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. .

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. Sponsor 1 Announcer:  Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes This episode is brought to you in part by listeners like you and by our corporate sponsor, Ventris Learning. Ventris Learning's culturally and linguistically responsive teaching resources help speech language pathologists, reading specialists, and teachers more effectively meet the assessment and instructional needs of [00:02:00]  all students, including those who tend to become underserved in language and or literacy. To learn more, visit www.ventrislearning.com .  Episode   Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are here with a fellow speech nerd, Ali Sherman. Welcome, Hallie. We're so excited to talk to you today about Tier 2 vocabulary. Thank you so much for  Amy Wonkka:  having me. Now, Hallie, before we get started, can you please tell us just a little bit about yourself?  Hallie Sherman:  Sure. So, my name is Hallie Sherman, and I'm a licensed speech language pathologist from New York. If you cannot tell by my thick Long Island accent, I will probably be hitting myself in my head with my hands because I talk with my hands. But, I worked in the schools for 16, 17 years, working primarily with 5th, And upper grades and early on in my career, I realized I had no idea what I was doing. Um, I'm five foot tall. These students were taller than me. I received goals that I did [00:03:00]  not understand and had to figure it out all on my own. And first school placement jobs that I had, it was almost like you were pledging a sorority. Like you can't ask questions like that's just like not, you're not, You can't appear like you don't know what you're doing. So I had to figure it out all on my own and there was nothing out there. There was no resources for older students. And I made a lot of mistakes. Um, I just pulled any ELA worksheet to work on some of these comprehension goals. And I realized early on in my career that I'm going to either get burnt out, or I'm going to need to get out of working with this age group if I'm going to survive. Um, and then I had a kind of aha moment, and realized, wow, if I teach these kids, um, a little bit differently, Then I get different results and we're actually having fun here and we're actually making progress and they're actually excited to come to speech and that was when 12 years ago, I started my [00:04:00]  blog speech time fun because I wanted to be able to. ShareIt was working with my speech students, with others, because it's what I needed. I wish I had someone to go to. I once had a student who finally got the R sound, and I ran into the hallway to share it with someone, and I had no one to share it with. And I ran back into my room. So, I wanted to be able to create a space for SLPs working with older students to not feel alone. And people, sure enough, found my blog and read it and was sharing it on Pinterest and things like that. And that's when I realized I needed to create the resources that I needed. So, more than just sharing what was working, strategies, what I was finding. I wasn't finding enough, so I started creating my own resources, putting them on Teachers Pay Teachers, and it was really resources for students that were older, but reading at lower reading levels. And it was embedding the different aspects of how to teach it differently so they can grasp it. They're already getting access to main idea in the [00:05:00]  classroom. They're already taught how to summarize. It's not sticking. And here I am, the SLP, pulling them out of art and music and all the fun things, working on it again, that's not fun. But I can teach it in a different spin, incorporating their interests, using their reading levels. And that's when I started creating my own resources, and that's when I wanted to be able to do more than just that. Give someone a PDF that they can use. I wanted to be able to share how I was doing it. And so I started doing professional development. That's when I started my podcast, SLP Coffee Talk, so that I can just help inspire other SLPs as much as possible, working with older speech students and getting the access to the materials and support and training that they warrant and deserve. And that's when I started in 2021, I believe, um, my membership SLP Elevate, because I wanted, again, just to. Combine the resources and support for SLPs working with older speech students because I call us the weird, crazy stepchild [00:06:00]  sometimes. We're not the ones working with the little itty bitties. We're not the ones working with the geriatrics. We're the ones in that crazy middle that no one understands and I want SLPs to not feel alone. So that's a little bit about me.  Kate Grandbois:  Well, thank you for sharing. Uh, I know that one of the things that we're going to be talking about today is resources for SLPs. And that's one of the things that we're very passionate about is open access information, clinicians being able to get what they need when they need it, because we already have enough barriers working against us in our workplace settings. Um, before we jump into everything, I do need to read our learning objectives and financial and non financial disclosures. I will get through that as quickly as possible. Todd. Here we go.  Learning objective number one, describe the benefits of working on vocabulary with your older speech students. Learning objective number two, list at least two resources available to SLPs for quick vocabulary activities. And learning objective number three, describe how to make vocabulary activities meaningful and fun for your older speech students. [00:07:00]  Disclosures. Hallie's Financial Disclosures. Haley is the owner of Speech Time Fund Incorporated and the SLP Elevate membership where she provides materials and support for SLPs working with grades 4 through 12. Haley also received an honorarium for participating in this course. Hallie's non financial disclosures. Hallie has no non financial relationships to disclose. Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I'm a member of ASHA SIG 12 and I serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy.  Amy Wonkka:  Amy's financial disclosures. Uh, I am an employee of a public school system and co founder of SLP Nerdcast and my non financial disclosures are that I'm a member of ASHA Special Interest Group 12 and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. Kate Grandbois:  So one of the things we talked about before we hit the record button is kind of the general [00:08:00]  backdrop of this conversation is tier two vocabulary. And while Amy and I were prepping for this episode, I very honestly said that I didn't know what that was. And I, I feel like I, I shouldn't be ashamed or I should be ashamed to say it, but the fact is I've never worked in a school for some reason that piece of graduate school from 20 years ago is just no longer in my brain. So maybe you could start off by telling us a little bit about what tier two vocabulary is and why we should care about it.  Hallie Sherman:  Sure, so there are three tiers of vocabulary. Don't worry, I didn't learn about it in graduate school either. I learned it from a book, Bringing Words to Life, the Robust Vocabulary Instruction by Isabel Beck, Margaret McGowan, and Linda Kukan. It's a really great resource if you want to dive deeper in what is Tier 2 vocabulary and the different tiers. So basically Tier 1 is that common vocabulary words that students are developing naturally. Dog, house, cat, sky, Rainbow, all those fun things that might not need to be explicitly [00:09:00]  taught. Now granted, we do know some of our students that do need that. But let's think about students in general. Those students, those words are typically just developed. I'm going to skip to Tier 3. Tier 3 is those curriculum based vocabulary words, words that your students are learning about in science, in social studies. They're studying them for a test, and then we forget them. Do you remember every single cranial nerve? Because I don't. Disclosure. So, those are Tier 3 vocabulary words. We study them once. We recall them, we need to know them when we need to know them, but then we forget them. So, a lot of times SLP is like, I want to help my students with curriculum, I'm going to focus on mitochondria and the parts of the cell, those three branches of government. But guess what? We often have times students working in different classrooms at different times. We can't always know what subjects they're working on and that's not really helping them when they get to that next chapter, right? There are strategies and we can discuss that, like there are frameworks that we can teach them on what consists of a good definition. [00:10:00]   But is it really benefiting them is how to define? When are we ever really defining words in our life? Unless you're working for a dictionary, you're not really. You might need to just know how to use it and understand it when you're coming across it. But those tier two vocabulary words are those words found across various curriculum and subject areas. Those words like increase, predict, convey, um, oh my goodness, I can't even think off the top of my head, um, convince, persuade. All those things that could be found in a social studies textbook or an essay could be found in an ELA something, but it can be found anywhere. And we need to teach our students what to do when they come across those words that they might not be familiar with, that can be helping them in any subject area, versus just an arbitrary subject area. Thank you. vocabulary list given by a science teacher for unit three. Amy Wonkka:  And I think that's super, that's a super helpful framework for us to think about going into this conversation [00:11:00]  because we're, those of us who are working in schools are working with students who may have varying language needs, um, and it can be hard to think about where your starting point is, right? So should, and I think one thing to think about is do you have one of those students where that tier one vocabulary does seem pretty essential? Um, and knowing that you can drill down into that tier two vocabulary, whether that, um, I think the big piece of a tier two vocabulary is also that it's higher frequency use, right? So maybe that student does need to know mitochondria and they do need to know all of those parts of the cell and maybe you help them a little bit with some of that. Um, But your bigger bang for the buck is going to be those two or two words that they're going to be able to use across their day and across their school career  Hallie Sherman:  and having those academic conversations throughout their school day is going to impact them. They're going to be hearing these from the teachers when they're readings, and they need to know what to do when those words come across that they don't know. So one question I get asked often is. How do you know what words, even tier two words, to pick from? [00:12:00]  Like, I, I named you like ten of them. That was going to be my question. There's  Kate Grandbois:  just so many.  Hallie Sherman:  And just like anything, we can't just pick arbitrary word lists because we don't know what words our students are going to come across. Now you can Google, and I'm going to give you a site so you don't even have to Google it, but Vocabulary does have tier two vocabulary word lists by grade. It's a great starting point if you're not familiar with. What's your two vocabularies words are and how they might get more complex as the grade level goes up now I'm going to put a disclaimer just because your student is in third grade Doesn't mean you should only be looking at that third grade word list because that doesn't mean that they have that Grade one grade two words mastered and they might still come across a fifth grade word And they need to know what to do when that word comes up Across their way, so it's a good starting point of I don't know what your 2 words are. I don't know what's your 2 words. My students [00:13:00]  might be exposed to, but another good place. If you're not familiar with this site or whatever, but you can also look at your students curriculum apps. A lot of times the scope and sequences that the teachers are utilizing has those tier two words embedded that they're expected to utilize in their classroom instruction, that they're expected to ask their students questions. And that can give you a starting point of, I know my students are being exposed to the word compare and contrast because that's part of the scope and sequence of ELA in the third marking period. So, again, it's doing a little detective work. It's not a exact science. That's the downfall. Sometimes of being an SLP is we don't have a curriculum, but almost the fun of it is we get to use anything that can benefit our students. So using a site like vocabulary, it's a great starting point gives you a whole bunch of words, but. It's a matter of teaching our students how to identify these words and what to do when they come across them and they don't know [00:14:00]  what to do with it.  Amy Wonkka:  Well, and Hallie, I feel like you bring up such a good point too in terms of talking to the resources in your building. We talk a lot on this podcast about the importance of collaboration and how it's so much better when you're able to work with other people and sort of meld your expertise. Um, I don't know if you have any tips for Perhaps classroom teachers working with classroom teachers, or if you're in a district that has like a curriculum specialist, um, and sort of how SLPs might be able to utilize those resources within their school building. Hallie Sherman:  It goes also the flip side of many school resources don't know how to utilize us. Because often we are referred to as the speech teacher and they think we're working on the R sound or we're stuttering all day. And they are shocked to find out that we are actually working on language. And I'm like, well, we are the speech language pathologists and sometimes just having your door open sometimes so people can hear what's going on in your speech room, that it's more than just saying sounds can go a long way. I actually happened to one time, um, [00:15:00]  borrow a, the literacy, like specialist office because someone needed to use my office and he was shocked to hear. He was like, wait a minute, you're teaching summarizing? I'm like, yes. Anyway, but we can also advocate for our students that in order to be a successful reader. They need to have adequate language comprehension skills and vocabulary is one of those aspects. So we can share with teachers, Hey, I am a resource. If your students are struggling with reading and this and that, because I can help provide you with strategies to help improve on their vocabulary. So not only can we provide the teachers with strategies, but we can also show them that we are available and then asking them, Hey, where are my students struggling? What are some things you're working on in your classroom? How can I help? Support you. And more that we open ourselves up for asking those questions, the more people, you know, not everyone's going to jump and say, Hey, help me, but some, some might. So we're all in it together to help our students. [00:16:00]   Kate Grandbois:  I also have to assume that and forgive me if this is a stupid question being so very new to the concept of tier two vocabulary, but. Because these words are so high frequency, I would also have to assume that one of the benefits of working on them in your sessions is generalization versus some other like tier three vocabulary where you're gonna see the word mitochondria in this context and then presumably that's why your long term memory is not capturing that, capturing that, but I have to assume that it. Focusing on generalization when tier two vocabulary is in play is a key component.  Hallie Sherman:  Yes, we want to make sure that our sessions are relevant. We're pulling students out of class. Yes, it's least restrictive environment, but we want to make sure our students are getting exactly what they need in the time frame that we're giving them. And by using arbitrary words, mitochondria is not arbitrary, but it's not necessarily helping them every single day of their life. I don't know. I'm not using mitochondria all the time. [00:17:00]  So, They're not using it in math, unless maybe that math teacher is like a science person. I don't know, but the chances are not as great. And we want to always show our students how what we're doing in our speech closets are going to help them in whatever subject they're in. And by using these vocabulary words and saying, Hey, you might've heard your teacher utilize this. And even, and if you have that opportunity of knowing how they are using it, Hey, when so and so said, please compare and contrast these two characters that you're reading in whatever novel you're working in. Oh, I did hear that. That was hard for me because I didn't really know what she was asking me to do. Oh, let me think about the context of how it was asked. Oh, okay. These two characters have a lot of things that are similar and different. Oh, that's how we're, um, that's what she's asking me to do. So we can help them show them how what we're doing and practicing in our speech room can be beneficial outside of the speech room when it is more obvious of what it's, when they are seeing it more often. Amy Wonkka:  Well, I think you're really getting at sort of that first learning [00:18:00]  objective about the benefits of working on vocabulary with our older students, right? I think we want to make sure that everybody has a solid foundation in their vocabulary and then you're building on that foundation. But I think something that you're able to do probably more often with older students compared to very, very young students is have more of those explicit conversations about how the work that you're doing together is going to benefit them outside of the therapy room. Um, I didn't know if you, if you could share with us just a little bit more about some of those benefits on explicitly working on vocabulary with that age group of students.  Hallie Sherman:  Sure. So there is actually tons of evidence that shows that working explicitly on vocabulary can impact their academic success. There's research that shows that working on top, uh, working, that working on vocabulary knowledge will help with academic attainment. That also, um, there's also evidence that children with lower levels of vocabulary are more likely to, [00:19:00]  are less likely to acquire vocabulary successfully. On their own. So they need to be explicitly taught it, and that's why they're coming to us, right? We have to assume they've been exposed to these words in the classroom, just like those tier one words they've been exposed to. There's evidence that our students with language difficulties need more exposures. They need to be explicitly taught how to figure it out and more often, and get more practice. And they need those meaningful exposures on how to, on how to learn these vocabulary words. So showing them one, how, how they're utilizing it, where they might have heard it. And how it's going to benefit them and then also having those meaningful exposures to it and just more repetition by using a word once is not going to be enough. Kate Grandbois:  I also have to assume because these students are older, in some cases, they likely have some metacognitive skills, right? They can reflect on themselves, their own experiences, and facilitate some of that generalization and maybe reflect on how it is helping them or making class feel a [00:20:00]  little bit easier or more accessible. Do you find that that's the case? Totally. Our  Hallie Sherman:  older students, the K 2 students, they're still learning to read. And yes, they still need vocabulary. In order to decode a word, they need to have that schema of that word. You can't decode a word that you've never seen before. It's like if I was thrown into a different language, it would be much harder for me to decode a word that I've never heard in that language. If I was like an alien or whatever. But our three, grades three and up, they're not learning to read anymore. They're expected to read to learn. Now, we do know that some of our speech and language students are still working on those decoding skills and phonological awareness skills, so they're still boosting and working on that, but they're also expected to read, to develop for an article and write a document based question essay and, and refer back and especially with like Bloom's taxonomy, they're expected to like, create and illustrate and do all these fancy things. But if they don't have a general, if they can't, they're not gonna be able to recall, they're [00:21:00]  not gonna be able to understand if they don't have the vocabulary. And that's where we come in, is that we can help impact their overall comprehension. If we can help get that foundation and what to do when they come across those words that they don't know. Amy Wonkka:  Okay. I think we're sold. Vocabulary intervention is important for students. I wonder if you can talk to us a little bit just about, like, what does that look like? What does that look like when you are in your speech office? You're having a session with a one on one with a student or in a small group. How are you doing things differently? And in your example, when you first started in your career, right? How does that, how do your sessions look different? differently now that you have this focus on vocabulary intervention.  Hallie Sherman:  So, like I said, I don't like using arbitrary word lists. I like to teach my vocabulary in a contextual manner, and there's tons of evidence that shows that students learn better when words are in a context. So, how do I do that? I like to start with words that they do know, and I like to make them [00:22:00]  nonsense words. So, I like to do tier one words to teach how to use context clues to figure out meanings of unknown words. So, I like to use the word blah. So, I'll say, The boy sharpened his blah. And started working on his homework, writing his homework. Okay, the students were like, I know it's a pencil, Mr. Sherman, I know it's a pencil. I'm like, okay, I know, but how did you know? Let's look at the sentence. I see writing. I see sharpened. I see homework. The only, I can tell that it's a noun in there. We can talk about parts of speech, how it is used. And it shows them, okay, these are the different clues I can use when a word I don't know. I can try to predict the parts of speech by understanding the sentence structure. I can guess what the sentence is about even without understanding what that word is. By understanding the gist, the main idea of the sentence, I can get an idea. Maybe I might not know that exact word. Maybe I know a synonym to that word. Maybe I know an antonym to that word. That's those word [00:23:00]  relationships we can pull back in. Now that we know you might have mastered those in, you know, the younger grades. But these later grades, we might not need to utilize that to kind of figure it out. So I start with the words that they do know to show them, one, to build, it builds them that confidence, like, oh, wait, I got this. This is easy. Two, shows them, how do you know? And then we work up from there. Then I'll do some more, maybe emotions, more, more challenging vocabulary words. And again, how did you know, teaching them to look for examples in the sentence, maybe abbreviations that will give them a clue. Maybe there's some illustrations on the page that will help them. And I model my thinking about my thinking. One of the hardest things that was, that I realized was so essential when working with older students was teaching them how I did things, things that we do innately. We don't even realize the self talk that we are doing when we come across something challenging. Or it might not even be that challenging for us, but we're just naturally doing it. [00:24:00]  And by that self talk, it's actually language. So we can give them a conversational script. Oh, I don't know what this word is. I think it could mean this. Let me plug that in. Oh, what's going on here. Okay. I see this word. It could be. I think it's a noun. It's right next to a verb and modeling that and then having giving them that script and then doing it together and tons and tons of practice. Our students need that explicit instruction, tons of modeling and those scripts, make it visual, give them that step by step on how to do it and show them them one, they can be successful and to how this is also going to help them will also when things get challenging, they're not going to give up. Kate Grandbois:  I also love the suggestion of using language in the framework of problem solving and self talk, because that can be utilized across all of life. Right? You know, identifying what you do know, it's, it's making me think of when you were like, um, Looking at the SAT in [00:25:00]  your future or whatever standardized test and like, okay, when you have a multiple choice, you know, you had to learn how to problem solve through, um, through a difficult moment and you're right. We do so much internal self talk for self regulation for problem solving. And I love the idea of modeling that explicitly and slowly. To only because it creates a foundation that can be replicated over and over and over again.  Hallie Sherman:  And I also model for my students, like what would happen if you just skipped over that word? So I'll even take like a song lyric and black out some words. And like, are we going to get the same effect if we don't know every single word in that song? Like, can Taylor Swift be as successful if we like, Just skip over half of her songs. We might not know what she's referring to. You might, you might guess wrong. And that's what can, our students can, what can happen to our students if they just, a lot of times they'll just skip over [00:26:00]  it. Amy Wonkka:  What other types of, you've given some really nice examples of using strategies to attack the A lack of comprehension within a sentence. Are there other things similar to that? Whether it's like activities, you mentioned vocabulary. Are there other resources if you're a speech language pathologist who's thinking about, okay, I would like to do more with tier two vocabulary, sort of where can I get started? Where can I get some examples of how it might look in my session?  