00]  culture if you see need for improvement across some implementation from evidence based practice. I just, I think that's a really wonderful example of how we can, as speech pathologists, implement change. shift our workplace culture to better embrace EBP. And then hopefully the outcome of that is elevated outcomes, better outcomes for our patients. Cause that's the whole point, right?  Nashifa Hooda Momin:  Yeah. And I will say with this pro, uh, project, we have seen a dramatic increase in P. U. Pio feeding since 2016, specifically with their single ventricle population. And I feel like it's important to say that because that's our critical population, right? So we've shifted the culture in the unit, but we've also shifted our mindset that we can do this with our, with our critical CHD patients. And then it also kind of highlights how it's not just like a lot of times when we think about like our speech pathologists or OTs are doing beating, but that's not really the case at the end of it. Our caregivers need to be empowered, [00:45:00]  our nurses need to be empowered. We all have to have that same goal. Um, and I will say one of the things that I reiterate to caregivers, nurses, and to anyone that really is in the, in cardiac is that when you have a baby, what the common things that a baby does is they poop, they sleep, and they eat. And when you're in a critical environment like the CICU or a step down unit, especially as a caregiver, you don't have that much control. What if we were to empower you? What if we could give you a little bit of that control back and let you P. O. feed and have a little bit of that Normalcy., right?  Um, so I think it's, it's. I, I think there's a lot of interest around this. I think that, and I think that's why it was so successful because everybody wants to support this population, nurses, physicians, um, caregivers, speech language pathologists, OTs, PTs, the neurodevelopmental care team, like everybody is invested. And I think that's why we got to see this change. So it was cool. Like you mentioned, stakeholder, having stakeholder buy in is extremely important. [00:46:00]   Kate Grandbois:  I wonder if you could talk to us a little bit about the parents, because as all of this is happening, You know, and you've talked a lot about the importance of forward thinking, uh, developmental impact, discharge, carryover. The parents are going to be the ones doing all of that. Not only that, but many of these parents may be experiencing trauma of their own. You know, being separated from their babies, complicated, perhaps they, the mother experienced a complicated birth, perhaps, et cetera, et cetera. I wonder if you could talk to us about what the role is of the speech pathologist in terms of supporting the parents and centering the parents throughout this experience. Nashifa Hooda Momin:  Yeah, absolutely. So as a speech language pathologist, um, when we get to bedside and are working with this particular population, oftentimes maybe the first, it depends really, Previously I would say that the first feed was always done by the speech language pathologist, but ever since I've [00:47:00]  become a mom, I've realized that's a big thing, right? That's a huge thing to take away from somebody. Um, and so I will do my very, very best if I can, if the caregiver is there to try to, if, And if they're interested in doing the oral feed to support them to do the oral feed now, I will be probably all over them and helping them position and kind of holding the bottle and like hands on with the parent. But I, I think that that's where it starts. That's where our relationship will usually start. And then usually after the 1st or 2nd feed. It is really like, hey, like, if the caregiver is there, I want you to feed and I will support. I will, you know, usually be crouched on my knees or, um, hovering over the parent, feeling for signs of aspiration, watching the vitals, like explaining and providing strategies, maybe some hand over hand, like, hey, we're going to pace the baby now. Hey, let's remove the bottle. Cause I see this, but really our relationship starts really early on. from the beginning. It's, hey, let's empower you to do this because the great part about this and usually how I end sessions is, hey, I'm, [00:48:00]  you know, we're, it was great working together and, you know, we were going to change the plan this way, but I want you to know, you know, I'm here and this happened this way, but I can guarantee you, it's not always going to happen this way. So when I come back tomorrow, I want you to tell me like everything that happened, how much they ate. You know, where you struggle, what came up, um, if it like, what questions you have, because you have to let that marinate a little bit. And then let's, let's just keep this going. And the great part about that is that by the time they get ready for discharge, I feel like they are pretty confident about feeding their infant. Oftentimes I think it, like it shifts, right? They're like, no, like, I know you're saying that this is happening, but I feel this way. And a lot of times I'm like, you know, your baby and I believe you, right? Like, um, And so I do think that that's a huge thing is empowering the, of the, the caregiver. But the other thing about just the caregiver in a, um, in working with an infant with CHD and thinking about neuroprotective care is we, something that was really eye opening for me was that we, when one of our neuroprotective care [00:49:00]  meetings, we had a parent who came and spoke about, their experience. Um, and I will say that this, um, mom, their child, she took her child home on palliative care and the patient ended up passing away, but she came and kind of talked to the neuroprotective care team about just kind of her experience and what was considered normal in the ICU and what was considered normal in the CACU unit, right? And it was so eye opening to see, like. There's, there's a lot that a caregiver is going through that we often just don't really process. Um, and so I think after kind of hearing that perspective, it's really just emphasize that we have to have to have to have a caregiver at the center of the care, right? We have to put bring the caregiver in. We have to get their perspectives, because one, we get a holistic understanding of the patient's needs. There's more patient advocacy, because remember, we're not always there, right? The caregiver may be there watching what's going on with the patient and can advocate for, hey, like, I'm noticing every time they feed, they have a [00:50:00]  desaturation event. I know you're saying there's no clinical signs of aspiration, but why does this happen, right? Um, it could be, like, thinking about enhanced parent care management. And then another huge thing is, like, you have to start thinking about the social determinants of health for the patient. So when the patient goes home, is the plan that we're recommending feasible? If we're recommending follow up every week, um, They live two hours away, they have, they rely on Medicaid transport, or say there's only one car with eight people in the house, is it feasible? What if we're recommending thickening, right? Is it, in, in, in terms of financially, like, that might not be an option. So, really, really, really, we have to have these, like, ongoing conversations with a caregiver to make sure that the plans that we're recommending are feasible and we're understanding what their perspective truly is. And then like I mentioned empowerment and then, um, I think all of this truly fosters a collaborative environment. So yeah, that's, that's kind of my little tidbit on the importance of having a caregiver in involved in care.  Kate Grandbois:  I also wanted to ask [00:51:00]  just in that same, through that same lens, what role counseling plays in all of this? Because in your first few days of supporting a parent, I have to assume that there has to be counseling has to be at the forefront to just kind of make space for their experience everything from their own healing if they gave birth to fear for their baby's life to I mean, there are some really big emotions in that room. And I have to assume that if you go in with, Well, we're going to use the slow flow nipple and this is how you pace a baby like none of that's going to land because of all of the stress and, and all just all those feelings. What can you tell us about the role of counseling in these, in these environments? Nashifa Hooda Momin:  Absolutely. Um, I think that it's as a speech language pathologist, it's a skill that you definitely need. Um, and it's something that you learn that kind of reading the moment, right? There's been times where I've come in, [00:52:00]  um, in communicating with the team, right? So I've come in after the nurses told me that they've gotten some news, perhaps that there's like, uh, confirmed genetic involvement on top of their speech. And then I'm supposed to feed this baby and sometimes you just have to gauge like, is it an appropriate time or do I just need to have a moment to be there for the caregiver? Or do I need to reschedule? Do I need to take a moment and let them have their moment before I come in saying, Hey, let's feed your baby. Let's do XYZ. So I think it's a huge skill for the speech language pathologist to have. Um, there's been times I will say that I've had to completely pivot my session and just, um, Just talk, talk to the caregiver and just listen, just listen, right? Um, and then come back at a different time and do therapy, because I think that it's important for them to have their moment and to express how they're feeling. The second thing I'll say that I'm super thankful about is having social services, like social services with this particular population is involved very, very early on and they are incredible. Um, and so a lot of times. There's things that might come out during [00:53:00]  my session, uh, that may, may not be, like, public knowledge, and a lot of times I'll, like, can, can, uh, communicate with the, you know, the caregiver that, hey, is it okay if I pass this along? It seems like you're dealing with a lot here, and I can easily pull in social work and fill them in on what I know, but a lot of times they already know because they're excellent at their job, uh, but it is a huge, like you said, it's very, uh, emotional, and, you know, We need to have that support there. And I do believe that we try really hard to make sure that caregivers are getting that support. Now, do I think that there's no room for improvement? No, I think there's always going to be room for improvement. It's just a high risk population that needs a lot.  Amy Wonkka:  So at some point, um, hopefully the treatment has gone successfully. And the babies are going to be discharged. What does that, what does that process look like for you as a speech language pathologist? What does that look like for the families? What might that look like for if the baby's going to need to continue receiving some sort of outpatient services? Can you just talk us through that [00:54:00]  process  Nashifa Hooda Momin:  a little bit? Absolutely. Um, so it can vary depending on the patient. So if we have a patient that is doing well, PO feeding, maybe it's an asianotic defect. Maybe they were the kid that, um, got diagnosed at birth and then went home and just had, you know, cuddles and love and, um, and then like required the surgical intervention. And then they come to the, they come to get their surgical intervention, intervention. They meet the medical team and speech language pathology and rehab. And Um, maybe for them, it could be as easy as just, Hey, like, we're going to recommend outpatient services should you need it, but you're fully PO feeding, you're doing fantastic. Um, and then, you know, giving that information and they may just go, go home. I think general practice for most of us as rehab is to make sure that you still have plugged in, even if you may not need it, because you never know what's going to happen, right? But then if you have the example of a cyanotic baby who is likely going to require more support, I [00:55:00]  may or may not, but I would imagine so, um, like I said, standard practices that we're going to try to get them plugged into all different types of therapy, outpatient, PT, OT, and speech. Um, and then the other component of that is like, say you have a family, like we talked a little bit about the social determinants of health. Like we're not. They're not going to be able to attend these appointments. It's going to be a lot. They need to have service at home. Well, social work and, um, has a way, uh, for at least in Georgia, it's called babies can't wait. And I'm sure it's different for every, um, state, but essentially it's a way for therapy to be in the home setting. I will say it's a great option. Um, it does, it just depends on the availability of a, of a therapist that can go and, um, See these patients at home. So that's definitely something to consider. But I will say that having therapy is having therapy and versus not having therapy, right? Especially when you need