Hallie Sherman:  Sure. So one of my favorite tools and it is free is vocab grabber. There is, if you go to this, if you type in vocab grabber by visual thesaurus, it may say to log in. You don't need to log into anything. You can enter in any text. So say you go to Readworks, News ELA, any of these sites where has free articles, Wanderopolis. You can, a lot of those sites have vocabulary words bolded, but it might not always be the words you might think of. If you [00:27:00]  copy and paste any text, or if you want to be wild and crazy and type in the novel that your students are reading, and you click vocabulary, you click go, whatever the word is, there's a whole bunch of different buttons. If you unclick all and you click the vocabulary one only, those are two, two vocabulary words that they pull out for you. And they also show you by a visual. view, which word was used more often in that text. And then if you click any of those words, it shows you where it was in the text, the sentence it was in, the definition, the parts of speech. All that fun stuff. So if you're, okay, my student is reading this in class, I want to help them prepare for when they come across words they don't know. We might not have that time to maybe pre read it ourselves, or have that time to self analyze, we're busy. So if you can just. Put it into this site, it will pull out the words for you, and this way you can prepare ahead of time those words that your students might not know. So you could do some [00:28:00]  pre reading strategies with them, like hey, I like to call it, um, Acquaintance Stranger, Stranger Acquaintance Friend. So it's a little like, like a KWL, what do you know, what do you want to know chart, like, what, like a background knowledge assessment. So I'll read, read the words out that might be in that text that they might not be familiar with, or I'm not sure if they are. Are you, are you a stranger? Have you never heard it before? Are you an acquaintance? I've kind of heard it, but I have no idea what it means. I couldn't buy it a birthday gift. I wouldn't know what to do with that. Or are they your friend? Like, I can use this, I use it all the time. I'm texting my best friend using that word. That kind of thing. And this way you can go ahead, like, why waste your time with those friend words? And I like to start with those acquaintance words first. Let's build their confidence up. Let's go. Okay. So you've heard this word before. Now we're going to give it to you in a context. Let's look at it. What parts of speech is it? What does that tell us? Maybe think of another word that can be utilized in the place of that. And then we can teach them what to do with Senate with the unknown [00:29:00]  words. And it might need to be a building up their background knowledge, a little bit of it, and maybe explicitly teaching it, but it's giving you ahead of time. That prep of. Hmm, I don't need to teach every single word, but what word to focus on? And just because that article might have told me four words to focus on, those might not have been the best four words. Or maybe those are too challenging words for our students, and we need to take it a little bit easier for them. Amy Wonkka:  The other thing I love about that example you just gave is also that you're still helping the students to develop those self assessment skills. as well. So hopefully if that's a strategy that you're using often in your session where they're identifying, okay, is this a stranger? Is this an acquaintance? Is this my friend word? Um, then hopefully they can then start to internalize that. So perhaps when they're in a class and they're facing a word that they're not so sure about, instead of just skipping it and being like, ah, I I'll deal with that later. Maybe they ask themselves and go through that little inventory. Um, and, and that helps them better attack the situation as well. [00:30:00]  Are there any other suggestions? I love that suggestion. Any other suggestions that we could use, um, as we're trying to incorporate more of this tier two vocabulary instruction?  Hallie Sherman:  Oh my goodness. I have so many. Um, I love utilizing YouTube videos to teach, um, using context without reading. I'm all about taking the reading piece out and changing things up when my students don't know what is coming of me. So taking any Pixar short, like for example, snack attack. I don't even think it's a picture. It's a YouTube video. And it's a three to four minute video of this woman who buys snacks. Someone else tries to take it. I don't want to like give, um, this, uh, the, uh, spoiler alert. You can pause at many different points and embed a sentence that you create. The man is sitting adjacent to the lady. They can use what they see in front of them, they don't have to read, they can read the sentence you're providing, and try to guess what those unknown words are. And there's more opportunities to [00:31:00]  practice in a fun and engaging way, where they don't realize they're learning, but the more opportunities to practice, the more opportunities they get to, the more confident they will feel when they come across those words that they don't know. And again, always modeling, again, how you are thinking about your thinking, what you are doing, and showing them like you, us too, have to do thinking to be successful. We don't know every single word. And that's okay. And I even, I even use like vocabulary of Fortnite. Like, I'm like, I don't know what a skin is, and a, and a, I don't, and I, I'm like, tell me, tell me everything you know about Fortnite. And like, these words are foreign to me. I'm gonna use my context of what you're telling me to figure out what these words mean. And they're like, and they're like, they wanna just tell me the answer. I'm like, no, no, no, no, no, I'm gonna figure it out by what you're telling me. And showing them that we, too, have to use these same strategies when we come across something we're not familiar with. So, I've had students make me Fortnite dictionaries [00:32:00]  so that they can, like, teach me vocabulary words. Um, anything that allows our students to teach us is a teachable moment for them. And it shows, it builds their confidence and shows them how they can use the same strategies on something they do already know.  Kate Grandbois:  I love that. I love anything that is approaching therapy with humility and bringing humanity into the room and the reason I say that is because you're showing in modeling a student how you deal with problems because all humans have problems. We all, we all approach things that we don't know. Nobody knows everything. I think that's like the second time today I've said that. Um, I, I really just love that. What other, what other bags of tricks you got up your sleeve over there?  Hallie Sherman:  Just like I like using Pixar shorts and wordless videos, you can do the same thing with wordless picture books. The best part about wordless picture books is there's no words, so we can pretend there are words there. So whether you're reading Pancakes for Breakfast and the lady is distraught [00:33:00]  that the Animals destroyed her kitchen, the word distraught is not there, but we can put it there, you can take a sticky note and put there so pretend it's like a word, and they have to use the picture, they have to use what they see what's happening in the text, what they see in the, and it's not just so text based, and it allows them to be a little bit more successful and we can, and we can show them like, again, What are some other words that can fit into that blank? What words that don't fit into this blank? Is she, like, let's look at her body language. There's a lot of social inferencing also that can be, uh, incorporated. There's other skills that all, that all are intertwined in order to be successful. So we can tap into our students strengths if they are visual learners. If there was, we can use what they are strong with to help, um, build a vocabulary in a fun and meaningful way.  Kate Grandbois:  That was going to be my next question was about fun. I know like two teenagers. And their idea of fun is not my idea of fun. Well, my idea of fun is not many [00:34:00]  people's idea of fun, but, but in, but in reality, I mean, what in your experience, what is the approach when you're working with an older student who doesn't want to be in your therapy room? I mean, how do you, how do you make that fun?  Hallie Sherman:  One, you have to get them those quick wins by showing them that they can be successful. By starting with those. Acquaintance words by starting with those tier one words like duh, mr. Sherman. What do you what? I know that it's a pencil I'm okay throw rocks me. Yes a duh, but how did you know? And showing them, look, you can do this and building up from there and not starting at the hardest level. Let's start, let's start where they're at and show them, look, you got this and building that confidence and also building that safe, comfortable environment. It is so essential, especially the older students that you take the time to build rapport, get to know them. Let them get to know you, like before, I make mistakes too, [00:35:00]  I need, I, I cannot draw to save my life, you give me a soccer ball, I'm going to hit my head with the ball, like I don't know what to do. And oftentimes my students are like, I can teach you how to play soccer, I'm like, see, you can teach me something, I'm going to teach you something, and by the end of this year, we're both going to be good at something new. And showing them everyone has different strengths and weaknesses. Everyone has different learning styles and taking those times to have those conversations. There's free sites online where you can have students take some learning style quizzes so they can see for themselves, Oh, I do need frequent breaks. Oh, I do need things broken up into smaller pieces. Oh, I do like things read to me versus when it's whatever. For them to see for themselves, like there's nothing wrong with you. We just all learn differently and that's okay. And also having those conversations about what do you, what do you want to get out of coming to speech? What do you want to get out of coming to school? What do you want to be when you grow up? Maybe their goal for the year is to make the soccer team, to ask a girl out on a date, to get a job at the movie theater, whatever the, whatever it might [00:36:00]  be. We can incorporate that while working on these various goals. So if a student told me soccer, I will find some YouTube videos on soccer. I'll find some articles on soccer that have some tier two words embedded. And if not, I will create them and work on these skills while incorporating their personal goals and their interests. And also. Showing them, in my speech room, it's not a matter of getting things right or wrong. You're always going to get it right. It's a matter of when. And it's okay.  Amy Wonkka:  I think incorporating student interests is just so important and being able to identify that they're an active participant in this whole process. Do you find that you often talk to students about their IEP goals explicitly? Hallie Sherman:  Definitely, definitely as they get older, even more, I know many often, especially in the high school age, students are expected to go to the IEP meeting and be a part of the conversation. And you don't [00:37:00]  want that meeting to be the first time they're hearing, I have a language disability. Oh, that's why I'm here. Like, we don't want to have those conversations. So a lot of times in the beginning of the year, I like to go through like, what are their goals? Even their accommodations and modifications. Let them be self, like, how can they advocate for themselves that I need more time? My test should be read. Why? Sometimes these, the other teachers that they might be working with don't have that time to go through it all. We can, and the more we can take the time to be like, okay, everyone's here for a different reason. Everyone has different strengths and weaknesses, but this is what we're going to get out of coming to school, this is what we're going to get out of coming to speech. And if you want to graduate from speech, this is what you have to do as well. And that's okay, but having those conversations. Obviously, when they're a little younger, you want, might want to get parent permission if it needed, but often like they might not know they have an autism diagnosis or whatever it might, they might not be aware of certain things and you might want the permission from a parent, but as [00:38:00]  they get older, you can still have those conversations about just learning is different and that's okay. Kate Grandbois:  I also think that ties really closely to some social emotional concepts like self acceptance and, uh, self esteem and empowerment. So, making sure that there is that close relationship between their confidence and competence to advocate for themselves in accepting who they are and what accommodations they need. And I, I think that's something that I know adults that struggle with that. I mean, it's a really, you know, it's hard emotional work to, to get there. And I love the idea of wrapping language around that for empowerment purposes. I think that's awesome.  Hallie Sherman:  Yeah, definitely. Especially students that need things read, you know, repetition. I need to hear it again. They should not be in fear of asking for that. And I always say to them, if anyone gives you a hard time, you tell me, you come straight to me. Kate Grandbois:  So knowing how strapped SLPs are, how we are constantly [00:39:00]  fighting for resources and time, what are some quick tips that you have for getting some of these resources at our fingertips? Hallie Sherman:  There are so many free resources out there that you don't need to reinvent the wheel such as one of my favorite sites is Bamboozle all you need is a free login and if you type in Context clues or tier 2 vocabulary a bunch of activities will show up. So for example, I typed in context clues and I'm gonna click one of these here And it pops up different passages with pictures and it gives you four choices. So I looked at the plans for your new house. This is earthquake county. You need to fortify the frame or you'll have a disaster with the first tremor. The word fortify means, and it has a picture of a house shaking. So I, okay, what do I see? I see a house shaking. I see things moving. I see, I know, I see the word earthquake. Okay. What do I know about an [00:40:00]  earthquake? Okay, well, things shake. So my choices here are destroy, shake, strengthen, or build. Okay, this earthquake, this earthquake county, you need to fortify the frame, or you'll, okay, we have to use our clues to figure out, it's just an example here, what to do with that word. And there's a lot, this is not the best choice because there's a lot of words here that might be difficult, but that's why sometimes you need to like preview it. I'm going to give you another example, Pam and Gia are sisters, and they're very different. They just look at how they are, uh, Just look at how they are dressed. Pam doesn't care what she wears or how outdated her clothes are. Gia, on the other hand, is quite chic. And it's a picture of the two, uh, Olsen twin sisters and one's not, it's more trendier than the other. Poor Pam. I feel bad  Kate Grandbois:  for her. That was,  Hallie Sherman:  I know, I know. Or whatever her name was. And then you can work on any other goals. Like what, what would you say to Pam? But here's just an example of how you can take [00:41:00]  pictures and have some passages, and you can find things at different levels, whether it's a sentence level, at the paragraph level, with pictures, without pictures, and using whatever level your students are at to practice the skill over and over and over again. And this site is great for its quick, easy data, because your students are each taking turns picking a card from the, whether it's a, this one is, this cards. So that's, if you have a group of two, you get 12 opportunities each. Um, so, and if it's an odd number, I like to do teams and things like that. But Bamboozle is a great tool that you can find a plethora of games. At different levels, um, work on vocabulary and isolation, and it could be that you might want to work on reviewing synonyms and antonyms, looking at teaching parts of speech, working on, uh, root words and prefixes and suffixes, all those things you can do right on Bamboozle by just typing in the search bar. Um, so that's just [00:42:00]  one tool that I love to utilize. Just as similarly, another fan favorite in my speech room is Bluket. If you're familiar with Kahoot, it's a similar tool that, like, the students do need their own devices, where Bamboozle, you, uh, it's the only, you're the only one who needs a device, but you can, every, you have, you're the host, and there's tons of games right on there, so you can search, and I'm going to give you, I created one with GIFs, you the link so that you can access the GIFs and the sentences ready to go with the tier two words that I made, um, to utilize with my students, um, But you can find if you just type in context, there's a whole in the search in the discover tab, a bunch of games show up. The best part is there's different game modes. So a lot of the students like gold quest. Which is when, when they get their word right, when they get the answer correct, they get three different treasure chests to pick from, they don't know what's inside of it, it could be gold, it can be stealing gold, it can be [00:43:00]  losing gold, and us as the SLP, as the host, we can decide is it gonna be a five minute game, a seven minute game. We're going to play a certain amount of rounds. The negative of this one is because they're all on their devices and they're all doing different words at the exact same time. It's not great for like data and teaching, teachable moments, but it's a great way to practice once they're finally grasping the concept. So Kahoot is a little better because it allows you to have like pausing after each question to like, let's discuss how we know. Dambouzle the same way like let's discuss it once they're ready to do it more on their own and practice and just to have fun. Look, it is a great fun tool. All you need is a free log in Gmail account or any email account to log in. And the best part is students are familiar with these sites, especially your older ones. The classroom teachers are using the blue. They might not be using bamboozled, but they're using blue kit and Kahoot. And [00:44:00]  there, those are 2 easy ways, and I'm going to show you, I have a tier 2 word game on Kahoot as well. I'll give you the link to that one as well that I created, which has pictures. I have one with non sent words, so they can like, like the block, um, right in there, so they can play that with their students to practice that using, using picture clues as well. Um, so. Look at Bamboozle Kahoot. If you go to, um, like some sites like readworks.org that you can search certain articles based on skill. So you can search by vocabulary and context clue. So it's other opportunities to just practice even further. Um, but like I said earlier, I do love using YouTube videos. So I love the site ed puzzle, which allows you to embed some of these sentences already into the videos where if the video pauses, a sentence pops up. And it allows you to go through what's going on in the video. Um, so I have already ones, and I will give you the, if you type [00:45:00]  in, if you type into Ed puzzle again, all you need is a. Login information, I type in just context clues, a whole bunch of videos already made by other educators might not be speech pathologists show up with teaching either teaching you how to use context clues or different videos on using context clues. I literally am seeing a whole bunch here. Um, a bunch of Simon's cat videos. Storybooks that are on YouTube, you're incorporating context, clues, and you can preview it. I recommend previewing everything ahead of time. And the best part about Edpuzzle is you can edit someone else's work. So either you can create your own video with embedding the Tier 2 words. Go into Flocabulary, get some inspiration over there of what tier 2 vocabulary words, you know, your students should, should not know, and then pause at various points, create your own sentences as if you were the narrator, or take something that's already done, and say you don't agree with what that person made ahead of time, [00:46:00]  you can edit their work, and they won't know, it's really okay, so that's the best part, you're not offending anyone that the whole gist of Edpuzzle is educators supporting educators there and creating different videos with quizzes embedded. Teachers are using it for like a homework assignment, especially during COVID times. They're like assigning it via Google Classroom. I don't have students write anything in because I don't know how to delete it. I just had them verbally tell me out loud what their answers are. And the best part is The video pauses, you don't have to remember, 2 minutes 38 seconds, I need to remember to pause here, give them this sentence, you can set it once and have it for life, and the best part is, you get to choose when you go on to the next, the next clip. So say they need more assistance, there is actually a rewatch button, so it teaches our students those self advocacy skills, like, I need to see that again. And it's right there embedded. Let's click. Let's click rewatch and we can [00:47:00]  watch it again. What model, what I'm going to do this time. You can give it, you can make it a multiple choice. You can give them picture symbols. You can throw in some board makers or whatever symbol systems are in there that they're utilizing. You can embed pictures into the questions and the answer choices into Edpuzzle. So whatever your students need, it might take a little bit of work up front. Not if you find one that's already made, but if you find if you need to make your own, you have it then for life and videos are so motivating. We can find ones on their interest. You can find something on video games. You can find I have glued is a great YouTube video. If you if your students are obsessed with video games. Um, there's if your students are into science, this preheated where the boy gets access to his dad's science experiments. There's there's snack attack. I said, that is a really great 1 coin operated is a boy who wants to go to the moon. There are so many things already out [00:48:00]  there that you don't need to reinvent the wheel. It's motivating and you can embed all those strategies built in. So that's a puzzle is a great, great tool. It is free. Um, and you don't even need to save it to your account. You can just stream it. Um, and it's super easy. You can share it with each other, create them with a colleague, and there's a share button so you can share it with them. You can share it with, if you want to send it for home practice, you can do that as well. Um, there's so many possibilities. It is a great tool if you like using YouTube videos in your speech room. Having Edpuzzle is a great, um, a great tool to use. Do that in a more organized manner and if there are any YouTube videos that you find that are not on Edpuzzle There is actually a Chrome extension for Edpuzzle that you can go into YouTube If you have the Chrome extension downloaded, there will be a button on that YouTube video. Just click it And it opens up Edpuzzle and brings it in there.  Kate Grandbois:  That is awesome. [00:49:00]  That sounds like such a great resource. And to anybody who's listening and driving or folding laundry or whatever, we're, Hallie's going to send us all of these links. They will be in the show notes, um, for just to have at your fingertips when you need them so you don't have to write anything down. Hallie, thank you so much for sharing all of this with us. In our last couple of minutes, do you have anything else that you would like to share with our audience?  Hallie Sherman:  If you got anything out of this episode, I hope it is that we can make learning fun, that we can make learning meaningful. And one way to do that is utilizing tier two vocabulary words and doing it in a contextual way. And it doesn't always have to be a paper and pencil activity. So if you have fun, they will too. And I, hopefully you got a bunch of ideas here that you can change things up, keep students on their toes and always keep learning fun.  Kate Grandbois:  This was great. Thank you so much.  Amy Wonkka:  You're so welcome. Thank you so much for having me. Yes. Thank you so much for sharing your time.  Sponsor 2   Thank you again to our [00:50:00]  corporate sponsor Ventris Learning, publisher of the Assessment of Literacy and Language, or ALL, and the Diagnostic Evaluation of Language Variation, or the DELV. SLPs, school psychologists, and reading specialists use the ALL to diagnose developmental language disorder and to assess for emergent literacy skills, including dyslexia, for children ages 4 through 6. The DELV is appropriate for students ages 4 through 9 who speak all varieties of English. To learn more, visit www. ventresslearning. com. Outro   Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the [00:51:00]  episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Kate Grandbois:  Welcome everyone to SLP Nerdcast. We are really excited for another edition of SLP On Demand. For those of you listening for the first time, SLP On Demand is a series that we put out occasionally where we answer [00:02:00]  questions from our audience. So if you are a member and you have a clinical question you can write in and our doctor of speech language pathology who is here with us Dr. Ana Paula Moomy will answer your question. Welcome Ana Paula. Thank you. I'm very excited for today's question. It touches something that I do for a living. I was really excited to kind of catch up with you before we hit the record button and learn a little bit more about what the research says, because that's always fun for me. Before we read our clinical question aloud, I am going to quickly review our learning objectives for today's discussion. Learning objective number one, identify the relationship between data collection, target selection, and goal writing. And learning objective number two, identify at least two different types of data collection that can be used when working with AAC users. Uh, anyone who is listening can also find information about, uh, our financial [00:03:00]  and non financial disclosures in the show notes. And Apollo, why don't you get us started by reading aloud our listener's question?  Ana Paula Mumy:  Sure. So the question relates to resources for data collection for AAC users. And Andy, um, who wrote in. Um, stated that her mentee has 14 life skills elementary students on her caseload, and she's looking for ways to help her efficiently track device use throughout her student's day. So that's a  Kate Grandbois:  really big question.  Ana Paula Mumy:  Yes. And I think we just have to first acknowledge, like, this is a big question that's hard to answer, um, because there is so much that we don't know about these particular students. And there's also. Um, we don't know specifics about what devices they're using. What does that look like? And so, um, I would say just in general, this is gonna be a little bit difficult to, to touch on, but, um, also acknowledging that I would say data collection is tricky regardless, [00:04:00]  right? It's strictly tricky whether, um, we're working on articulation or language or it doesn't really matter, right? All of these areas. Um, especially. Tracking, um, data or taking data without sacrificing genuine engagement with the person that's in front of you, right? So that's the big thing. I think, um, I work a lot with grad students and I think about how sometimes they're so attuned to the data collection process that they forget, like, oh, wait, but there's a person in front of me and I should be engaging and just really building that relationship and the rapport. So, yeah. Um, I just wanted to acknowledge those, uh, setbacks in a sense, right, um, related to data collection.  Kate Grandbois:  And to kind of piggyback on that, obviously this episode is likely, you know, it's under an hour long. Uh, we are not going to be able to cover everything about data collection in this short amount of time. Uh, anyone who is listening who would like [00:05:00]  to learn more about data collection, either while you're listening to this episode or after this episode is over. We do have three or maybe even four episodes specifically on Monitoring progress and data collection, including probe data or discontinuous data, which I know we're going to talk a little bit about today, uh, that is a very complex topic. So if you are listening and you know already that that's something that you'd want to learn more about, check out the show notes. We will link, um, we will put links to all of those episodes in the show notes for  Ana Paula Mumy:  you. So I wanted to focus on one article in just my research and really just admitting, first of all, that. I am not an expert on AAC. And so it's an area that is a stretch for me. And so, um, as I looked through some of the research, um, I found one helpful article, um, on data collection and monitoring AAC intervention in the schools, um, by Katya Hill, um, in 2009 in the [00:06:00]  perspectives on AAC, a journal. And I appreciated how they talked about, um, collecting the data, To collect, depending on the design and the targets of the intervention program. So, in other words, really thinking about, like, what are we actually tracking in relation to device use? And, um, they divide up 2, uh, areas or talk through 2 different areas. Um, performance data and outcomes data. So with performance data, um, representing really the quantification of specific language targets. So things like, uh, spontaneous or novel utterances, um, communication rate potentially, or any word based measures, um, that might include things like. Uh, total number of words used, or maybe it's percentage of core vocabulary that's used, um, or mean length of utterance, um, even diversity of words. So is there, um, a [00:07:00]  mixture, right, of are they using nouns, verbs, adjectives, and so on? So just looking at these word based measures and other types of performance, um, data. And then the other Area was outcomes data really representing the results of intervention that's related to things like quality of life and satisfaction and functionality. So, um, that was helpful to me to categorize, um, and make that distinction. Um, and because our goal. And this is what they talk through is to optimize communication in a student's daily environment. Um, then we really should have both performance data that's collected in those environments and then also outcome measures, um, that report, you know, perceptions or satisfaction of performance by, um, Those closest to the student. So that could be teachers, of course, caregivers. Um, but then, of course, the student him or herself, right? And so [00:08:00]  I did wonder, Kate, if you would just touch on, um, examples of those, the performance data that might be tied to or, or more appropriate for complex learners, because this might be easier for a child who, um, Um, is maybe more verbal, but not one that is, um, where, where there's just more complex, um, profiles. So if you wanted to talk about that for a little bit, I would love to hear your input.  Kate Grandbois:  Sure. So, I mean, anyone who's listening to this podcast knows that, or has been listening for a while, that this is my jam. This is the, this is my clinical wheelhouse. I'm very fortunate to have worked in AAC for the last almost 20 years now. Uh, not quite 20 years, but over 15, not that we're counting. Um, and this particular profile, complex learners, emergent learners, early language learners, is what I, what I love to do. Um, I really appreciate the way that you've described, at least from this article, these two different categories of data [00:09:00]  collection, um, that you've Because I think often when people think of data collection, they think of tally notes scribbled on a sticky, right? You know, we're going back to your point of not wanting to sacrifice connection. We grab what we have, and we, oh gosh, I've got this, I've got this goal on whatever it is, and so we, we, we scribble our tally notes, and we think that that's our data collection, and yes, that is data collection. Uh, is it quality data collection? Perhaps not. Um, and I, I really just wanted to take a second to, um, to think to at least appreciate the different qualifiers when it comes to the kind of data that you are collecting. That is a really important first thought to kind of zoom back to this learner's question or this member's question about what recommendations they can make to their mentor. And I think the first recommendation based on that article from what I'm hearing from you is really reflecting on your purpose. What are you taking data about? Is it outcomes related? [00:10:00]  Is it performance related? Is it aligned with our EBP model in terms of considering clinician's perspective, client's perspectives and values? Um, I think when you keep that as a lens, it's a lot easier to then zoom in a little bit further. Um, and think about what data collection methods are most appropriate, uh, to your next step or to the targets that you're, that you're trying to work towards. Now, I know that I just went really off topic, but to answer your question about an example for a more, a complex learner or an emergent learner, um, I think that when you're, first of all, every child is unique. Every learner is unique. There is no, I have, I have big feelings when I hear things like, well, this is the way it's done or this is what we do here or no, you are always customizing your AAC intervention to your learner, especially if that learner has a complex profile. So a number one, um, you're always making data driven decisions, person driven decisions, [00:11:00]  patient centered decisions. Um, particularly when there is complexity involved. And a lot of com, when you're working with complex learners, often your first objectives are related to teaching symbolic exchange, teaching the use of symbolic, uh, language. Now, when I say symbolic exchange, I'm not talking about pecs before anybody gets a little grouchy thinking about pecs and all of the grouchy feelings that we've developed about pecs. We are talking about moving through a developmental lens to teach a person how to use symbols to communicate. Um, and I think, you know, that can look like a lot of different things that can, when you're talking about AAC, depending on your learner, that could look like point selecting icons in a sequence. It could look like scanning a visual field to select an icon and make a purposeful choice. It could look like sequencing two icons. together to produce voice output, [00:12:00]  uh, it could, it could be producing one symbol for a function that isn't just requesting or perhaps they are an emergent learner and they're, you know, in developmentally making requests and making basic wants and needs known is a main goal. So you want them to produce a single symbol to get their wants and needs met and then everybody's throwing a party, right? So it really will depend, um, So much on who the learner is in terms of choosing that those targets and choosing that data collection strategy for performance. If anyone is listening wants to learn more about, um, the lens of AAC and going back to basics, we did a great interview with Dr. Kathy Binger, um, and Dr. Ken, Jennifer Kent Walsh called AAC back to basics that really specifically takes a good look at what. Um, the intersection of AAC and language development and how we can better integrate those two things. Did I answer your question? I know I [00:13:00]  went on like four tangents. No, you did. Ana Paula Mumy:  And  Kate Grandbois:  thank you. That's  Ana Paula Mumy:  perfect. I appreciate it. Um, that makes it, uh, a lot clearer and, um, for sure, Just having those tangible examples are super helpful. Um, another recommendation that I found in the initial stages of device use, which kind of goes back to a little bit of what you were saying, um, was to actually take data on what the SLP or the communication partner is doing. So, um, there were some really helpful questions, um, Again, for me, because this is not my area, um, that helped me think through like, okay, so what does that mean? Exactly. So things like how often does the student have access to their system throughout the day? That is a pretty important question, right? And then how many opportunities did the student have to actually use their device? Um, another question, how often are adults modeling on the device? And so that modeling component being huge, and maybe you could [00:14:00]  speak to that a little bit more.  Kate Grandbois:  I was going to  Ana Paula Mumy:  say, I've got a great example for that, but keep going. Yes, so I have one more here. Um, how often is the student attending to the modeling that's provided? So again, this isn't necessarily looking at the output from the child. It's really more talking about the input, right? What is happening? Um, with the individuals around that child who are doing something or providing access or providing that modeling and so on. So yes, please give me examples.  Kate Grandbois:  I was going to say, I was like jumping in my seat because I have such a great example for this. So backing up really quickly. Back to our sticky note with tally marks on it, right? We think that that is frequency data. So frequency data collection strategies would be, you know, marking every single instance of the target behavior that happened. And again, we're not going to get into this in detail. We will list additional references or episodes in the show notes. Unpacks a lot more of different kinds of strategies of data collection. Frequency is one of them. [00:15:00]  Percentage, who doesn't love a good percentage? I think we over rely on them out of 80 percent of opportunities, right? Everybody knows how to take percentage data Um and rates how many times you do things in a certain period of time Those are a pretty common data collection strategies in speech pathology. One of the less common ones that I love, and I swear I'm going to answer your question, is trials to criterion. Trials to criterion is a data collection strategy where you're looking at the number of opportunities or the number of trials, trials to criterion, that a person needs to achieve a certain outcome. Threshold or to achieve a predetermined set of mastery. The reason that I love trials to criterion is because I have applied it to measuring the behavior of communication partners. And this is my story. I consult to a wide variety of. of programs in in Massachusetts area. Uh, because I'm a BCBA, don't anybody hate me. I'm not evil. Because I'm a [00:16:00]  BCBA, I work a lot with behavioral programs. I work a lot with BCBAs, um, and trying to integrate some of this speech pathology. research, knowledge, best practice, person centered care in some of these programs. And in that work, we have one, one program in particular, we did a lot of patient education, a lot of teacher education around the importance of modeling, around the importance of language bombardment, around the importance of making a, making someone's, um, program linguistically rich. And what we did was To kind of flip the script, we said, okay, how many trials does this one particular complex learner need to produce a word? How many models do they need? And what's nice about this is that we switch from asking the question, what does a student know, to how do they learn? Once you know how a complex student learns, rinse, repeat, you've got the recipe, [00:17:00]  let's make all the cookies, let's make all the words, let's, let's do this again and again and again, but when you really flip your thinking to thinking about asking questions and taking data to learn about how they learn instead of what they know, you can really apply that to the entire environment. So in this particular example, we took trials to criterion data on the number of models that were provided in a day. And to learn how many times did this one kiddo need to get exposed to this one word for them to be able to produce it. And the answer was hundreds. What's amazing is that he was able to get hundreds of exposures in a short period of time because the staff got super competitive and they, and you know, they started becoming more aware of their own behavior and their own roles and responsibilities as communication partners. Um, so. So another tangent, I guess that's my, my function and my role here today is to go off on these tangents, but it's the different data collection [00:18:00]  strategies you choose can really help you shift the way you're thinking about where that, where the quality data comes from because it's not just your communication. It's not just, it's not just your student. It's not just your client. You could be looking at data about the environment. You could be looking at data about the communication partners. We're really talking about a whole. a whole human and a whole microcosm, a whole environment, a whole set of variables that we need to consider for AAC success. I hope I answered your question again.  Ana Paula Mumy:  Yes. Thank you. One more thing that I wanted to touch on before I'm going to pose another question to you, Kate, is I found just a variety of data collection sheets that were downloadable for free. And again, for me, it was helpful just to think through, like, how are they structured and, you know, just in different ways and organized. And so there were some that were goal based versus prompt based data collection. And so one example was, um, data collection that was based on, um, [00:19:00]  modeled words. So you select a word and then show, of course, the child, you know, what happens when you select that word. And so having that, um, sequence of modeling and then seeing, um, Or giving them a taste of what does that produce, right? Or what's the outcome after that happens? Um, and then, uh, the, Um, it was also, uh, a word selected by the child after a prompt was provided, um, and then a word selected spontaneously by the child without any prompting. So they had essentially like an MPS format where you were tracking modeled words, words that were prompted, and then words that were spontaneous. So MPS, um, was one way that it was structured. Um, another one, um, another example was, um, Based on a variety of language functions like requesting protesting are they commenting [00:20:00]  describing negotiating and so on so there was lots of different options to think through because I, um. I feel like so often we get stuck on just requesting, right? It's just a request a button. It's just and that's like the only thing that counts or that really is being monitored when there's so much more right that we can look for when it comes to language usage beyond just number of words. So. Those were really helpful for me to look through, just in terms of thinking about, you know, efficiently tracking usage, um, with different parameters. Do you have anything to add, um, in relation to, to that?  Kate Grandbois:  I, I  Ana Paula Mumy:  think,  Kate Grandbois:  you know, everybody wants a good data sheet. You know, data sheets are better than your sticky note with Scratch with, with tally marks. I think something that you bring up that's really important to think about is the relationship between data collection and goal writing. Uh, we, again, this is a whole other, [00:21:00]  this is a whole episode that we can link that we've done on the importance of measurement target selection. Uh, we will link that in the show notes as well. Um, the short CliffsNotes version is We think of data collection and goal writing as something that happens in a sequence. So first we write our goal, then we take our data. And that's absolutely not the case. We need to be thinking that these are two things that happen in tandem. They influence one another. Uh, we want to be thinking, before we write our goal, we want to be thinking about what kind of, what's the data collection going to look like? Is it reasonable? Is it doable? Who's collecting the data? How often is it going to get collected? Um, you also want to think about your target when you're writing your goal and how your target's going to get measured. Is it a target skill that's really fleeting and you have to be watching the entire time? Is it a target skill that is prolonged? Um, is it something that's low frequency? So you're going to be lucky if it happens once a day, or is it high frequency where it's potentially happening multiple times in a half hour? Um, all of [00:22:00]  these things are really important to consider when you are thinking about your data collection. Uh, and when it comes to recording your data, There are a lot of different ways in AAC to do that. I think the way that the best way is the one that works for you, that keeps your hands free, that keeps your attention on your client. Um, there are two strategies that I think are, um, there are a handful that I think could be considered that I think are worth considering. The first is maybe a tally counter or a golf counter. I don't know why it's called a golf counter, but you know, they're like little clicker. They're like bouncers. You see them at like the, at the clubs, uh, you know, uh, clicking for, for capacity in a, in a, you know, in a bar or whatever. Um, those are nice to kind of hang on your belt with a carabiner. You could do one on each side. And then, uh, Um, if you're doing percentage data, one, your right side [00:23:00]  is for successful trials. Your left side, left side is for unsuccessful trials. At the end of the session, you've got a total percentage. Um, you didn't have to do any sticky notes. Um, another consideration would be, um, another consideration would be probe data. So probe data is really complex. Um, we have a whole episode on probe data. The short version of the story is that any data collection system that you have, you want your data collection to be. accurate, reliable and valid. If you are not measuring accurately, then you're not going to be able to inform your goals and you're not gonna be able to measure progress. It's impossible to, in a lot of instances, track every single instance of an occurrence. That is when you get into this trouble of not being able to engage with your client and have a nice connected session. Um, a potential answer to this problem is probe data where you're only recording predetermined, a predetermined set. of a certain number of trials. The problem with probe data is that it can be really [00:24:00]  inaccurate. It can violate that, you know, ideal standard of data collection that's accurate, reliable, and valid. The way to mitigate and take probe data in a way that is better is to take more, the more probes you take, the more accurate. And if you add a qualifier to that, so let's say you're recording the first three trials, but you're also recording whether or not it was prompted, you're also recording how long it, you know, the duration, you're, you're adding some qualifier onto the probe, the more probes you take, and the more qualifiers you add, the more accurate it is. And again, we have an entire hour long episode that reviews the research. Not that any, it's very dry. I know it sounds boring, but we really liked it. Um, so there are a lot of different ways that you can make your probe data more accurate, reliable and valid. I think another problem with AAC in particular with data collection is that it feels cumbersome because you've got this extra device. So you're like, but I got the device and I've got the student and now I have these golf counters and a pen and a sticky note and there's all these things. Um, [00:25:00]  it can feel really overwhelming. And I think there is often in a lot of. A lot of instances, a big temptation to use the internal tracking system. So a lot of our devices come with internal data collecting data collection trackers where you can toggle it on and it will record every instance of a target behavior or every instance of a target communications or every instance of an icon selection rather. Those are really tempting, but they are very, they have a lot of limitations. So the first major, major limitation is ethics. We have heard from the AAC community that these mechanisms feel very much like spying. Imagine if there was someone walking around with you all day, following you around, listening to every single thing you said. But didn't tell you that they were listening. Uh, we need to be, if we're going to use these mechanisms, we need to be extremely careful about turning them on and off and doing it with informed consent. And that's informed consent for the AAC user and potentially their families, depending on their age and all these [00:26:00]  other kinds of things. The other thing that we really need to think about with these internal data collection systems is the law. So, we could, depending on your state, there is a potential that you are violating a privacy law, uh, by taking this data and storing it in a cloud. Um, that is not part of your district. It could be a violation of FAPE here in Massachusetts. We have to be very careful about that. And we have families sign additional permissions, some schools and some programs I work with won't even do it because it is too close to some violations. So check with your administrators, check with your state and make sure that use of these is even within the provision of what would be considered. Um, Uh, secure storage of data as part of an educational file. So that's another consideration there. Um, the other and last limitation of these internal tracking systems is that they are going to track everything. This, these little tiny robots and say, these machines don't know if it's you that selected the button or the child that's or the student that selected the button. So if you [00:27:00]  are using them for short periods of time, because we know we have to turn them off so that we're not theoretically, you know, following someone around listening to what they say all day. While it is on, you want to make sure that you're only capturing what it is that you're measuring. So if you're capturing models for a communication partner, you want to make sure that the student doesn't select a device, doesn't select an icon, or conversely, if you're using it to measure independent student productions, you have to make sure you're not providing any prompting, that you're not providing any modeling on the device, that the tally mark that you're getting is actually independent productions of the student. So there are a lot of limitations to those. Uh, and those are all really important things to consider.  Ana Paula Mumy:  Absolutely. Yeah. I hadn't thought about that. Um, for sure. And it really, I think in some ways that almost defeats the purpose of, um, the therapy strategy of modeling. Right. So if, if your goal is to model a [00:28:00]  ton and to really see that growth through modeling, then you almost would be shooting yourself in the foot if you used it. Right. Like, yeah. Yeah, well, I want to just ask a follow up question to just, um, in relation to the gold writing. So you kind of already answered the initial question that I had. So I'm just going to add on to the question. Um, just because again, thinking about our member who's mentoring someone, um, And really just understanding that relationship between goal writing and data collection. How might she help her mentee with goal writing to help with better data collection? Does that make sense?  Kate Grandbois:  Yeah. And I think, you know, again, this is a really great question. And like you said, at the beginning of the episode, to really answer this question, well, we need a lot more information, right? Because we don't know if this individual is a complex learner, we don't know what their goals are. And the goals and [00:29:00]  targets are going to have a significant impact on how progress is monitored, because again, Data collection and goal writing are BFFs. They cannot be separated. You cannot do one without the other. They don't happen in a sequence. They happen in tandem, and they influence each other, influence each other continually. Because as you're monitoring progress, theoretically, if they're making progress, the goal may need to be adjusted, right? That's why we have annual IEP meetings, because we're rewriting goals based on progress. Um, I think when you're working with a mentee, And you're trying to unpack some of these concepts, I would go back to the goal first and I would go back to the target and think about what it is that you're measuring and all the variables that will influence how that measurement is taken. Um, that might include all of the things that we've already mentioned, but the environment, the communication partners, how fleeting the communication [00:30:00]  target is. Um, and I also think it's important to have a little bit of forward thinking. And I know where this is a question about a school environment. Um, so theoretically you have an entire year under the IEP to take that, to take that data collection. But having a really good baseline measurement is also really important because if you don't know where you started, How do you know where you're going? And for some, particularly complex learners, really small steps are really huge deals and we don't want to miss them. Uh, we don't want to not give credit where it's due for our students who are working so hard and the paraprofessionals who are working so hard and the teachers who are working so hard and the whole team who was working so hard. Right. So taking those, I would also be really asking a lot of questions about where the student is currently and taking really good baseline measurement. So that you have a strong foundation off of which to judge what progress was made to begin with. Did I answer your question? [00:31:00]   Ana Paula Mumy:  Yes. Okay. So do you want to talk a little bit? Do we have time to just touch on, um, do you have like favorite ways to, um, measure baseline or recommendations or strategies that you, like your go to, um, options, you know, for baseline? Oh, that's a really, it's a  Kate Grandbois:  really good question. Um, I think not as a standard because it is going to be influenced so much by the learner and the environment. Um, I think in a perfect universe, we would take enough baseline measurement to have a solid understanding that this is exactly where the student is and not just a bad day. Um, particularly for more complex learners who might be, you know, presenting with sleep disturbances or, you know, there might be other things going on in the child's life that make that one day that you took baseline measurement, not the best day for baseline measurement. So in a perfect world, we would have a decent amount of baseline. A decent amount of measurement at the beginning of treatment to have a good understanding of where [00:32:00]  we are, so we can decide where we're going. Um, I also think that designing data collection systems that feel achievable and doable is really important because if it's not achievable and doable, then the data that you collect is going to be. Inaccurate. Uh, in one of our data collection courses, we talk about this a little bit in a little bit more depth, but there's an expression, garbage in, garbage out. So if your data collection is inaccurate, that's going to inform your progress. In an inaccurate way, which is going to lead to inaccurate decision making and clinical reflection, um, and potentially poor choices for implementation and intervention. So, really making sure that we hold data collection strategies that are, um, Accurate, reliable, and valid at the center is really, really important. And there's really no gold standard because it's such a customized experience. We also have a, we have a handout on our website that I will include in the show notes as well [00:33:00]  on what accurate, reliable, and valid data means. Um, and again, referring people back to our original, you know, some of our previous work in data collection, just because I recognize that this is a very, a very nuanced, very nuanced conversation.  Ana Paula Mumy:  Yes, well, and just, you know, one takeaway for me, just as you were talking is to really think about representative samples, right? And when we think about this, whether it's a speech sample for an Arctic kid or language sample for a child with a developmental delay. I mean, it doesn't matter what the. Uh, situation is we have to make sure that we are doing what we can to make sure that we are sampling, um, their speech, their device usage, whatever in the best way possible, but also yielding the most representative sample possible. And so. It might take more than one trial, right, to get there. And because, like you said, there's so many variables that could impact that individual's willingness [00:34:00]  to participate or willingness to show what they do know or what they are capable of doing. So, um, so, yeah, that's important. I think sometimes, you know, with AAC, we, we tend to maybe think, um, differently, or, or we don't use sometimes like just the basic knowledge that we already have about like, yeah, in the same way that this applies to X, Y, Z, it's going to also apply for our AAC users. Um, there's maybe, like you said, nuances or different things that we have to take into consideration, but it's still, there's some basics that. Are just foundational, right?  