it. And we have to think about what's feasible for the caregivers. Um, and then you can also have the super critical [00:56:00]  infants with a single ventricle physiology. who require three different pallet palliation surgeries. Um, and that particular population, we do set up outpatient, but we have a dedicated single ventricle clinic, um, where we'll be following up with them outpatient as well. So there are a couple of things that are in place, but it does, I will say that it's, it's a lot to consider because PCP, right? Your pediatrician, you're still going to have outpatient services. Um, You're probably going to have, like, a cardiology follow up appointment, um, and then if you're more critical, you may require more, more things, right? Um, it is a lot on the caregiver, so it's, it's, we always want to make sure that it's feasible, so we try to provide options and try to see where the caregiver is and what their, um, needs are and try to meet those needs. Amy Wonkka:  And in terms of the babies who have more complex feeding needs, do you typically get enough opportunities while the baby is in your NICU or in [00:57:00]  your step down unit to work with the families to where they're feeling comfortable with the feeding before they go home?  Nashifa Hooda Momin:  Yeah, so oftentimes it, I will say that it does depend if you have a critical CHD baby, like someone with single ventricle physiology, those patients, I do feel like generally we get a little bit more time because they're a little bit high risk and we're not going to discharge them right away. Um, so I do get that time. Does that mean that they all go home full PO feeding? No. And so a lot of times. These kids may go home with enteral support, like an NG tube and maybe taking some by mouth, um, and not in general, just in CHD in general, that could be the case, that could be the case for a cyanotic lesion as well, where we worked on it, um, we weren't able to get to full PO feeding because perhaps there's a genetic comorbidity, and so they may be going home with enteral support, um, and then with the goal of hopefully getting to full PO feeds. Kate Grandbois:  You've shared so much information with us today and I, I feel smarter [00:58:00]  and I, I, I, I mean, I'm serious. There's been so much that's been new to me personally. One of my takeaways from this conversation is that this relatively new field, even though the vast majority of the field of speech pathology in general does not work in a cardiac ICU, it sounds like this has implications for all of us, especially for You know, working in early intervention, um, in all of pediatrics, looking at that medical history, being a little bit more aware of the long term impact of a congenital heart defect. Um, I wonder if there's anything else that you'd like to share with our audience that we haven't gone over yet. Nashifa Hooda Momin:  Yeah, I think one, one thing I'll say as a speech language pathologist is that I love how we all can do such different things and then take different parts of our lives to do other things and learn about it. I will say if you're in the world of, um, I guess in a hospital setting, um, I feel like you probably can echo this, but it's so [00:59:00]  important for multidisciplinary communication, um, and collaboration with this particular pop, especially this particular population. I will say that I practicing for 11 years and I say this all the time and, uh, learning. I love learning and there you're always going to learn and always keep yourself open minded to opportunities to knowledge. Um, and. You know, there's there's no end. And I think that's the one fantastic thing about speech is that even being in my doctorate program right now, um, that I've had the opportunity to meet such different speech language pathologist with vast knowledge on different areas that I have no idea about. And it's. It's so interesting to just collaborate and learn from them because I think there's still so much overlap between us, right? Like you, uh, you guys all mentioned when we were before we recorded like offline, just thinking about like, how does this, how does this come into effect as the patient, um, is, well, not the patient as a child is five, six years old in a school setting, right? [01:00:00]  Like, so And the only way we're going to know that is to talk to each other and collaborate and learn from each other. Um, so I think it's, I guess my take home message is keep learning, have an open mind, collaborate. Um, because there's so much that we can learn and grow and, uh, contribute to the world of speech language pathology. Amy Wonkka:  I totally agree with you. I mean, I feel like, I've learned to echo Kate. I've learned so much just in our like hour long conversation here. But I do think, you know, as somebody who works in a really different environment than, than a NICU, um, I am still seeing students in my case who are coming in and I might read in their history that they have these like medical conditions as part of their medical history. And I think just having a better understanding of what that actually very helpful as the person who's treating them much later on, um, in their course of development. And so we have so much to learn from each other as speech language pathologists, but we also have so [01:01:00]  much to learn, like you had said, from other disciplines where, where we work closely together. Uh, we didn't really talk about it too much today, but I'd imagine, you know, for instance, you're working really closely with OT and PT to think about, you know, positioning and all of those pieces. Um, so yeah, I think having an open and collaborative mindset is so important. I totally agree with you.  Nashifa Hooda Momin:  I agree. Um,  Kate Grandbois:  thank you so much for being here with us. This was really wonderful. We're so grateful for your time. To anyone listening, whether you're in a hospital setting, working as a med SLP, working in a school, working in pediatrics, whatever it is you're doing, we hope that you found some value in this conversation because it does touch so many of us in the field. Nashifa, again, thank you so much for your time. All of the references mentioned will be in the show notes and you can use this episode for ASHA CEUs. Everything you need is in the show notes. Thank you again so much for being here.  Nashifa Hooda Momin:  Of course. Thank you for having me. It was great chatting. Thanks so [01:02:00]  much. Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, 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. .