Kate Grandbois:  Totally agree. Totally agree. So, I mean, I think, I think I really appreciate the literature that you brought to the table. I know I shared quite a bit, but I couldn't help myself because this is my area. This is my clinical area. I love  Ana Paula Mumy:  learning from you.  Kate Grandbois:  So great. Um, we will link every all of the additional resources in the show notes and Apollo. Was there anything else that you wanted to [00:35:00]  share?  Ana Paula Mumy:  No, that's it. That's all I had for today.  Kate Grandbois:  And to the listener who wrote in this question, thank you so much for writing in. We hope we did it justice, um, on, you know, in terms of what you shared. Anyone out there who's listening, if you have a question for us and you're a member, Please write in, we would love to read your questions and do a little literature search for you and discuss your clinical case on the air. Um, Dr. Anupama Moomy, thank you so much for being here. This was really wonderful and we look forward to the next iteration of SLPD On Demand.  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, [00:36:00]   www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois:  Welcome to SLP Nerdcast. We're so excited for our topic today. We are here to talk about something that is under discussed in the field of speech language pathology, and yet at the same time, something that is critically important [00:02:00]  for every single thing we do as speech language pathologists. We're here to talk about counseling, and we have two content experts here with us to make the conversation even better. We're very excited to welcome Dr. Corrie Clark and Kate Mellillo. Welcome Kate and Corrie. Hello. Yeah. Thanks for having us. We're very excited to be here. I was thinking why I listened to this podcast. Amy Wonkka:  We're so happy to have you here. Thank you so much for sharing your time with us today. Um, like Kate mentioned, you're here to discuss counseling with a focus on children and adolescents and executive functioning and relationships. But before we get started, can you please tell us a little bit about yourselves? Kate Melillo:  Sure. I'll go first. Okay. So, um, I'm Kate also. Um, I am a speech pathologist in North Carolina. Um, Cori and I co own Be a Problem Solver Services, which is our private practice. [00:03:00]  Um, and my focus is on executive functioning and social skill building. Um, and our practice is actually both mental health. and speech services. So it's a little bit of a unique combination. You don't see that a lot. Um, and I'm, I also write a lot of social emotional learning content as my other job. So I'm, I'm in this world all the time. And I'm Dr. Corey Clark. I am, um, a licensed clinical mental health counselor. Um, I specialize in working with, uh, children and adolescents and, um, I also teach, uh, a, a clinical mental health counseling program, uh, called the Chicago School and I, I am also the president elect of the Association for Child and Adolescent Counseling, um, and so a lot of my focus is on, you know, the unique work with, uh, counseling children and teenagers. Oh, and we're also married. [00:04:00]  We are also together. So if you hear us having a marital argument, that's great. That's what podcasting is the perfect platform for side chatter. Um, so that's, that's wonderful. And I, I want to circle back. I were tickled that you listened to this podcast. It's always funny for Amy and I to hear that kind of thing because we hang out in a zoom room and then we send these off into the ether. Kate Grandbois:  So it's, it's always nice to hear that. Um, and we're, as I already mentioned, we're so excited to have this conversation, it, you know, counseling touches everything we do, and your practice is unique, and it sounds wonderful blending these two areas of competency, um, and we're very excited to get started. I do need to read our learning objectives and disclosures. I will try and do that as quickly as possible. Learning objective number one. Describe key knowledge areas, attributes, and skills of child counselors To incorporate into speech sessions as they [00:05:00]  intersect from the competencies for counseling children and adolescents. Learning objective number two, describe three relationship based counseling strategies that can be easily included in speech sessions. And learning objective number three, Identify how the mental health strategies discussed intersect with executive functioning treatment in the relationship based model of executive functioning. Disclosures, Corey's financial disclosures. Corey is the co owner of Be A Problem Solver. Corey is the co owner of Be A Problem Solver Services, PLLC, which is a mental health and speech therapy practice, and Be A Problem Solver Education, LLC, a parent education service where Corey received a salary for a speaking fee. Corey is a faculty member at the Chicago school where he receives a salary. Corey is non financial disclosures. Corey is president elect of the association of child and adolescent counseling. Kate's financial disclosures. Kate is the co owner of be a problem solver [00:06:00]  services, PLLC and be a problem solver education, LLC, where she receives a salary and a speaking fee. Kate is a research strategist at 3C Institute where she receives a salary. Kate's non financial disclosures. Kate has no non financial relationships to disclose. Kate, that's me, Kate Granbois. I am the owner and founder of Granbois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka:  Amy, that's me. My financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I am a member of ASHA Special Interest Group 12, which is AAC, and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, we've made it through the disclosures and the learning objectives. On to the actual content. Um, [00:07:00]  Kate and Corey, why don't you start us off by telling us a little bit about the first learning objective? So I guess both what are some clinical competencies for counseling children and adolescents, but also why is it important for SLPs to be aware of and to develop these competencies? Cory Clark:  Yeah, so I'll start. Um, this really, for some context, this really started in the last five years where I, as a, um, counselor saw that counselors were being trained to treat adults from a more general model. And I found that working with, um, and teenagers was a very unique process. And I think that really started from working, uh, Kate and I met, uh, working at a preschool and, um, I had a, you know, background in working with kids in that way. And, and I saw that a lot of people were going into the field, just kind of treating kids like little adults, you know, and it was, there was an [00:08:00]  incongruency there. So I was really interested in what makes working with kids and teens unique because I knew there was. A uniqueness there, but I wasn't quite able to pinpoint it. And so, the last five years, I've really been focusing on interviewing experts in the field of, uh, child and adolescent mental health and identifying what makes working with kids and, and, and teens unique and what are the basic best practices and working with, with that population. And so, that is, is where I, um, published and, and, and focused a lot of my dissertation research. best practices for working with kids and teens. Um, and really what it comes down to is really the foundation around child centered therapy. And so what that means is child centered therapy is in its nature very non directive. Um, it is very much based on the Carl Rogers, uh, person centered counseling [00:09:00]  model, which is unconditional positive regard, having congruence and empathy for the, for the person. And And because of that, there's not really a lot of, like, specific behavioral goals in, in, um, child centered therapy, um, but a lot of research supports that a lot of behavioral change and, um, good, uh, coping skills and good development happens from that. Uh, play based child center therapies. So, um, that is sort of the foundation of, of a lot of the, the, um, best practices for working with kids and teens. And so, you know, looking at, uh, What kind of the model that I came out with initially, um, there's attitudes, actions, knowledge and skills. And I broke it down to those four kind of domains. Um, and so go ahead.  Kate Melillo:  Oh, so before we jump in, because are you about to jump into those domains before we jump into that. [00:10:00]   I just want to touch on why this matters for SLPs and why we see like a really big crossover with executive functioning skills. So, you know, I think like if you're listening to this, you're like, well, what does that have to do with what I do on a daily basis? Um, however, like at our practice where. Counseling and speech therapy all the time. I mean, and I think a lot of SLPs, especially when you're new, you go in and then you're like, Oh, I didn't like now a kid is crying in my office. And I didn't expect that. Right. Like, or they're dumping out like, Oh, well, my home, my mom told me this, like, they're just telling you everything. And actually, it's funny. I remember in grad school, I had this one professor who's like, you're going to be so surprised. They're going to come in and tell you everything. Cause you're like the sort of, you know, side person in their life. A lot of times, like you're like this extra [00:11:00]  support person. Who's not the parent. And there's no other, like, side person. Like, you don't have this other, um, stake in the game at, like, you know what I mean? Like, they are kind of coming to you, like, friendly, right? Like, I think, like, the SLP role tends to be really, um, warm, empathetic. The things that Corey just described, but like Kate said, like, we don't get a lot of this training. Um, even though we're doing this relationship based therapy. All the time. Um, and so in terms of where we see it a lot is this like crossover with executive functioning and that's a lot of times because, um, executive functioning at its core is really regulation, right? It's, it's how our brain can regulate itself so that it then can like plan tasks, organize tasks, um, Execute tasks, right? Like impulse control, working memory. Um, [00:12:00]  and a lot of that comes down to emotional regulation. Like I always say, like I describe to my clients, like when you're in mental health. is not in a good space, like your executive functioning skills become scrambled eggs. And so it's really hard for, for students to be regulated, right? Like cope and release emotions and then be like, okay, let's, let's work on pronouns. Like it, it, it just doesn't work like that. The human brain doesn't work like that. And I think a lot of times we go into sessions and we have an agenda where like, these are the goals. That's what you learn in grad school. You're like, these have to be like good functional goals. They must achieve them. The insurance company must approve them and you must do them like, you know, and then we skip over this other stuff. Meanwhile, like, you know. Little Johnny comes into your office and he's like, Oh, my [00:13:00]  grandma died this weekend. Like, you know, I mean, and you're like, but he's the, like, you're the person he trusts. And so he's told you this information. And then you can't be like, well, let's do some grammar, you know, like it, it, it doesn't jive.  Cory Clark:  Yeah, and I, I often say that, um, I am a, I'm the person for a lot of kids, right? And teens. And what that means, what I mean by that is, is a lot of times a kid will have a person that they deem supportive and safe to say those things to. And it might be a counselor, but it might not. It might be a speech therapist and, um, or another professional. And when you're the person, right? Or one of a few persons, um, it's a. Really big responsibility and as far as how you handle those moments where they say, my grandpa died or this and that happened, or I'm feeling X, Y, Z. And so it's important to capitalize on, on creating that space, um, for, for young people. [00:14:00]  And, you know, so, so that's where I'm, I'm going with a lot of this is these best practices, um, are not just. Really just counseling. It's cross discipline in that way, so that you can hold that space. wherever it comes as a professional.  Kate Grandbois:  I also want, I want to piggyback on some of what you've mentioned. It's making me think of a lot of the content that we've produced recently, particularly as it relates to self acceptance. Uh, for example, this has come up a lot in our conversations related to stuttering therapy, uh, or self advocacy. Um, and, You can't really work on self advocacy and self acceptance without counseling and this is what we are now considering to be best practice based on evidence in the field of speech pathology and you cannot uncouple those things. I think there's a specific. Uh, flavor to working as a speech language [00:15:00]  pathologist because you are working closely with someone who is, their existence is living with a communication disorder. That is a communication disability of some sort. That is, that's why we're in their lives. So I don't, I, I wholeheartedly, I'm thrilled to hear some of this, you know, some of these threads being woven together because it is so ingrained in the fabric of what we do. Did you like that little, that little similarity there, the threads in the fabric? I just came up with that on my own. Yeah. Yeah.  Cory Clark:  So going into kind of my, um, more into the background around attitudes, actions, skills, and actions. Um, I think. I looked through the best practices that I've been working on over the years, and there's a few that I want to highlight today that are really relevant, Kate and I feel, to the speech therapy world. Um, and so, Starting with attitude, um, [00:16:00]  specifically, there's three that I want to highlight and, and they are the, the first one is something that a lot of experts mentioned, uh, when asked about, you know, what's important when working with, with children. And that is to meet children where they are. And I heard that over and over again over the years. And I was like, what does that mean? And essentially what they're saying is. You can't go into a session, a speech session, therapy session, um, with a item by item, minute by minute, breakdown of here's what we have to do, here's what we're going to do that entire time. Because kids will come in and throw a curveball or a wrench in that plan real quick. And it's important to be able to be flexible, um, to what, flexible for what, The child or teenager needs to work on or needs to address right like Kate just said if they come in and mention something about their, you know, family member passing away. You can't just be like, well, we got to work on preposition. So we're going to move past that. Right. [00:17:00]  Um, you have to, you know, And, you know, like I say to a lot of my kids, like, think like a palm tree and say, all right, I'm going to bend to this and go, okay, uh, let's pivot. Let's hold some space. Let's reflect and, and, and be supportive and empathetic. Um, so it doesn't mean throw all plans out the window, but it means. meeting children where they are and what they're giving you that on any given day. Um, that attitude is, is very important. And secondly, um, all behavior is communication.  Kate Melillo:  Wait, I want to go back just for a second. So I wanted to say about that mean children where they are, the, you know, we said a couple of negative, really negative examples, but actually The positive example can also help propel your goals forward. So for example, if a kid comes in and they're like, Oh, I'm actually going. You know, like miss Kate, I'm going camping this weekend. Well, I, you know, [00:18:00]  we'll take that and make my examples and therapy about the campaign, right? Like it becomes more relevant. Um, and so it, it doesn't have to be like a big, catastrophic, traumatic event that you're kind of being empathetic to. You're really just like tying into the kid's life and like, great. That's a vocabulary builder. I can talk about planning, right? Like there's executive function. We're going to do working memory. Like there's so many things that can be based off those examples. And I think that, you know, interestingly, I've, I've had the experience where I explained this kind of model to like a newer clinician. And, you know, like I've had job interviews and stuff, like interviewing people to come and work at our, our practice. And they're like, I don't think I can do that. Like, I don't think yet I can, I can, like, that seems like an advanced skill. Um, now granted, I like what Corey and I are saying is, is a clinical, [00:19:00]  is your clinical judgment, like your clinical sense. And that does come with time. So I don't want to make it mean like, this is so easy on the fly. Think of 10 examples that you can use when the kid says one sentence like that. I get that that is like a really hard skill to do. Cool. But I think as SLPs, we can kind of hold this in our mind. Um, and we'll talk about at the end, some examples of how I incorporate, like how I get this going. All of my students know, um, what I'm going to ask at the beginning of every session before they come in. So they're ready and I'm ready. Right. So I've primed it so that like the structure of my sessions is ready for that acceptance, right? It's, it's, ready for whatever's snowballs come my way. Um, and we can talk about that a little later on, but I just wanted to say, I just wanted to note that I get that this is like, uh, takes a little bit of practice, especially if you're used to going in and being like, you know, this is what we're doing today. Um, it's [00:20:00]  definitely a change in that. And you're in your own attitude, which is also what Corey's found in the counseling world as well.  Cory Clark:  Yeah, I think, yeah, I think everyone has their own, uh, uh, preference in terms of how they want to go into a session. And also it's based on what your, um, specialties are and how you run your, your practice. Um, for me, being flexible is just, that's what I prefer, you know, and I, I don't have a lot of agenda in, in, um. A lot of my sessions don't  Kate Melillo:  like to plan anything.  Cory Clark:  I don't. I'm just like, I just want to walk in and say, how's it going? Yeah, I love it. But there's plenty of professionals that I work with that are like, no, I need I need an agenda. I need this. It's very structured. Um, so, you know, for some, it'll be natural. Some not as much. Um, but. The, the second thing I, I want to highlight is all behavior is communication and um, that sort of attitude and understanding is important with kids and teens because there's a, there's a saying in the, in the child [00:21:00]  counseling world, um, so it's important to listen with your eyes because when you're working with young people, they're going to be giving you a lot of information content wise, particularly when how they talk, what they're saying, um, what it's about, you know, what you're working on, but also, um, Non verbally, what are they giving you? What are they saying? Um, what is their body doing? And both of those things have to happen at the same time, listening with your ears and with your eyes. Uh, because kids communicate so much, in particular, and teenagers for sure, um, with how they're, how they're sitting. Are they fidgeting? Are they, You know, do they need to move? Um, do they need a break? Are they listening? Are they focused? Um, what is their affect? All of these things are happening in real time. And it's important to be attuned to that because otherwise you're going to miss really important cues as far as how they're able to be present with you and how they are in that moment. And if you can reflect some of [00:22:00]  that, That's really, really valuable learning for them and awareness. What does  Kate Melillo:  reflect some of that mean?  Cory Clark:  Um, I noticed that, you know, you're, when I ask you to do this, you start to fizz it around in your chair. It seems to me like you may be a little nervous. You're not sure what to do, right? That's a reflection of like, Maybe they know they're doing that, maybe they have no idea. But, and sometimes it's, you know, not accurate. Maybe it's a reflection that they'll correct me on. It's also a good opportunity for them to advocate and say, No, it's this or that. Um, but regardless, you know, listening with your eyes involves that real time kind of, interaction where you're listening to what they're telling you without words. Kate Melillo:  I also think it's ironic because it is what like we teach when we're teaching perspective taking skills, right? And social skills were like, look at the other person. What are they telling you? You know, like look at their body language. Like what did that, what did it mean when they started to walk away when you were in the middle of your sentence, right? Like it's so I think too, like [00:23:00]  we're sometimes go into the sessions, like not doing the things that we're trying to teach. And I, I, I like that, you know, in the counseling world, there is this piece of reflection because it, it, it brings everybody together, right? Like you as the clinician and the student, right? So you've got both parties being like, Oh, I recognize there's a behavior here. And I I'm, what am I trying to say or communicate to this other person?  Cory Clark:  Yeah, and the third aspect of sort of attitudes and understandings that I want to highlight is that all children must be and teenagers must be viewed holistically. And what I mean by that is sometimes it's easy to fall into kind of a The trap where you are looking at one particular aspect of development, whether it be, you know, from the counseling world, like a emotional development or something with relationships, um, [00:24:00]  but you have to think about young people in terms of all aspects of their development and, you know, in particular, I often kind of. Disregard or discredit certain things, not intentionally, but be like, oh, that, you know, looking at how they're doing emotionally at school is very much tied to their social life and their social development and also what's going on at home, right? And also physically, um, their physical development, how is that impacting their social life, especially with like tweens and teens and all of that, right? So you have to consider all these, you know, domains when you're working with, with young people.  Kate Melillo:  I think we hear this all the time. If you have a middle school student with articulation errors, you are not just like, Hey, let's fix those errors. It is impacting them socially, right? Like those friendships are coming into play. Um, and I, so I think this like core best practice of the [00:25:00]  holistic child is so important because, and I think, I do think like Some of these things are becoming more mainstream in SLP, where we are starting to look at, hey, how does this affect you in these ways? And maybe you're making, you're working on some like, um, social, like, strategies to, you know, help, not just with the articulation disorder part of it, right? So like, you're, you're, you're using multiple domains there, um, to help that kid. But I think that, It's different than what we thought of as like the traditional Western medicine model where we're like, let's just treat these one this one symptom and make it better. Like we really actually need to be looking at everything because that's going to round out a kid's mental health, and the way they interact with the world. Cory Clark:  And I, so the next. area, the domain that I want to talk about are knowledge bases [00:26:00]  and understandings, um, of counseling with children and teenagers. Um, and the first one I, I really want to focus on is, is the most common, um, issue I hear. And when people come to see me in counseling, they will say that, um, they've tried counseling before or they've tried some sort of, um, therapy service before. And the parents or guardians or caregivers were left feeling like I had no idea what was going on. Uh, they never told me, they just kind of went back into the session and I didn't know what was happening. And then they were left frustrated, like, I don't know what the goals are, what's going on, right? Or they didn't understand them. And so they come to me, like, will you let me know, like, what's going on, like, you know? And, um, I always tell them that although I'm, you know, I'm not going to say exactly what the content is of the session, like there's privacy there. You will always know what my treatment plan is and what my background [00:27:00]  is and what my training is and how I intend to use that to support your child or teenager. Um, so the, the first really knowledge base that I wanted to focus on is, um, how to involve family or caregivers or guardians in therapy services. Um, it's so important to involve. Other stakeholders in a sense, but family members in, uh, as appropriate, because kids and teens operate in a system, uh, they're part of a system, and you have to be able to translate what you're doing to, um, how it can be reinforced at home and other settings, um, so that involves communicating a lot of those goals and a lot of those things to parents and to, to, um, family members. And that can be tricky, um, depending on what the situation is in, in your service, um, but you have to be able to, to translate that, um, or else you risk losing the [00:28:00]  connection you have, um, with, with the family, um, and they'll pull, you know, maybe prematurely pull them from services or feel like it's ineffective. Or, in a lot of cases, think that you're not doing effective work because they don't really understand what, what the goals are.  Kate Melillo:  Well, and I was also going to add, because a separate, a separate best practice is also the developmental models and how to apply them, and I want to just integrate this into the sharing with the family, because the other thing we hear quite a bit is, you know, families will come and say, Like, I didn't know what was going on and not really for, for speech. I actually have a lot of parents in my sessions. I, I, I just prefer that. Sometimes if it doesn't work with the kid, I'm like, okay, you got to get out because you're, you're entering this session parent. Um, but I like the parents to hear because a lot of times I'm giving homework to the family and which is more counseling ask, right? Like, I'm like, this is how we're going to integrate this because we do hear a lot. Oh, I've tried that before, and it doesn't work. [00:29:00]  Um, Cory hears that in counseling all the time. Yeah. And the, uh, the developmental piece that I wanted to point out is, you know, we are in this field, we're experts at these developmental theories. Like, we know all of this, like, background information that a layperson parent doesn't know. So a lot of times parents will come and say, like, you know, Oh, my kid is like now climbing the bed with me. It, they don't sleep anymore, blah, blah, blah. And maybe that in that kid's life, you know, they're going through a developmental transition, which we know about. And we have other parents come and tell us like their eight year old did the same thing. And we're like, okay, now we can show that that's fairly common, but not every. You know, person is going to know, like Erickson, Piaget, Bandura, like they're not going to know that. And a lot of times SLPs, uh, we get like a little bit of that. And I feel like it also depends on your grad school program, right? Like where the focus was on those things. And they're so varied that maybe you [00:30:00]  don't know as much about that. Which is why it's like, we're talking about this because that's something to share with parents. Um, hey, let me find out more information about that for you. That's helpful. Or make a referral, which we'll talk about at the at the end here, but I I'm pointing that out because I think that there's times when families feel like they're just. navigating this alone. They're the only person that it's happened to. Um, and that it's just, that's just usually not true, actually. Like usually it's happening to a lot of people, but nobody's telling them that. And so when they come in your office, they're like, hello, professional person, do you have the answers for me? Um, you know, and so it's a good, it's a, it's always a good idea to involve the family as much as you can.  Cory Clark:  Yeah, and the next, uh, understanding that I want to highlight, I just want to have a caveat about, um, and that is, it's important to understand the basic foundations of play therapy, and the caveat there that I want to [00:31:00]  distinguish, I do not expect this. I did not expect every therapist to be a registered play therapist. I did not expect speech therapists and other professionals to be play therapists, um, that has a separate and distinct, uh, licensure and, and process and credential. But, the foundations of play are important to consider in working with kids and into teenage years, um, because they allow, um, Young people to express themselves in their natural, in the natural form, which is play. And, um, and so a couple of important points about play therapy, um, they, it's important to accept children exactly as they are and allow themselves to express themselves freely, um, and have a sense of permissiveness to do that. So, you know, thinking about where your, your practice is, whether it's telehealth or, um, an outpatient setting or a clinic somewhere. You have to think about what is that setting doing for them to be able to express themselves, [00:32:00]  um, and you have to ask yourself, like, what, what does that look like for you and your practice? Um, it's important that they have that space. They feel free to express and be themselves with whatever they're, you know, intending to do. Um, and as a therapist, you reflect what they're doing, like listening with your eyes, and um, allow them to gain insight into their own behavior. So that looks like, it can feel very, um, odd at times, because, you know, you're almost like narrating their life, like, like a, you know, bird's eye view, if you will. You know, someone's like playing and they're like, they hand you something rather than just, you know, like they're handing you a figure, you know, and they start, they want you to play with them. My instinct as like a father is to take my son's, you know, figure that he gives me and then I'm going to create like a game with it or a story or whatever. Let's play therapy a lot of times in most modalities. You're not going to do that. You're not going [00:33:00]  to direct them and, you know, say, Oh, now I'm going to create a story. You're going to say, Oh, you want me to play with you. You're really excited for me to play. No, you're giving me that. Okay. And then you sit down and you let them dictate what the play is. Because they're communicating that way. Right. And so in, in a, in a speech sense and that speech therapy, in a sense, it's being able to reflect what, um, your client, what your, your person is, is giving you in a way that allows them to gain insight into their own behavior and their own affect and feelings. Um, and that's really, really healthy and important for their development.  Kate Melillo:  Well, and I think speech therapists, speech therapists are doing this, right? Like if you think about like. the fundamentals of like early intervention really, you know, here's, you're at a kid's house and you're like, here's the farm that you have. I'll just use the good old farm example, where, you know, you're like, Here's the cow. What does the cow say? Right. So you've got a lot of opportunities there for [00:34:00]  like vocabulary building and all of that other like syntax stuff that you want to target. Um, and I, I, I wanted to point out that so play therapy gets the rap of being for little kids. Um, but court. So we haven't mentioned this yet. We didn't say this because this isn't really that relevant yet, but so we're also both trained improvisers. And so we do a lot of improv with our clients, especially tweens and teens. Because I think that the other thing about play therapy is that it's about that acceptance. And those improv games, that is what they are, right? Like if you've ever heard the concept of yes and it's, I accept the idea that you've just given me and I'm going to build on it. And that is what, that's actually what you're doing when you're in your little farm scene. That's what you're doing, right? It would be weird if the kid was like, here's my cow and the cow wants to drink. And you were like, [00:35:00]  ah, that cow's actually on a rocket ship going to the moon like that. Right. And that doesn't make any sense. That is one of the fundamentals of improv comedy. And so we use that a lot. And I think, um, it's confusing to parents, parents will, how many times have you heard, Oh, all they do, they go to that therapy and all they do is play. Um,  Cory Clark:  It's like saying, oh, I went to therapy and all I did was talk. And it's like, that's, that's right. You know, playing is communication. But, but that's not a common, I don't think, understanding that like, You know, and play therapy is very evidence based, and it's very, um, it's very clear how to do it once you learn it, um, but it's very misunderstood because we use the word play all the time, like, let my kid play, and my kid's playing in the other room, um, but, you know, I use so much improv with, with kids and teens where, you know, I'll have a figure and it looks like a superhero to me, like, But they'll hand it to me and say dad or whatever. I'm like, okay, this is [00:36:00]  dad, right? Like you accept what they're giving you and in that way They're telling you their story and you get to hear it from their lens not you know What your instinct is tell you like no, this is a figure of Batman, you know, whatever, right? So you have to be able to roll with that again be flexible and meet them where they are and reflect And I think that's essential  Kate Grandbois:  I, the only thing I have to add to that is some of my own experience. I've been trained. I had to go through this very specific training in child led play and it was hard. It was so much harder than I expected it to be because of exactly what you said. I'm like, Oh, playing. I can get on the floor. I can do some Legos. I can get out the cow and the chickens and you know, make some animal noises and make it fun. I can play. I know how to play. I'm a pediatric therapist, but really taking the child's lead and filtering your own responses and not coming up with [00:37:00]  directives and not asking a ton of questions and really letting them direct where the play goes is a Harder than you think. So if anyone is listening, and I just, I think it's a, it's a great exercise. What you're, what you're proposing is a really great exercise to really think about what play means from a therapeutic evidence based lens, because it might not be That colloquial casual. Oh, we're just playing. We're just on the floor. It's very different and it's gonna feel hard It can feel challenging. That was my experience  Cory Clark:  It's and it's so hard that I mean it's important to note There are some modalities that are more directive play therapy but You know, without getting into the nuance of that, um, there's a misunderstanding that like, oh, if I play UNO with a child, that's play therapy and that's, that's free play. That's, that's playing a back and forth game that has set designed rules. Um, so that's not play therapy. That's playing a game, right? So there's all these. You know, misunderstandings [00:38:00]  based on the language really. Um, and play therapy is, is a distinct process. Um, and I always say the most exhausted I am after a session is a non directed play therapy session because, uh, 45 to 55 minute session is, It goes by, you know, it's, it's exhausting. Kate Melillo:  Well, and I would say too, like, I don't know if you guys, have you read the Declarative Language Handbook by Linda K. Murphy? I love that book. It's a really good resource. It's not a play therapy book, but I use it a lot. And Cory mentioned terms that were declarative language. Like, I see you're doing this. What happens next, you know, um, Tara Sumter, too. She has her reflexive questioning guide. Like, those are also those reflexive questions. And it is, Kate, like, to your point, so hard to, like, bite your tongue and be like, But didn't you mean this? You know, and, or, like, weren't you going to do this with this? Or, like, you're trying to guess the kid's plan. And that's actually not teaching [00:39:00]  them the skill for that, like, future thinking, right? Those executive functioning actions of, like, Oh. You wanted to see what I was going to do. And then when they make a choice that's like, I don't, I don't know if that was what we were going for here. Then you're, you have the opportunity to discuss it and see how you could have done it differently. Whereas if you had done the directive play, you would not have gotten to that point. Um, it's also why we love those improv games because they're They're totally impulsive. Like you don't actually know what the kid's thinking. We can't know what anyone is thinking, you know, um, which is a big, that's a big like nugget there between the counseling and SLP world because we, since we do tend to go in with like, here's our strict, you know, plan that we've got, here's our goals and counseling. It's a, it's really a free for all. You're there to share what, It's going on with you. Um, and as [00:40:00]  SLPs, I think we, we tend to, I don't want to say like disregard it, but we're just not as, you know, it's not our area. We're not as skilled at looking for those clues. But when we do something like a child centered play therapy session. We open up the door, right? If we, if we allow kids to kind of lead, um, and also not tell them what they're supposed to do,  Cory Clark:  what we thought they were  Kate Melillo:  going to do,  Cory Clark:  right. And if, and if you're listening like, well, I'm not a play therapist, how would I know how to do that? And I do not expect even every therapist, every counselor to be a play therapist again. It's about. Um, understanding the foundations of what, what play can mean in counseling or can mean in therapy, um, and what it looks like and how you can reflect in a way that allows for that development, right? That's, that's incorporating play in, in therapy. That's, that's what this is about. Um, and the last kind of thing I want to mention about understandings and, um, knowledge bases [00:41:00]  is atypical versus typical child development. We all learn development of models in school and we learn, you know, the basics, but it's easy to forget some of the more kind of subtle pieces of development. For example, you know, someone will come in. And I'll hear, um, you know, uh, concerns from a parent or guardian around how their child is just so rigid about, you know, a sense of justice, like, it's not fair that my sibling gets this, or why does this peer or classmate get to do this and I don't, and it causes problems, and I'll have to kind of remember, oh, there's a very specific point in child development where that is just front and center in their development, like, I, this, deserve this, and this, and like, and there's very black and white thinking that is common, uh, as part of development. So, sometimes, you know, the therapy session involves me kind of walking through [00:42:00]  typical kind of phases that, that kids are going through that is commonly seen in certain ages. Um, and so it's important to kind of think about, okay, Is this behavior or is this issue, um, part of like common social development or is this something that's like, ooh, that they're 14 and still kind of chronologically still kind of struggling with this thing that is usually seen chronologically at age 8. And, um, we're doing that a lot as professionals in speech, I'm sure, but it's easy to kind of get lost in the nuance of that. Mm  Kate Melillo:  hmm.  Cory Clark:  All right. So, um, moving into. best practices and skills from a counseling sense. Um, I've mentioned a lot of these before, but the first one, you know, basic counseling micro skills is what, what I'll say. Um, what are micro skills? These are the little, not little, but subtle behaviors that a counselor or a [00:43:00]  therapist does in sessions to allow someone to feel heard, to feel supported, to feel that they're not judged. And so, you know, the main things I want to highlight are It's important to reflect, like I've mentioned before, um, what you're, what you're getting and, um, encourage rather than praise, uh, so, you know, I always have to stop myself from saying like, oh, that's  Kate Melillo:  good job,  Cory Clark:  good job with that drawing you made, right? And that's, that's praise. Um, encouragement is your work. You worked really hard on that. You were so focused when you were doing that, right? That is encouraging them and their behavior in the process rather than the end product. Um, so, uh, another important piece is being creative, um, and in sessions. Um, so. You know, being able to tailor what you're working on, um, as far as your goals and sessions to be, you know, being creative around how that looks. Um, we get, we settle into our, our favorites kind of [00:44:00]  activities or interventions. And sometimes we can get frustrated when we're like, oh, that didn't, it's not working. Right. And it's important to be creative, um, as far as how you. adapt to, you know, what a, a young person is giving you in sessions. Um, and, you know, staying up to date on, on the, um, at most evidence based practices in your field, I think is another piece that you have to always incorporate, um, like doing this, like staying up to date with, with your, what you listen to and, and trainings and, you know, specialties. Um,  Kate Melillo:  I would say like, so this like resonates with me for my just SLP practice where. I get in like ruts of I use the same material or there's a trend I'm seeing with a lot of kids at the same time. And so I'm like saying the same thing over and over or something like that, right? Like you're just like, you get in these like cycles of like, oh, I'm really hot on this game right now or [00:45:00]  whatever. Um, I don't know if that resonates with everybody. Maybe people are just like way more creative than me, but I don't think that it's, it's not just about like, there's some really creative, like type B SLPs. You know, like if you like a teacher's pay teachers who make like amazing materials and I'm like, wow, that's incredible. But beyond that, I think it's about creativity in the way you think like using. practices that you wouldn't normally do or even like leaving the room that you're in. Like, you know what I mean? Like just thinking outside the box a little bit, um, which again, I know is a stretch because sometimes they're so limited and what the timing that we have for a session, like the space that we're in for a session, those are all realities. So I'm not trying to like, give you a blue sky pipe dream here, but I think that it's, That's where it really resonates with me because I feel like I, I personally, I feel like I do a good job keeping up with evidence based practice. And then I'm like, how can I even implement this? Like, this is going to be hard for [00:46:00]  me to do, even though I know it's the right thing. Um, yeah. Yeah.  Cory Clark:  And that sort of leads into my, my last kind of domain around. Clinical skills, and that is, you know, actions in and out of sessions. And the first one is about, you know, again, making sure you're have the right supervisor, the right CEUs, the right education over time to match what your people are giving you, right? What they're presenting to you. Um, and then making referrals appropriately as, as you need to. Um, we see it a lot with our practice with it being a speech and counseling practice. Um, know, What an appropriate referral to counseling looks like, or to OT, or to physical therapy, or to feeding therapy, or, no, makes sense, speech therapists, but, um, other professionals. Because, you know, for example, a common kind of stuck point is, if a young person's anxiety has gotten to the [00:47:00]  point where it's so severe across settings, they can't really learn very effectively at school, or in a speech therapy session, because they're so Uh, and a heightened state of tension and anxiety. Uh, they need more support and getting to a place where they can, you know, be regulated to learn. Um, and so knowing how to, to refer, knowing where to refer, getting to know your area, I think is really important. Um, so, you know, researching that and, and kind of making a few calls if you need to, to see what's open in your area, what's appropriate referrals is important. Um, and then I've mentioned this before, but the last one is, you know, empowering others to have a larger role in their child or teenager's life. So again, that's involving family as needed, um, as appropriate. To, you know, allow them to reinforce the things you're working on, um, is, is really important in working with young people. [00:48:00]   Kate Melillo:  Um, okay. So I wanted to talk about like, we just, Corey just told us like so many things and there's actually like a billion other best practices that he researched. And those are like just the highlights. So I realized if you're like falling asleep now, you're like, okay, thank you. That's enough. Um, yeah, yeah. Sorry. You're boring. Nobody's falling asleep.  Kate Grandbois:  We're on the edge of our seats over here. We're listening  Kate Melillo:  with our eyes. Yeah, there you go. There you go. There you go. Um, but I think so taking all that I've mentioned it before. Um, I, I read this, I think it was, I'm in Tara center's community for executive functioning and I, somebody posted like something. It was like, um, once you see executive functioning, you can't unsee it. I don't know who said it. So I'm trying to give credit to the person who said it, but that, that is like, My whole life because a lot of times really every session kids are coming in and I'm like, oh gosh, like there's so many, it's not just those like surface [00:49:00]  goals, those symptom things that I need to address. It's really how the entire brain is functioning as a whole. And that's why I mentioned at the beginning that like, when your mental health is, is not in a good. space, your, your executive functioning becomes scrambled eggs, then you can't do a lot of other things. Right. So there's sort of this like hierarchy, um, where you, you're needing, like Corey just mentioned, making those referrals appropriately so that you get services in an order that makes sense to you. Like there's a lot of times where I get parents coming in and saying, Oh, I want executive functioning therapy for my kid. But then I learn like, The parents are going through a recent divorce and, you know, the kid lost a bunch of friends because he had to move due to that, right? Like, so there I'm like, Oh, let's pause this for a minute. Like, I get that. Maybe he's not firing on all cylinders, but there's other reasons for that. And so we see this crossover with counseling and executive functioning all the time. [00:50:00]  Um, You know that exact. Oh, I haven't even mentioned the word anxiety yet. I don't know. Have you, have you guys see this? I see, I, I work with a lot of teenagers and like tweens and the level of anxiety that I see on a daily basis is, is really striking. I mean, and there is also new literature about this, right? Like we know that the mental health stigma. Um, state of tweens and adolescents in the past five to 10 years has significantly, anxiety has significantly increased. So it's, it doesn't surprise me anymore, but it's almost like I immediately have to take that consideration into my treatment plan. Um, because honestly, sometimes I have to parse apart with parents, like, Ooh, this trouble with executive functioning is actually anxiety, right? And, and they go, so they're so closely related that what the behavior looks like, right, [00:51:00]  that what the kid is doing, um, that the parents like, well, What do you mean? Like if he, okay, prime example, my kid doesn't want to go to school in the morning. And I'm like, yep. Okay. So what, why is that? And they're like, well, they, because they're ADHD. And so they don't like, they can't get their backpack together. They can't do this. They can't do that. Well, few sessions in, then I'm finding out like their first period is math. They don't want to go be going to math class. They are procrastinating for that and that is actually a symptom of anxiety. And so I'm having to like really juggle like this. We have to address that anxiety piece because yes, they probably do need help getting that backpack organized. Let's be honest. Like a middle school boy backpack. I don't know if you guys have seen them, but they're a nightmare. Um, there's a lot of crumbs, unexplained crumbs and crumpled papers. As a parent  Kate Grandbois:  of two tweens, I can confirm the crumbs.  Kate Melillo:   [00:52:00]  It's a real  Kate Grandbois:  problem. It  Kate Melillo:  is a huge problem. It's not always like the kid has, you know, this like severe executive functioning disorder. Sometimes they do. Um, and every middle schooler could use executive functioning help. Let's be honest. But the, the brain regions between, um, That prefrontal cortex and limbic system, like they're going, you know, I don't know if anyone wanted a brain review today, but executive functions live in that prefrontal cortex and those emotion responses that emotional regulation lives in the limbic system and they interplay, right? And so if the kid is having a ton of anxiety, uh, or. Depression, a lot of fear, a lot of times, a lot of fear in the tween space, right? Because it's a new, you've got hormones, you've got new friends, you've got transition to middle school, like there's so many factors at play. Um, so to bridge this kind of gap, we try [00:53:00]  really hard in our practice to like, build on these relationships, which goes, this is where those best practices that Corey talked about come in. Those are all relationship building practices that I think we need to do a little bit better job of incorporating into our speech sessions so that we can parse apart. Is this anxiety? Is this actually executive functioning? Is this, you know, a pragmatic language disorder? Right? Those, those kids with, um, ASD, ADHD, you know, disruptive behaviors a lot of times, like if you have kids on a BIP, or you know, does everyone know what a behavior intervention plan? You don't know sometimes, like, what's the origin? of this, right? A lot of times, um, on my case, so to get kids who are just like simply misunderstood, uh, and some of their behaviors are, they are from ADHD, but they have never been addressed with actual executive [00:54:00]  functioning strategies. They are often just like, go in this other room, be pulled out to this other class that will help you. And then they throw a chair in that other class. And they're like, why didn't this help? You know, like, Ooh, well, what, probably if you, you can't unsee the executive functioning. So part of the relationship building is also getting that team. Corey and I just talked about this with the family. The other thing we didn't mention is like related caregivers. You know, um, we, at our practice, we have it so that like, if. A lot of times, Corey and I will see the same client for different things. And so, like, we're talking to each other with permission, right? Like, getting those, um, other providers on the phone sometimes can be really helpful. Because I've also found that when I have a kid come to me for executive functioning therapy, but they're also receiving counseling somewhere, they, a lot of times, tell me things that they don't tell the counselor. And I'm like, You know, and [00:55:00]  it goes back to what I said at the beginning, where like, the counselor seems more threatening, maybe, right, like, I'm supposed to go there and tell them all these deep, dark secrets, but if I go to Miss Kate, I'm just like, well, you know, like, I stole a candy bar, you know, like whatever it is, like, I don't know. I live in like 1955. So like, I'm like, go to the corner store. Yeah. And I love that milkshake. I don't know. Um, but we're trying to like get the everybody on the same page. Um, So when we're trying to bridge these gap in sessions, this is what one of the things that I do at the beginning of every session. I, and some people I've heard a couple of people mentioned this, like in my SLP circles, I do a high low and a Buffalo at the beginning of every single session. Um, so. My kids know that I'm going to ask this. I actually love it. It's great working memory. It's like excellent working memory. That's right off the [00:56:00]  bat, like executive functioning, and they don't even know I'm targeting it. And I'm like, what's your high, low Buffalo? So high, something good that happened to you. A low, something not good that happened. And a Buffalo's weird, funny, silly, interesting, kind of out of the ordinary. And I, you know, every single tween or teen will be like, I don't know. Whereas I've seen this kid for a year and they know exactly what I'm going to ask at the beginning of the session, I'm like, nope, we've, we've got a good thing going here. You're going to tell me all about your life. Um, you know, I've heard like there's some, there's like a rose and a thorn is another one that people use. So that's like a good thing and a not good thing. I, I tend to like the buffalo just because it makes a little more fun. Um, I like the buffalo. I've never heard the buffalo before and I like that a lot. But I set the precedent that the session is going to be about the kid, right? So like, those kids know that they're one going to be asked that question. And two, that I kind of expect them to to share [00:57:00]  something meaningful because like I said earlier, I will take that information to inform how I target those goals that day. And I, again, realize that that's, this is a little bit of an advanced skill. You do have to have like kind of a lot of things in your toolkit in order to be able to do that. But once you get good at it and make that the expectation, it becomes easier, right? You've got. This opens the door for like all of that play stuff. Like our first example of a strategy is small world play. I don't know if you guys call it small, small world is kind of like the dollhouse or the farm or in there. I've never heard it called small world play, but I like that. I used to work at, Corey and I, another fun fact, I used to live and teach abroad, and I worked at the British School of Beijing for a couple years, and in the UK curriculum, that's what they call it, is Small World's Play. So you're a little. I love it. I know, it's such a good little name for that.  Cory Clark:  Right.  Kate Melillo:  Um, that, and, and Corey too, we [00:58:00]  haven't talked about SANTRE, which is a whole other certification for, for counseling. But SANTRE is basically miniatures.  Cory Clark:  Yeah, a lot of minifigs.  Kate Melillo:  Yeah, like minifigs in the, in a SANTRE. And that is like a, cause, The reason they do that is it's a blank slate  Kate Grandbois:  like  Kate Melillo:  we were talking about earlier with play therapy. It's like a totally there's no predetermined thing. It's just whatever you're creating that sand tray. So when you're one, I start the session with this high low Buffalo. And then if we're using this example of small world play. I, this leans into heavily what we were saying earlier, you've got a lot of improvisational problem solving and perspective taking. I tend to, um, I, I really love the phrase reading the room. I use it a lot. Like, I try to give my, and we'll talk about this with social dilemmas too, but I try to make sure that like, Even if my kids like my students on my caseload don't have like [00:59:00]  glaring pragmatic issues. I'm still incorporating this in a small world scenes because they're just there. There's that is like the integration of life, right? Like that is taking the communication skills that you've been practicing and and throwing them into some sort of like realistic scenario. Um, so I love small world play for, for those social nuances and targeting some of that. And then you get that extra piece of counseling where you can reflect and empathize, right? All the skills that we just talked about before.  Cory Clark:  Yeah, and I want to talk about one exercise I love to do that's, it's more of an art therapy blend, but it's an excellent crossover between mental health and executive functioning kind of therapies. So what I do is, I saw it from an exercise for particularly with those with ADHD, but it can work well with any, any young person. Um, [01:00:00]  So I, I get a video from YouTube, just find something, a short, maybe five minute ish, uh, video of how to draw a basic. thing, right? Like how to draw a dog, how to draw an elephant, or a house, whatever. And I will put it on with the instruction, uh, that me, myself, and the, um, child or teenager are going to draw it together. Um, we each have our own paper. We're going to draw this house or this elephant together. And that's it. I'm not going to stop the video. We're just going to draw. And I, at that point, I've done it, uh, a bunch of times, right? I do it over time. And so I, can just do it, or it's, it's, I'm not great, it's not perfect, but it's, I can do it. Um, but it's their first time ever seeing this video. And so, we just draw it, without stopping, and then when it's over, it's done, right? It's simple, right? Like, we're just drawing an elephant, for example. But what we do is, in processing it, it's important to then say, Okay, a lot of [01:01:00]  kids, for example, will get frustrated because it's too fast. And so what do they do? They either quit, or they start purposely messing up, or they put an X through it, or they're scramble the crumple the paper, right? Um, or maybe they do it, but they're working through a lot of, um, frustration tolerance or a lot of negative thoughts during, right? And that mimics a lot of school, a lot of school behaviors where if they get lost in math or lost in something, um, it mimics that process. And so it allows me to work in real time to process. Okay. What was going on in your head when you started to, you know, get, get behind and drawing that elephant or, um, what do you think I was thinking while I was doing that, right? Perspective taking. Um, what kind of allowed you to keep drawing even though it was getting harder and harder to keep up, right? Um, I noticed you put the pen down and quit after about three minutes. What was going on? What happened, right? Um, it allows you to [01:02:00]  process with them. Kind of what barriers they had, um, you know, what kind of thinking traps they had or distortions, um, and kind of really make a plan for, okay, next time, what can we do that where you can work through that? And then we'll do it again, right? Um, either next session or whatever, um, to, to work on that process so they can translate that across settings.  Kate Melillo:  Well, and that's executive functioning one on one, right? That second piece of like here, next time we're going to make a plan for how to do this and we're going to apply these steps So that you can be successful because then, you know, maybe the kid has an issue with initiation, right? Like you're making a plan to get over that hump. Maybe it was the emotional regulation or making a plan to get over that hump. Those are all those executive functioning skills that a lot of times we see behaviors for, and they're misconstrued or misdiagnosed as possible language disorder. Or Pragmatic disorder when in fact, like they're really lying executive functioning. [01:03:00]  Um,  Cory Clark:  although one time I did that and uh, This is teenager. No, they drew the most amazing elephant i've ever seen in the entire world And I was just like, uh, let's process it. That was just amazing. Good job I didn't know what to I don't know how to like do my process after that. They just  Kate Melillo:  Great artists. Yeah.  Cory Clark:  Yeah  Kate Melillo:  So the last, the last kind of example here, which I think a lot of SLPs use, and there's, there are a lot of resources for this, are social dilemmas. You know, any of these like social cards, we also have, um, like some of the teen talk cards. We really liked those at our practice too, which are a little bit more open ended than the dilemma itself. Um, and I'm sure every SLP has seen these vignettes of a social dilemma. Like, what would you do? The. The thing that I think makes it a little bit lean into the mental health piece more is if you can start incorporating more of the emotional language that goes along with these, [01:04:00]  because sometimes we're focused on the problem solving outcome. And so we want the kid to quote unquote do the right thing. Um, and I know in like the neurodiversity world we're, we're, Leaning away from that and saying, like, well, what is your perspective on the situation? What was the other person's perspective on the situation? As opposed to this is the right way to do it. This is the wrong way to do it. Um, but I think that one of the important things is pointing out those emotions that come with what happens with the social dilemma, right? Like, um, There's that the concept of those like upstairs downstairs thoughts, which I think is Dan Siegel. I want to say it's Dan Siegel who it could be. I would have to check that. But I think that's because that's on the what's that workbook? Yeah,  Cory Clark:  it's upstairs and downstairs brain.  Kate Melillo:  Yeah, yeah. Um, so if you're not familiar with his work, that's a he's a really good resource. He's got like workbooks that go along with those. [01:05:00]  Like emotional thought processes, and in the SLP world, we're, we do tend to look at that perspective taking piece, um, but there's more involved in it than that, right? Like, why did that person, like, why did that person do that action? Well, they were feeling XYZ, right? And so I think that there's a really big crossover opportunity there. Um, and also we have not talked about this, which is self monitoring. And self advocacy. So self monitoring is like, well, what I would do in this situation is this. Um, and then I'm like, how do we feel about that choice? Right? Like providing that, or we can give social dilemmas, have them play them out, role play, and then self monitor. Those responses. Um, I use a scale of negative two to positive two. In my practice, I do not like a scale of one to 10 when I'm self monitoring, um, because [01:06:00]  the one to 10 I feel like what's the difference between like six and seven. Right? Like to me, there's like not really a difference. Like, how well did I do on this scale? Six or seven is kind of the same thing. Whereas in the scale of negative two to positive two, a zero is actually meeting the expectations. A one is doing better than that. A two is doing like amazing. Negative one is like, I did not meet the expectations and a negative two is like, I totally blew it. And so that scale allows a lot of my students a little bit more. One, wiggle room, right? Because they're not like judging between a six and a seven. But two, they're like, well, now I know I didn't actually do the thing I was supposed to do, right? Like, or what I did was unexpected. Um, other people might think that the, their perspective is that was a little strange and maybe that's okay for them. Like that, that's, maybe that's fine for them, but it, it is a, an actual skill to be able to go back [01:07:00]  and self reflect and then use the self advocacy to say like, Hey, next time I needed X, Y, Z, right? Or I would prefer if you said something like this to me, whatever it is, I'm in this social dilemma. So the last part is when to refer. Cory Clark:  Well, we've covered a lot of this. I don't want to kind of go too far into it that we've already done, but it's just really important to know your area. Like I said before, to know how to know where to refer. Um, for things like when the anxiety is getting too heavy to really, you know, carry out sessions. Um, when trauma has been noted that you didn't know before, you know, early on. A lot of times you don't know, um, when you start services with someone and then it comes up, you know, throughout. Um, or if, you know, someone's behavior is, you know, Getting to the point where they're so aggressive or disruptive at school or at home to where it becomes unsafe to, you know, to, um, [01:08:00]  do therapy services or, um, you know, just hearing about unsafe things at home. Um, it's important to refer. So, you know, connecting with local counselors in your area is important. Um, creating relationships, creating a referral list if your practice doesn't already have one. Um, of where, you know, you can refer to where they won't be turned away, right? And it's really hard, um, nowadays to, to. To find places that are accepting, uh, new, new clients, uh, that see kids, aren't  Kate Melillo:  full.  Cory Clark:  Yeah, they accept the insurances they need, you know, so it's important to know what's available, what's possible in your area.  Kate Grandbois:  You've shared so much with us. I could talk to you for a whole other hour. I already, I'm already thinking of all of these additional questions about how to approach this in a school environment, about, but we don't have time to go to any of these, these Avenues that my brain maybe that's my executive functioning really failing me here wanting to go off on all these tangents You've just shared so much helpful [01:09:00]  information And reaffirmed so much of of my own personal perspectives of how important counseling is So much of what we've said on this show in the past in our last few minutes Do you for? For the SLP or the special educator who's listening who might be somewhat familiar or somewhat new to this general area, do you have any, you know, final thoughts or words of, of, um, words of wisdom and, and suggestions for next steps?  Kate Melillo:  I, so I think the biggest takeaway here is to, for SLPs to like, I challenge you kind of to go into your next session and change the way you think about how you deliver the session, right? Like, change your mindset around like how you're going to approach those goals today and make it more about the relationship with that student and not about the goals. Um, because that that's really like the crux of what we're saying [01:10:00]  here, because I think you'll see things like the executive functioning stuff like bubble up, like, you'll see things like the other goals, um, come into, you know, in front of your face. If you just made it about the kid and the relationship that you have with them, which I think is definitely. A mindset shift. Um, it's not the way that everybody approaches their session. And yes, it could be your, you know, maybe it's preference, but the evidence actually does lean this way. Um, and a lot of new research and social skills and social emotional learning. So that would be my challenge to everybody after today.  Kate Grandbois:  Thank you so much for being here. We really appreciate all of your time. I have learned so much. Um, I'm sure our listeners have too. Everything that you've mentioned today will be in the show notes. So anybody who's listening while they're driving, walking, whatever, what have you, um, all of those links will be there. Thank you again so much for your time. This was really awesome. Thanks for having us. Thank you. [01:11:00]   Amy Wonkka:  Thank you.  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:  Welcome to SLP Nerdcast. Today, we are talking about a, an under discussed topic in our field. We are here to talk about cluttering with one of our field's leading content experts, Dr. Kathleen Scaler [00:02:00]  Scott. Welcome, Kathleen.  Kathleen Scaler-Scott:  Thank you so much.  Kate Grandbois:  Before we get started, can you tell us a little bit about yourself? Kathleen Scaler-Scott:  Sure. Hi, everyone. I'm so excited to be here today. Um, I'm Kathy Skaler Scott. I'm a professor at Missouri Cordia University. That's in Dallas, Pennsylvania. We call that the little d. If any of you watch The Office, it's near Scranton. That's usually how people know us. Um, and this is my 13th year there. I've been in the field for In the field of speech language pathology for 30 years, I was a clinician for 13 years and then decided to go back and get my doctorate and I focused that on cluttering and atypical disfluencies and, um, I've been working at Misericordia ever [00:03:00]  since, but I do do just a very limited private practice Um, just to keep my hand in it because it really informs my practice. So I kind of feel like in my heart, I'm, I'm a researcher. I've written articles and books on cluttering, but I am a clinician first. And, um, I see lots of clients with, um, especially cluttering or cluttering and or stuttering and concomitant disorders.  Kate Grandbois:  Well, we're so glad to have you, uh, prior to hitting the record button, we reviewed all of your accomplishments and the books that you've, that you've written and the podcast that you have. And I'm really, really excited to unpack all of that for our audience. Um, we're also here today with our resident SLPD, Anna Paula. Welcome Anna Paula. Thank you so much. Do you want to tell our audience a little bit about you?  Ana Paula Mumy:  I am a program director and associate [00:04:00]  professor at a small private university in East Texas, and I, um, also, um, I say happened into the world of stuttering, um, through my own personal experience with my son and some other family members who, um, stutter and, um, have just Um, become immersed in the stuttering community through our nonprofit Sparrow Stuttering. Kate Grandbois:  So I've already disclosed to both of you, and now I will disclose to our audience that I know absolutely nothing about this. And I'm very much looking forward to Anna, having you here, Anna Paula, to elevate the conversation and, and really kind of unpack this very under discussed, but very important topic of cluttering. Before we do get into the conversation, I need to read our learning objectives and disclosures. Learning objective number one, list at least two characteristics of cluttering. Learning objective number two, list at least two myths about cluttering.  Learning objective number three, describe at [00:05:00]  least two best practices for treating cluttering. Disclosures, Kathleen's financial disclosures. Kathleen received an honorarium for participating in this course. Kathleen also receives book royalties from authored books, including The Source for Stuttering and Cluttering, Fluency Plus, Managing Fluency Disorders in Individuals with Multiple Diagnoses, Managing Cluttering, a Comprehensive Guidebook of Activities, and Cluttering, a Handbook of Research, Intervention, and Education. Kathleen's non financial disclosures. Kathleen is the co host of a podcast titled Cluttering Conversations. Kate, that's me, my financial disclosures. I am the owner and founder of Grand Blanc Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial 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. And [00:06:00]  Apollo, would you like to read yours?  Ana Paula Mumy:  Anna Paula, that's me. I received compensation from SLP Nerdcast. For my work as ASHA CE Administrator and as the SLPD On Demand, I am employed at East Texas Baptist University. In my non financial disclosures, I am the co founder and president of Sparrow Stuttering. I'm a member of ASHA and TISHA, and I serve on TISHA's University Issues Committee. And I'm also a member of the following ASHA special interest groups, uh, Fluency and Fluency Disorders, SIGFOR. Issues in higher education, SIG 10. Administration and supervision, SIG 11. And cultural and linguistic diversity, SIG 14.  Kathleen, if you could just begin by telling us what is cluttering, just starting with maybe a basic definition or traditional definition of cluttering. And then what I'm really interested in is just, um, having you expand on this definition, because based on your experience and your [00:07:00]  work, I think that's a wonderful contribution that you have is just how you refined or expanded it. Kathleen Scaler-Scott:  Great question. Thank you for kicking us off with that. Um, You know, depending upon when you received education about cluttering in your, in your clinical journey toward becoming an SLP, um, or if you got any information about cluttering in graduate school, you may have all kinds of varying definitions. And it used to be a really broad, confusing definition. And thank goodness to Dr. Ken St. Louis. and Katrin Schult from Germany who scaled it down in 2011 to the lowest common denominator. It's probably the most commonly used definition. It's the one that I find so straightforward for treatment and for diagnosis, especially for diagnosis. So in the LCD, uh, definition, what they did was they [00:08:00]  said, okay, there's not There's not a hundred percent of symptoms that cluttering experts agree upon, but these are the ones that they do agree upon, that if, if I think about cluttering, these things may be possible. So, the first is that the person's rate of speech sounds rapid, um, or irregular, meaning rapid sometimes, not rapid other times. And it's It's important to note like it sounds rapid. So it's a perceptual definition. We know now that it's not necessarily always measured as faster than average, but it sounds fast to the listener. And if that person has that, um, where sometimes they're sounding fast to the listener, doesn't have to be all the time or in all situations, but sometimes a teacher, a parent, uh, you know, a friend, a significant other, Okay. gives feedback to the person, Hey, you sound really [00:09:00]  fast. Um, then that's kind of your go signal to explore if cluttering might exist. So that's the mandatory criteria to further explore diagnosis. And then we have fast talkers, right, who have no breakdown in communication. But in order to be diagnosed with cluttering, you have to have at least one of the three symptoms. after that in the LCD definition. And one is, um, excessive overcoarticulation. So we all know what coarticulation is, where the sounds blend overcoarticulation, the sounds blend too much. So it sounds like the speech might sound like there's sounds missing or syllables missing. Um, And so a lot of times, perceptually, people will say their speech sounds kind of mumbled or mushy or unclear. So they're missing the, the word, um, like what is that actual word that you [00:10:00]  said, or that phrase, I missed the actual word. Um, so that's one. The second one. is excessive. In the definition, it says normal disfluencies. What that means are what we know as non stuttering disfluencies. So interjections, ums and uh, fillers, phrase repetitions or revisions of thought. I want a sandwich. No, I think I'd rather just have a glass of water. Those types of things that we all experience when we're trying to put our thoughts together. So, and the whole definition is perceptual. It requires clinical judgment. So, excessive There's no number or cutoff for excessive normal disfluencies. But the way I look at it as a clinician, most, most of our clinicians, even if they've never worked with cluttering, if you've worked with [00:11:00]  language disorders, you know these speakers when you work with them. And I usually say, does, is it that the speaker's communicating a message? And I, I understand their message, ultimately, but it just seems very inefficient because there's so many stops and starts before they get to their final point. Um, so that would be the second criteria that might diagnose cluttering. The third is a typical pauses, and that's pauses in places grammatically. So, it might be like, I'm going to the store to get some Halloween candy. Um, you wouldn't expect the pause to be there. I'm going to the store to get some Halloween candy. Now that is like a very basic example. But what happens is if someone does that in lots of places in connected speech, the speech [00:12:00]  spurty. So, that's. The basic LCD definition that I work with, um, and through the International Cluttering Association, they're working on some other pieces to expand the diagnosis, but it's tricky because again, if we go too broad, in my opinion, it's going to end up being confusing, but they are working through that. For me, just now, um, you know, One of the things about cluttering is that there's a myth out there because back in the day, awareness, people thought awareness, like lack of awareness, was kind of a diagnostic criteria for diagnosing cluttering, that clutterers are not aware. That their speech, you know, might not be clear to the listener. So this lack of awareness has been out there, um, as a myth. [00:13:00]  And, um, okay, right now I'm going down a rabbit hole. So let me just see. We want rabbit  Kate Grandbois:  holes. We encourage rabbit holes around. You do go for it,  Kathleen Scaler-Scott:  but it's the, well, no, it's just more, I want to make sure I'm staying on point, but the lack of. Um, awareness piece, um, is, is something that was a myth and now that we're hearing more from adults who clutter, especially through social media, different outlets, and they're telling us our experiences, just like we've learned so much from adults who stutter, we're learning so much from adults who clutter and, um, you know, The myth was that you're not aware, so there's no life impact. There's no negative listener reactions like there are for people who stutter. There's not people giving them negative feedback, but in fact, when you talk [00:14:00]  to adults who clutter, they recount very similar experiences from listeners. The differences, the key differences, a lot of the people Who clutter what they, the feedback that they were getting, they didn't necessarily understand because they didn't have a diagnosis like people who stutter might. So cluttering was so confusing. They They hear feedback, like, ah, you need to improve your communication, or, boy, you talk really fast. They were aware of that feedback, and sometimes the feedback was insulting, like, because of the overcoarticulation. It would be like, are you drunk? Are you stupid? So the same kinds of negative things that Um, stutterers might hear, but they didn't even have, they just didn't have a label to put on it. So, now that we know that life impact is, um, is, is important to cluttering, [00:15:00]  that's something that I definitely look at too, expanding, like, what's the life impact? What's your experience of cluttering? That's a huge way that I'm trying to expand my view. Um, and then I'm also kind of looking at Where are they on their readiness journey to  Kate Grandbois:  talk more about a readiness journey? What is that?  Kathleen Scaler-Scott:  So it's not new to the field of stuttering, but it is to cluttering. Um, in terms of that, um, the first person was Trisha Zabrowski and a lot of her students in the field of stuttering. They discovered the trans theoretical model. By discovered, I don't mean that they are the ones who created it, but they discovered how it could be applied to stuttering. So the trans theoretical model, I think it's Prochaska and DiClemente. It was their work [00:16:00]  in the area of addictions literature. So They developed this model to show that everyone, when they're thinking about making any change in their life, goes through different stages. And they start with like pre contemplation where you're not even really thinking about making the change and moving all the way through till, okay, you're really ready to make a change. And people move in and out of those stages. Um, And their work was mostly like with like quitting smoking and things. So Trisha Zabrowski and her colleagues took this and thought, huh, this really applies to, you know, teens who stutter who might not be ready yet, um, you know, to do something about stuttering. And, um, Trish has done a ton of work in For Teens Who Stutter, and I've learned everything I know from her work. I'll just say that, um. [00:17:00]  So she, not just in this and everything and stuttering, um, but they, she applied it more to like the journey and like, um, and then Naomi Rogers, who was one of, um, Trisha's doctoral students and now is, uh, a professor in the field, she has applied it specifically to teens and is developing like a clinical tool to use for, um, um, for looking at when a teen is ready to make a change. And so once I heard about this tool, I started using it with different clients, cluttering, stuttering, but I started to really think about its application to cluttering because in cluttering, a lot of times what happens is That teens can be really defensive, teens and sometimes like young school aged kids, and so their response is often, [00:18:00]  um, if someone says, you know, I don't understand you, you talk too fast, the response often is, my friends understand me, my parents have something wrong with their hearing. You know, like what's wrong and when we've talked with adults who clutter, they will say, looking back on their teen years, they just felt like sometimes they were kind of aware that some, they were having challenges with something, but they weren't ready to fully embrace it. I mean, that makes sense with the age anyway, so. We have reports of adults who clutter who say, like, when someone used to say, talk slower, they'd be like, you need to listen faster. So, this can be a big source of frustration for speech pathologists, especially, like, in the schools. They're like, okay, hey, I finally know what this cluttering is. I know what to do with, with, um, you know. And I've identified it, but now the [00:19:00]  kid is like, nope, nope. And the parent is like, please, you need to do something. And the kid's like, nope. And then therapists are left like, what do I do now? So this is like a work in progress, but we've kind of got two things in progress. One is that my student and I were working on trying to adapt this stages of change to cluttering, and it will be a really long process, but it's just more. You know, how can we start to have the conversation with kids and see if maybe they're misinformed about what cluttering treatment is, about what we're going to do, and also how can we educate parents? Because the big frustration a lot of the time is that parents are looking for us to treat. And then make their child sound like, you know, Oh, I can understand them 100 percent of the time. [00:20:00]  And if, you know, they find times, Oh, I still can't understand him sometimes when he's at home and he's excited. It's hard for them because they're looking toward the future and they're anxious about people are going to misunderstand them and misjudge them. And that does happen, right? We've talked about that. So their concerns are valid. But what we need are the tools as speech pathologists to be able to have the discussion with them and say, it's okay. Like they've learned some things that maybe they want to use now so their listener can understand them, right? Just so that their message doesn't get lost. And that's something very different between stuttering and cluttering. Like in stuttering, you know, If you choose not to monitor your speech, the listener, it is on the listener, they need to give you more time, and that's, you know, totally valid, like, the stutterer [00:21:00]  doesn't need to change their speech for the listener's comfort, right? And in cluttering, it's the same thing, like someone who clutters doesn't need to change their speech for the listener's comfort, but where a difference may lie sometimes is that in cluttering, if I choose not to monitor my speech, and I have a very good listener with the best of intentions, but I over coarticulate, then they may miss my message. And, um, we have stories from people who clutter who say, I was in a work meeting. I presented this idea to the group, and they all just kind of smiled and nodded. Two minutes later, my co worker presented the exact same idea, and everybody said, Great idea! So like, there's the potential that things could get lost, but that doesn't mean they need to monitor their speech all the time. It means we have to have conversations with them about how do you want to navigate this. What, [00:22:00]  you know, what could happen in this situation? What's a situation that's important to you or not? And I think if we had this official, you know, application of the tool, um, speech pathologists could feel more comfortable. At least this has kind of been my journey working with parents. I've always said to parents, Hey, they're on a journey, you know, and it's okay. Like they know when they want to monitor their speech now, they're not going to do it all the time. So we need to just let them go fly on their own. And if they need more support, let them know the door is open. And it's hard for parents. And I feel like they would look at me like, really, but I wasn't using this trans theoretical model where now I can say, this is normal. This is where they are in their readiness, and they've done this much, but they might move back a little bit on their journey, and they're going to [00:23:00]  move forward later, and it's going to be okay, and we want to leave the door open, you know, that, so that just has, like, Been a game changer for me, because I feel like as we develop this, maybe I don't know. I mean, maybe I shouldn't have to have this, but I feel like it'll be like, I can say there's this model. This is everyone. And it will feel like it has more. To the parent, like, this is a legit thing. This is not just her saying, taking my kid's side and saying, like, oh, they need more time. It's like, this is legitimately what happens when people are making a change for anything in their life. So that's one thing. And then also, um, One thing I, uh, wanted to mention is that you probably, I think on your podcast, you've had Nina and Scott Yarris, Nina Reeves, and they've talked about, um, the OASIS. So that's probably been something you've discussed. That [00:24:00]  was a huge game changer in stuttering, right? To be able to document the life impact. So Scott and I are working on the, applying that to cluttering to have the OASIS SEC. So that's something down the line.  Ana Paula Mumy:  That's exciting. So just a follow up question in terms of, um, are there other misconceptions that you would say play into? Whether it be like the parents understanding of cluttering or even the SLP's understanding of cluttering, like, what are some other things that maybe get in the way of our ability to approach it with maybe more understanding? Kathleen Scaler-Scott:  Yes. Okay, great question. Um, I feel like from all of these sides, there's things that if we could kind of get rid of the misinformation, it would help a lot. So just even from. The SLP perspective in terms of what's been out there in the universe, right, that may [00:25:00]  confuse them in diagnosis. One is what we covered, like, that you don't have to speak faster than average, you just sound fast. But also, this keeps coming up. You don't have to clutter all of the time, and you're not going to clutter every time you open your mouth. And I think we know that. We've learned that in stuttering. Like, just because a person doesn't stutter during your evaluation doesn't mean they're not a person who stutters. In cluttering, I still find a lot of times people are like, yeah, but he didn't clutter during the evaluation. I didn't hear anything. And I'm like, that's because it's situational, just like stuttering. So, I've only worked with very small number of people who their, their rate of speech was rapid, like all the time. Um, or rapid sounding. So that's one, it's situational. Um, the other, we talked about like life impact, that there's not, there is. and [00:26:00]  can be a life impact. With awareness, there are some people who clutter who are not aware, but many are aware, but they just might not have a name for it, but they're aware they're having challenges, or they're aware they're getting feedback that someone doesn't understand them. And also, sometimes people are aware that they clutter. But our research shows they're not aware in the moment that they clutter. So, like, those are some of the things that I think make it challenging when people look to make a diagnosis. They're like, but are they a clutterer because they don't do it all the time? Yes, they could be. Um, And then from, I guess, even the parent side, and this is probably something that we really just have to do so much more education about, is we experience this in all kinds of things, right? Articulation, other things like, okay, [00:27:00]  if you give them more exercises, eventually, this is just going to resolve. And we don't have any research to support, like even in stuttering, how we have rates of recovery at different ages. Maybe we just don't know enough in cluttering, but we don't have any reports of spontaneous recovery in cluttering. And so what we think is that this could always be a tendency for someone and so it's something that they just kind of learn to manage. Like, hey, this is a tendency that I have and when it's important to me, I might make a These changes to my speech just to make sure that my message doesn't get lost, but it's not something that. Usually goes away or I don't even want to say it that, that bluntly, but like more like it's just something that, [00:28:00]  um, they're probably always going to be on a cluttering journey. They're always going to have to just monitor when they want, um, like something that they always have to think about, but not that you can magically fix. And not that it's so easy for them to just change their speech and monitor their speech all the time, just like we know that in stuttering, like, that's exhausting to have to think about your speech all the time, same in cluttering, so I think that's something to really educate parents about, for sure. Kate Grandbois:  I'm wondering about The prevalence. Is this a, is this something that happened? I'm, you know, I'm reflecting on my own experience in this field. I went to graduate school in 2005. It was an eternity ago. And I, no one even mentioned this to me. And I had a great stuttering professor. Um, I love, um, and I'm sorry, Ahmed, if you did [00:29:00]  mention it and I'm just completely forgotten, but it doesn't matter in my, in my experience as a clinician, this is not something I've ever encountered. I'd never heard of it. Or maybe I had and I didn't know what it was. Is it, is it that there, the definitions are, you mentioned 2011 as a, as a timeframe when things kind of started to solidify, right? I'm wondering if this is. a low incident issue or if it is higher than we think and we just don't maybe have the tools to clearly identify it. Kathleen Scaler-Scott:  I think it's probably a little bit of both and I think the research is still emerging. Um, I know that Like we always kind of said, and this was just anecdotal, like there's not, there wasn't enough known and here, like even just to take a step back because cluttering was such a big open definition, the old research would [00:30:00]  say this study had eight people who clutter diagnosed by a fluency specialist. So what criteria did they use? You know, like everyone could have been using different criteria. Were they cluttering? Did they have something else going on? Did they have both? You know, so it was a little bit messy. So now it's better defined in the research going forward. Um, but it used to be just focused on anecdotal and we used to say, like, for every. Um, I think it was for every three people who stutter, maybe two might also clutter, but let me just tell you, that just gets really messy, in my opinion. And now, like, even some of the characteristics of stuttering, like a part word repetition, an easy whole word repetition. I'm finding many people who clutter have that, but they don't report the same things as people who stutter. So, like [00:31:00]  now, sometimes I question all these people that we said were clutter stutterers, did we just not understand? Um, you know, that there are some things that might be unique to cluttering. I think the latest Incidents reports in their small studies are like maybe it's some of them say anywhere between less than 1 percent to maybe 2%, but again, I feel like it's based on very small samples. So I feel like there's so much more we need to know before we get good hard facts on that. But I guess what I would say in general is I feel that cluttering is more common than we think. You know, so because you can find it going along with a lot of times with other things. It does not have to. There are people who just clutter, but you can find it [00:32:00]  like I identified it in my dissertation and is a very small sample once again. but more in children with autism spectrum disorder. But it doesn't work in reverse where, oh, if you clutter, you definitely have autism spectrum or you definitely have ADHD. But I've seen it more in kids with learning differences, kids with autism. So we just have to be aware that it could be there, you know, Ana Paula Mumy:  can you talk a little bit more about, um, just when it does co occur with settering, you know, what are the things that you see, um, because of course that muddies the water even more, right? It's already a little bit confusing. It's already, um, sometimes inadequate, um, coming to these conclusions or that differential diagnosis piece. So what have you seen when it does co occur?  Kathleen Scaler-Scott:  Yeah, yeah, those are great questions. Um, I'm just like, thinking about when it does co occur, I'm thinking about some of my clients I'm working with, like teens and [00:33:00]  adults. And so what I'm often seeing is that if it's co occurring, then I'm seeing some of those symptoms that we talked about in the cluttering. Typically, the stuttering, when they're describing stuttering, they're experiencing the stuttering blocks. So, a lot of times if there's just There's cluttering and that's kind of predominantly what's going on that's having the life impact for the client, you know, just, um, intelligibility, getting their message across so that others understand them. Um, then you're, you might also hear, like I said, some of those part word repetitions, whole word repetitions, but. You know, first of all, a lot of times in stuttering, those might be things that we say, Hey, let's, you know, do you want to do anything about that? Or do you want to just let it go? Um, and in cluttering, like a lot of times, [00:34:00]  When that happens, um, I have seen cluttering is like the only thing in speech pathology where if you regulate your rate, because we believe that a speaker is speaking at a rate that's too fast for their system to handle, that's why they might not be faster than average. They're too fast for their system. So that results in the communication breakdown. So, if we want to make the cluttering symptoms disappear, we just have someone regulate their rate, and usually they disappear. If you have dysarthria, you can slow down, but your speech still will not, like, normalize, quote unquote normalize, like it would in cluttering. So a lot of times what I find is if someone is cluttering, but let's say they have these other things that might be like a part word repetitions, whole word repetitions, but very easy, no tension or struggle. [00:35:00]  Um, and I'm asking them about blocks and getting stuck and some of the things that people who stutter experience, and they're saying, no, no, no, I don't experience that, and I have them regulate their rate, they just go away. Now, I know that can happen in stuttering too, um, but it just makes me think that, okay. If there's stuttering here, it might not be something we have to address, but when we do usually address it is they're reporting blocks like people who stutter experience where it's like, I can't move forward. I have all this tension and struggle. I know exactly what I want to say, but I can't get that word out. I feel like in my experience, that's the more common. What I'm saying when they both co occur,  Ana Paula Mumy:  so would this be a good time to talk about, you know, how, how do you address it in terms of, you know, how, how do you, um, handle one, I guess, maybe starting with the rate component. And then there is that feeling of being [00:36:00]  stuck and just not knowing how to move forward. Yeah.  Kathleen Scaler-Scott:  And I will say that I'm, I'm a very pragmatic person. Like I just have a very pragmatic, functional approach to how I treat things. So I always get the question, what about DAF to slow down? What about a pacing board? What about, you know, anything like tapping out the syllables? You can do those. They will help a person pace, but in my experience, like they don't transfer over. So my whole goal in treatment. Is first to just kind of normalize what I call the communication breakdowns that occur in cluttering. And I feel like that helps break the defensiveness in the teens and the kids who might be resistant, you know, and maybe they're just not ready yet, but sometimes they are ready, but they're really defensive because they've gotten all this feedback like, Oh, I can't understand anything you're [00:37:00]  saying. Like, you just have to slow down. And, you know, um, So we talk about how everybody has breakdowns and it has communication breakdowns and if you look around you'll see sometimes someone says a word and they're like, you know, a lot of times kids would go, like, Oh, that didn't come out right, you know, um, or you say something to, you know, Your significant other and they're like, wait, well, I didn't hear that. And so you have to say it louder or slower or something, right? So we talk about how everyone has communication breakdowns and then we talk about, we don't say everyone clutters, but we say everyone has communication breakdowns and sometimes they might happen more often for you and that could be frustrating. But we talk about, okay, if your rate of speech is Well, I don't want to just tell you to slow down because you're going to be really [00:38:00]  annoyed. That's easier said than done, but we do have some research, just a teeny bit that helps us. We, um, know that clutters don't pause as much as your average speaker. So, if we teach them to put natural pauses in their speech, you know, where you would expect them, then that helps them. regulate their rate in a more natural way. And so that's one thing that I do to help regulate rate. And it's just teaching them what we all do in our speech. And they may not do as much. Um, and some clutterers don't necessarily, like, know the places to put the pauses. Like, I worked with a gentleman who said he didn't know that he cluttered. But he knew that people weren't understanding him and someone said to him one time, you know, you go really fast. You should pause. [00:39:00]  But then he's like I would just put pauses. I didn't know I didn't know where to put them. And so he said then people would go what's wrong with you? Like, like the pauses would sound awkward and when we taught him he's like Wow, this is so simple. It makes such a difference, but like it wasn't intuitive for him to know where to put the pauses. I'll say some cluttering clients, it's, it is intuitive, but they just don't do it. So that's one way to regulate rate. Then your client could be putting in those pauses, but then they could be talking really fast in between the pauses. So there you're still hearing like the, Yup. Mumbled sounding speech, so then I was like, okay, well, what is the functional everyday solution? If I was talking to my spouse and he was like, what? What was that word you said? Right? I would say, I said information. So I would emphasize it a little more, but not in a [00:40:00]  crazy robotic way like information or tap it out or anything. I just emphasize my sounds a little more. So we talk, I talk with my clients about emphasis if they, if they need it, if the pausing is not enough and everybody has Words like some of my words are unusually, I really have to slow down to motor program unusually and teaching research message methods, statistically significant, like everyone has those words that can be tricky. So like we learn about those and just be aware of those words. Um, so I do kind of natural things in that way.  Ana Paula Mumy:  Yeah, that's great.  Kate Grandbois:  I'm not one of my words is advertisement. I can't say it no matter, no matter how many times. Um, I really appreciate that you talk about the concept [00:41:00]  of normalizing the communication breakdowns. I mean, just from having interviewed Nina and Scott and several, several of our other stuttering specialists, this is, you know, something we're clearly embracing as a field as part of the stuttering community. So it's very logical that we would map. that on to our treatment with stuttering. Uh, I wonder if you could talk to us a little bit about the lived experiences. So as part of your podcast, you interview individuals who clutter. And I'm wondering if you can tell us a little bit about Um, what important takeaways you've learned, uh, obviously this conversation can't replace the actual lived experience of a person who clutters. And we actually have an interview scheduled for later in the season, um, with a person who clutters, which we can link to in the show notes as well. But What, what have you learned as a clinician that are important takeaways from those lived experiences that we can share?  Kathleen Scaler-Scott:  Yeah, um, so much [00:42:00]  But I'll try to unpack just a few. One huge piece is that everyone's journey is different. And I know maybe people would say, Well, of course it is, but I don't know if it's intuitive to people to think that way, you know, so we, um, kind of get into the habit of like, Okay, this is this is what applies to stuttering. And sometimes I've seen it applied broadly to cluttering, and it's not always the same. And so we've interviewed some people who say, I want people to ask me to slow down adults, right? And that's not what we would expect as like a listener reaction. Um, we did a whole interview with leaders in the cluttering community, and that's a perspectives article that. Would be available to people. We could probably link that as well. That's where they talked about some of the differences for them. But, you know, [00:43:00]  some people say, I want you to tell me to slow down. Other people are like, No, I do not want you to tell me that, you know, so. Everyone's kind of got different lived experiences. Some people like to use strategies and monitor their speech. Some people don't. A lot of people pick the situations that are important to them. And they talk about that. Um, they also, um, one common theme among the people we've interviewed is just the fact that Many people are aware. It's really just busting a lot of the myths that we talked about that. Yes, I am aware But there's other things too where they talk about disclosure Right, and so in stuttering there's a lot of talk about disclosing stuttering and some people who clutter have said I disclose But I don't use the word clutter and it's [00:44:00]  because there's Misconception and people as soon as they hear the word cluttering they think hoarding so like their story after story I never would have thought of that but that makes perfect And watch for it. Eventually, I think there's going to be a movement. The last person on our podcast, episode 15, talks about making a movement for this, but she's not the first to say it about making a movement to change the, the. Word cluttering to something else, but they'll say, I don't tell people like clutter. Like somebody might say, Hey, I stutter. You know, they just say, sometimes I talk fast. And if you can't understand me, please ask me to repeat and like all these things. I'm like, yeah, that's kind of brilliant. Right? You're still disclosing. You're still advocating for the feedback that you want or the response that you want from your listeners. But is it's not important that you do it. You know, say the term. Now I do have a teen, a [00:45:00]  young man, who he will educate the entire world about cluttering. And he's like, hey, I clutter and this is what it means. And I also stutter and this is what it means, you know, but everybody's different. So, yeah, but life impact is there. Caregivers talk about impact. They talk about misunderstanding from teachers.  Ana Paula Mumy:  Do you find that a lot of the, um, lived experiences that have been reported, at least, you know, through your podcast, um, have there been a lot of individuals that were misdiagnosed early on or that were, Um, you know, where stuttering was suspected and there just was that misdiagnosis piece and maybe how their journey changed over time, you know, just when they finally got a correct diagnosis, like, what does that look like? For some of the people we've worked with. Yeah,  Kathleen Scaler-Scott:  yeah, for sure. People reported, like, once they finally got an accurate diagnosis, they're like, wow, this makes sense. That's [00:46:00]  what it is. And that's definitely a common theme. Because of all the confusion with the definition in the past, um, Yeah, so they, many report kind of a sense of relief and a sense of, okay, yeah, like almost validation of what's going on. Kate Grandbois:  For anyone listening who is now reflecting on their own caseloads and thinking, oh my goodness, I think so and so might be a clutterer, or oh my goodness, I wonder if I've been treating this as X, but it's really Y. What other resources, so you've mentioned your podcast, we have hyperlinks to your books and show notes. What other resources or words of advice would you have for a clinician who is kind of having that first light bulb moment or understanding this conceptually a little bit deeper for the first time? Kathleen Scaler-Scott:  Yeah, I mean, first of all, yeah, every time I give a [00:47:00]  presentation on clutter and people come up to me afterwards and say, I think I missed this one. Like now looking back, I think I missed this one. I probably say don't beat yourself up because it was so confusing, but just know it going forward or if you have someone now that you can, you know, kind of work out the diagnosis with and, um, Yeah. Some of the like resources that you mentioned, like the fluency plus book will help with diagnosis. Um, because I've kind of got like a step by step in that. Um, so that's a resource. Um, I love, love. Rucker Wilhelm's website, Too Fast for Words. He's the author of Too Fast for Words. I get no royalties. I say this at every talk, like I get no royalties for this book, but I find the book so valuable that I recommend it to my clients, to SLPs. Um, it's called Too Fast for Words. Um, but he [00:48:00]  talks about, um. The impact, but like getting to what people could do about diagnosis, one of the things I think is also confusing out there and I encounter it with my students, they go out onto the internet and they're like, Okay, I'm Oh, Dr. Scott, I found a video on cluttering. And I don't know who is posted it. You know, it's the wild, wild west. And I'm like, No. It's not cluttering. Like, at least there, what I'm seeing is not an example that fits the definition. Um, but on Too Fast for Words, they have lots of good examples of legitimately cluttering. So, like, if you just want, like, a video example, that's there. But do keep in mind, everyone is different. You know, in terms of their presentation, some people have more of the overcore articulation. Some people have more of the atypical pauses. Some people have more of the, um, excessive. Uh, non stutter dysfluency. So everyone won't [00:49:00]  look the same, but just maybe by reviewing some of those videos and different resources, it might be able to help you. And you can always reach out if you have questions, too.  Ana Paula Mumy:  You also want to talk about the Fluency Bank resources, um, for cluttering? Oh, yes, yes.  Kathleen Scaler-Scott:  Yes, because the fluency bank, um, I know has some examples of cluttering, um, for if people want to use in class, but then also may be some. videos and things of people who clutter. So that might be another resource to use as well. If you just really feel like, I feel like people are always itching to get, I need, I need to see that video. And it's been hard, I think, throughout the years with our presentations, because you don't, a lot of the people we work with are our kids and like parents weren't always [00:50:00]  reluctant to. Or sometimes we're a little reluctant to put things out there, you know, so there's not, so those are some resources and Annapolis, they're open, but I feel like they're kind of more secure in a way, right? You may know more about that.  Ana Paula Mumy:  We have to register, but I think as long as you go through the registration process, it is free. Um, I find that it's really helpful because like you mentioned, you know, it is variable. And so you almost have to, you know, calibrate your ear to hear that cluttered speech versus stuttered speech. Right. And just kind of, you know, hearing this. And I think it's just nice to hear those different examples. I think there's audio and video there. So. You do have to register, but I don't know that they would ever, like, deny someone unless you have a legitimate reason to, you know, request that. Right. Um, so that's a really nice, um, way [00:51:00]  to just, um, hear what it might sound like. Right, right.  Kathleen Scaler-Scott:  Right. And it's nice because it adds that extra layer. And of course, those are all legitimate samples too. So great place to go. Yeah.  Ana Paula Mumy:  Yeah. I don't know that there are any, I know, um, there are both child and adult, um, videos and audios for stuttering. I don't know about children. Samples for clubbing, I  Kathleen Scaler-Scott:  know on too fast for words, there's at least a teen, you know, and I think, I think as the field is evolving, we'll start to see more stuff out there. I'm hoping, you know, people are coming forward and even like with the podcast, wanting to share their stories. Um, so hopefully we'll see more and more of it.  Ana Paula Mumy:  Can I plug one that you haven't mentioned? Yeah. Just, uh, one of the Asha Leader live articles that you [00:52:00]  wrote. The one, um, called Debunking Myths about. Yes. Thank you . And I just, I found, um, that to be so helpful and I just like how you really go through the myths and talk about. Um, and how we can address them as barriers and how that might impact, you know, you look at centering and, or excuse me, cluttering and understand it. And then also kind of just the, the, the counter of overcoming those barriers and just how to approach, um, making some changes in how we. Um, look at it and how we understand it. And so that's a, a great one that was really a huge help for me.  Kathleen Scaler-Scott:  Yeah. Yeah. Thank you. Kate knows from our previous conversation, I forget. Oh yeah, wait, there's that too.  Kate Grandbois:  Well, I'm sitting here frantically taking notes. So the only thing I was going to say earlier was that, you know, you've listed so many great resources here and I have just been frantically taking notes the whole time. Binding links, all of this will be [00:53:00]  listed in the show notes. So anybody who's driving, walking, folding laundry, what have you, all of those will be written down, um, in our, in, you know, in, in the show notes, as I mentioned, I'm wondering if there are any other, you know, really important takeaways that you would like to share for, for anyone listening, whether they're, you know, new to this field or, um, or otherwise. Thanks, guys.  Kathleen Scaler-Scott:  So I would say if you're seeking information, you know, one of the things is that it's out there and it's there more and more and more. There's the International Cluttering Association website, but there's also for lived experience, there's a Cluttering Facebook group. I think it's called cluttering speech. I should know these things, but I told Kate like all the ideas swim around in my head. Um, but I think it's called cluttering speech that was started by Sister Carol Mary Nolan. She's amazing. [00:54:00]  So she's a person who clutters and she was the one who kind of moved. The field forward, in my opinion, when she started that Facebook group, because that just started getting stories out there more and more in discussions among people, clutter, SLPs, parents. Um, so, you know, if you're looking for resources. It's kind of like, you know, people are like, well, there's not much out there. Like, and years ago, that was true. But I'm telling you, you just need to look for it. There's all kinds of resources out there for you now. If we have any faculty who happen to be listening, we also put together, my students and I, students previewed a bunch of different resources. Um, to help them learn about cluttering and they rated them. So like if you're thinking, what do I put in my cluttering curriculum? If you're teaching it, that's going to be at ASHA. We'll have that, but I'll [00:55:00]  send the link also to Kate as well. It's just. Um, a link to a living document that we're going to continue to update, but it's like a resource for you to know, oh, there's all these other things out here too that I can access. So just look for it. Look for our presentations at ASHA and elsewhere and, um, it's there and we're going to keep pushing it forward.  Ana Paula Mumy:  So let's talk a little bit about assessment and differential diagnosis, because I know that's a difficult thing at times, especially like we've already mentioned when there is a lot of misinformation and we don't have a whole lot of, uh, training background in stuttering and or cluttering and, um. And we've talked about the muddied waters and all of that. So if you could just talk a little bit about how you approach assessments. Um, are there like favorite tools that you use in terms of, um, [00:56:00]  actual, you know, assessments, um, whether they be, um, more, you know, uh, list or survey type or just what, what do you use when you are, um, approaching an assessment?  Kathleen Scaler-Scott:  Yes, um, for assessment, I really do stick to first just looking for, is there cluttered speech, right? So someone might have other diagnoses as well with cluttering. They may or may not, but I kind of just zone in on just focusing on the speech. And there's a reason for that, because with all the big wide definition and misinformation in the past, people would just get themselves so confused. And they might call something that might be, say, a symptom you might experience in autism as cluttering, right? So I I have just found the LCD definition so helpful. So I really just go through it step by step and I say, okay, right now I'm just [00:57:00]  focusing on does this person check the boxes for cluttering? So I, you know, talk to caregivers, significant others, the person themselves, have they gotten feedback that their speech is rapid? Do they feel their speech is rapid? Does it sound rapid to me? And if it checks that box, Then I'm doing more just kind of, um, samples, like getting a monologue sample. from them just to talk about topics they're passionate about, they know a lot about, those tend to bring about more cluttering symptoms. Um, and through that sample that I'm looking to see, because remember it's like a perceptual definition, so do I feel like There's examples of over coarticulation, right? Are there examples of excessive non stutter disfluencies that make maybe them, you know, lots of revisions where they're having a hard time [00:58:00]  getting their point across efficiently? Or I'll analyze the sample for like, are there a lot of atypical pauses and look at that. But keeping in mind that just because they don't clutter with me, they still make clutter, you know, I go by. Kind of what I see there, but then I also go by their report, a parent report, a teacher report, you know, and look for patterns, obviously, not just one person who says I can never understand them and everyone else doesn't report it. But, you know, to give you an example, I had a clutterer I worked with and he, um, He reported that he had overcore articulation, never heard it till well into when we were working together and the situation brought it about. He, we worked more on the non stuttered dysfluencies because he had a hard time expressing himself efficiently, but I still believed him that the other symptoms were [00:59:00]  there. So then in terms of like differential diagnosis, what you have to think about are with those three symptoms. What else could be causing them? So if it's overcoarticulation and the speech sounds mushy or mumbled, we have to rule out an articulation disorder, a phonological process disorder. Is there anything going on with even like a dysarthria? You know, just making sure we rule out that that's not what's resulting in the overcoarticulated speech. And then the non stutter disfluencies get even more tricky because we need to really figure out. Could a person have excessive non stutter disfluencies because they're avoiding stuttering, right? So is that they could stutter and clutter, but why is that happening? Do they have a language disorder or do they speak more than one language and they're just trying to find words? So like we have to [01:00:00]  consider all of those factors too. Like I just think about those three symptoms and I think about what else could be causing those symptoms that's not related to, um, when they get going too fast for their system to handle. And then that helps me try to rule out, is this just cluttering? Is it something else? Is it cluttering and something else? Or is it something else all together? And I feel like one thing for people to know with this, too, is I feel like, especially when you're trying to tease apart stuttering and cluttering, and there may be some avoidance, some fear, um, things like that, it may take time to work with the client and just really asking for their feedback. Like, hey, do you ever have times when you change words and, you know, having conversations with them ongoing? Sometimes you don't figure it all out right. In the evaluation. It's an ongoing journey. [01:01:00]   Ana Paula Mumy:  Can you, I know you mentioned that there's no percentage when it comes to the excessive disfluencies. Um, how do you determine what's excessive? Like, how, what are you looking for when there's not maybe that, you know, percentage. Um, or a threshold that is maybe standard.  Kathleen Scaler-Scott:  Right. And I'll say I used to say, well, you know, we don't have the research yet for the percentage, but I do think that, and I think Dr. St. Louis put this bug in my ear, but I don't want to put words in his mouth that, you know, everyone may be a little different too, in terms of what's, you know, their percentage. But, um, what I do is, yeah. Just think about is the person, you know, and I might ask for feedback from significant others or from them themselves, um, is it that they are, um, it's taking them [01:02:00]  longer to get to their point. And not because motorically they can't, but just formulation wise they can't. And to give you an example, one of the clients I worked with, I asked them to tell me something that happened to them over the weekend. They told me, and I was early on working with them, and I let it go, 23 minutes to tell me this story. And I said, Um, okay, I just want to summarize back for you to make sure I got your story and I summarized it in about two minutes and he looked at me and said, how did you do that? And now he can do it. And that's a very extreme example. So I don't think like all of your clients are going to be that inefficient. But it's that where you just feel like, I get your message, but I feel like you could communicate it more efficiently and not because of you can't get the words out, but because you, you're having a hard time formulating the idea [01:03:00]  efficiently. Ana Paula Mumy:  Yeah, that makes a lot of sense. And in terms of impact, what are you using to determine impact?  Kathleen Scaler-Scott:  That, thank you, because I meant to say that before. Um, in terms of impact in my evaluation, until we officially get the OASIC rolling, what I'm using now is more just really interviewing the client than any significant others and saying, how do you feel about your speech? Thank you very much. How do you feel it's going? And then also asking about, excuse me, how do you feel about others responses to your speech? So sometimes what you'll get at with school age kids and teens is They feel fine about their speech, they're not worried about it, but what really makes them mad is when people tell them to slow down or tell them they talk too fast. So, I feel like [01:04:00]  that gets at some of the life impact at their stage, you know? So, it's really just more asking them how they feel about it, how's it going, how they feel about others reactions, and exploring that, and that is like an ongoing conversation as well.  Ana Paula Mumy:  Do you find that there's, uh, communication apprehension like we do with people who stutter where they're, um, anticipating, um, whether it's a small group discussion or something, um, and there is that apprehension to participate or to voice their, um, thoughts or ideas? Is that common in cluttering as well?  Kathleen Scaler-Scott:  Yes, thank you for bringing that up. I mean, for some, it might not be, but absolutely, for many others, they'll talk about, you know, I really want to tell that joke, but nobody ever understands my jokes when I deliver them, or I've had clients who say, [01:05:00]  I just keep it short. Because I'm, I'm safer that way. So they're not really expressing themselves what they really want to express. And they are just kind of holding back because they're apprehensive about the reaction  Ana Paula Mumy:  or how it will be  Kathleen Scaler-Scott:  received. Yeah.  Ana Paula Mumy:  Have you ever used the personal report of communication apprehension as a tool with? Kathleen Scaler-Scott:  I have not. I need to look into that. Well, I'm going to put it in the  Ana Paula Mumy:  show notes. I'm going to Google  Kate Grandbois:  it.  Kathleen Scaler-Scott:  Thank you. What is it, Ana Paula?  Ana Paula Mumy:  It's called the Personal Report of Communication Apprehension, and I've used it. It's a, I forget now how many items there are, but it just talks about how or asks Um, and then it asks, uh, questions related to how they approach, um, a small group discussion or one on one conversation, and there's just different parameters, and then it gives you the score, which it's very, you know, subjective, but it just, for me, has been helpful to just get the conversation started about, are you [01:06:00]  experiencing any apprehension as you're going through the process? Um, communication, um, uh, exchanges or interactions with others. And so it's just sometimes it's just a nice, um, conversational, uh, just a starting point, right? To, to talk about this, um, and, and how they might be avoiding or like you said, saying less. Um, because they're concerned or something like that. So that's one that maybe could be used for cluttering as well. I haven't used it, um, for that, but I'm thinking to myself, as you were talking, I'm like, maybe I could.  Kathleen Scaler-Scott:  Yes, it sounds like it. I'll be checking that out. Thank you.  Kate Grandbois:  And I've Googled it. It looks like it's it looks like it's a free PDF. It is. Oh, we will have the link in the show notes. Excellent. I so appreciate your time. I have learned so much. I started this conversation, uh, wildly unprepared and uninformed. So I, I really feel like you've done such a wonderful job explaining the rough edges of what this is, but [01:07:00]  also what action steps we can take, what resources are available. Um, we so appreciate your time. In our last minute, do you have any final words of wisdom that you would like to leave our audience with? Kathleen Scaler-Scott:  Please just never stop looking for information on cluttering. Never stop learning. It's out there. When I first learned about cluttering was I had a little boy in my first job that I didn't learn about it in grad school either. I was like, what is this? It's not stuttering. And I found an old article and, you know, from there it went on, but you're getting so many more resources. So please keep looking. You're never too late to stop learning.  Kate Grandbois:  I love that message. That's a very nerdcast friendly message. That's wonderful. Well, thank you so much for being here. We're really grateful for your time and we're, we're all, we are all, we are all smarter for it.  Kathleen Scaler-Scott:  Thank you for having me.  Kate Grandbois:  Thank you. [01:08:00]  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

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 with a guest who is going to discuss congenital heart disease, which is something that we've never really talked about on this podcast before. So we're very excited to welcome [00:02:00]  Nashifa Hudamomen. Welcome, Nashifa. Hi, guys. Nashifa Hooda Momin:  It's a pleasure to be on with you guys. Yeah, we're excited for this conversation. And Nashifa, you're here to discuss feeding. infants with congenital heart disease. But before we get started, can you please tell us a little bit about yourself for our guests who might not know you? Yeah, absolutely. Um, so my name is Nushita. As you guys mentioned, I've been a practicing speech language pathologist for about 11 years. I currently work in an acute inpatient, um, children's hospital and work primarily with pediatric feeding and swallowing and pediatric dysphagia. And my passion is working with infants with congenital heart disease, um, specifically infants with single ventricle physiology. Um, and I am wrapping up my doctorate this month. Um, we'll be actually graduating this upcoming August and, uh, speech language pathology from MGH Institute of Health Professions and outside of the speech bubble, I like to read. Listen to podcast, um, a [00:03:00]  run, uh, and really just hang out with my kiddo. Um, she's five. So it's a lot of fun times right now with her. That is so exciting. Congratulations in advance. So we're recording this episode in the summer of 2024. And by the time our listeners are listening to this, it may be some, maybe winter out. We're not sure. But, that's really exciting about the doctorate, so congratulations. Kate Grandbois:  Or we talk about all of the good stuff. I'm going to go ahead and read our learning objectives and disclosures, and then we will learn everything about a topic that I genuinely don't know anything about, which is always the most fun. All right, here we go. Learning objective number one, identify three common feeding problems observed in infants with congenital heart disease. Learning objective number two, describe at least three medical considerations that directly impact feeding in infants with congenital heart disease. And learning objective number three, describe at least two feeding strategies utilized in therapy to enhance oral feeding skills , for [00:04:00]  infants with congenital heart disease. Disclosures, Neshifa's financial disclosures, Neshifa is an employee of Children's Healthcare of Atlanta. Neshifa received an honorarium for participating in this course. Neshifa's non financial disclosures, Neshifa has no non financial relationships to disclose. Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children.  Amy Wonkka:  Amy's financial disclosures, that's me. Uh, 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 in Special Interest Group 12, and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, Ms. Shiva, maybe before we even get into the first learning objective, could you just give us a little bit of background on typical heart function? Nashifa Hooda Momin:  Yeah, absolutely. I think that's a great place to start [00:05:00]  off. Um, so let's talk about what the components of a heart. The heart is composed of four chambers. We have the left atrium, the right atrium, the left ventricle, and the right ventricle. And then there are also four valves, which are the aortic valve, the mitral valve, the pulmonary valve, and the tricuspid valve. So overall, what's happening is that the right side receives deoxygenated blood from our superior inferior vena cava. And that pumps it to from the right side of the heart to the lungs to then get oxygenated. And then that brings it back to the left side of the heart. And then that goes up to our aorta to then be pumped out to the rest of the body. That's in the most simplistic terms of what is happening to our blood. Um, and then But I do think if we want to talk about more specifics, I like to like walk through like what the blood if I was a drop of blood, where would I go? It's something that I always talk about. So if you had blood that was entering the body, um, and you need it to get oxygenated, the blood is going to go towards the heart from, like I mentioned, the superior [00:06:00]  inferior vena cava. and it enters into the right atrium. And from there, it's deoxygenated blood. It then goes through the tricuspid valve to the right ventricle, and then from the right ventricle, it goes into the pulmonary valve into the lungs. And like I mentioned, that's where the blood then gets oxygenated. So then the blood then returns from the, to the left side of the heart through the pulmonary veins and goes to the left atrium through the mitral valve to the left ventricle. And then from the left ventricle, it goes through the aortic valve to the aorta and then it's pumped out to the body and that's oxygenated blood going to the rest of the body. So that's normal heart physiology. And then I feel like it's also important to talk about fetal circulation because that's different. Um, and the reason that's different is the oxygenated blood that the fetus is getting in the mom is all oxygenated. There is no process of Deoxygenated to oxygenated. It's oxygenated blood is coming from the mom and it's going to the fetus. And that [00:07:00]  happens through the process of three fetal shunts. Um, and so during fetal circulation, all the oxygen, the nutrients from the mother's blood are transferred across the placenta to the fetus. Also, I think it's important to note that when a baby is in utero, the baby's lungs are mostly fluid filled, so the blood is not going to want to go in the direction of the lungs, especially when it's when they're in utero, because there's a lot of pressure and a lot of times you'll hear this referred to as pulmonary vascular resistance. So the three fetal shunts. The fetus that the fetus relies on in utero are the ductus venosus, the foramen ovale, and the ductus arteriosus. So now let's talk about blood flow in utero, right? So you have the ductus venosus and what happens is that that branches off near the liver and goes straight to the inferior vena cava and then sends that oxygenated blood, remember it's going to be oxygenated, to the right atrium. So from there it's a little different because the blood can in two ways, right? So [00:08:00]  Like I mentioned with normal cardiac physiology, we're kind of going from the right side, going to the lungs, and then coming to the left side, and then being pumped out. But here, what it can do is it can cross from the right atrium straight to the left atrium through, um, the second fetal shunt, which is called the foramen ovale. And remember, it's oxygenated. Our goal is really just to get that oxygenated blood everywhere in, in, um, the fetus, right? So that's the second fetal shunt. The second way is kind of the typical way we were talking about, which is going from the right side to the right atrium, down to the right ventricle, and then up through the pulmonary artery. And there's another fetal shunt. called the ductus arteriosus. And remember how I mentioned that the lungs are very fluid filled, right? So if I was a drop of blood, I don't want to go in that direction. I'm going to do anything I can to find a different route. And so a lot of times what happens is from the pulmonary artery, it'll go up through the ductus arteriosus straight to the aorta and then be pumped out to the rest of the body. So that's kind of how fetal [00:09:00]  circulation works. And the reason I think it's important to talk about this is because when we talk about congenital heart disease, These fetal shunts are so important for a fetus, um, because once the baby's umbilical cord gets clamped, the baby is no longer getting that oxygenation and nutrients from the mother, and that's when things start to change, right? So that's when our lungs expand, um, the alveoli in our lungs are clear to fluid, there's an increase in the baby's blood pressure, and there's a significant decrease in those pulmonary pressures, which then causes, um, um, which then usually results in the closure of the foramen ovale as well as the ductus arteriosus. Again, like the ductus arteriosus can take a bit to close, but all of that changes in pressure, changes in pressure will usually cause these to close. And then if you have an infant with congenital heart disease, that's when it really starts to put pressure on to how are we going to manage that. Pulmonary and systemic flow for these patients, especially are critical congenital heart disease. So that's just a [00:10:00]  brief introduction. I always like to start with blood flow because I think physiology is extremely important. And if you can understand general physiology, it helps us better understand, um, what's going on and why clinically they present the way that they do and how we as providers can provide strategies to support them. Kate Grandbois:  So yeah, I love that you said that that was a brief review. I, every time I talk to you, I am so astounded by how much, you know, I'm also astounded by the fact that we have the same degree that you're a speech pathologist, because this is very complex. I mean, I think as a field, maybe we get a little bit of this background knowledge in graduate school. I really appreciated that refresher of I haven't used the word, you know, I haven't looked at the chambers of the heart in I don't even know how many years so that was really, really helpful. I have a question, just because I want to make sure everybody has a solid understanding of what the anatomy and physiology is here. When you say a shunt, [00:11:00]  can you describe what that is?  Nashifa Hooda Momin:  Yeah, so it's essentially like the almost like with the direction of flow, um, I think that's the best way to explain it. So, shunts can be two things. So shunts can be like the direction the blood is being shunted from the right to the left side. The blood is shunted to from the left to the right, right side, but they can also be a shunt that you're actually placing to help make the blood go in a specific direction. Kate Grandbois:  Okay, that was that that was that definitely answers my question. So thank you. And then I also want to, you know, say this back to you to make sure I've understood some of the basic fundamentals here. So we have, um, Uh, typical anatomy and physiology of blood flow or of the heart and blood flow in adulthood. And then we have this in utero experience that is significantly different from post clamping of the umbilical cord. And that's kind of the big, that's where the show begins. I assume for these, for these little babies. Okay. Now that we've, now that I have my bearings and I apologize to anyone in the audience who already, who already knows all of these things,  Nashifa Hooda Momin:  I [00:12:00]  do not. I think it's great. That's kind of what makes our field so fun, right? That we can all do so many different things with our degree.  Kate Grandbois:  Very true. Okay. So now that we have a solid understanding of the basic anatomy and physiology here, what is the, once that, once the baby's, uh, once the umbilical cord is clamped and things start to change, what happens next when something is not going well? Nashifa Hooda Momin:  Right. So, um, that, that's a great question. So depending on the type of diagnosis, like you will, that's going to depend on the intervention. So if you have a patient, like I mentioned, that has critical congenital heart disease at our institution, we are not a birthing hospital, but the patient, That's being delivered at an outside hospital will then be immediately transferred over to our facility and then there's going to be usually just generally there's going to be an echo where the patient's likely going to be in prostaglandins. So [00:13:00]  prostaglandins are a way to keep the ductus arteriosus open to then help that balance of that pulmonary and systolic. Um, so there's going to be a lot of interventions that will happen, especially if you're an infant with critical congenital heart disease. Now, if you're an infant with, um, and we'll talk a little bit about this. I'll kind of define what congenital heart disease is. But, um, when you say you have a patient that has like an a cyanotic defect, they're generally doing okay. That patient may be okay to go home and be followed closely with the cardiologist until they're ready for their intervention if they need a surgical intervention. So we can go, um, okay. In different ways, depending on the critical severity of the congenital heart defect.  Kate Grandbois:  Okay, and so this brings me to my next question, which is, what is congenital heart disease? You already mentioned we were going to talk about that. And on top of that, when that, you know, do we know ahead of time in uniro, that a baby has congenital heart disease? Like, what is the, what's the [00:14:00]  sequence there, and what is it? That's  Nashifa Hooda Momin:  it. Love it. Okay. So congenital heart disease is any type of structural abnormality in the heart that's present at birth. And these defects can widely vary in their severity and their impact on heart function. So remember we talked about the four chambers and the four valves. If anything is underdeveloped or if there is potentially like we will like to refer to it as like a hole between the two atriums or between the two ventricles, it's going to impact the way the blood is going to flow. And that's going to, that's going to be your defect, right? So that is a general explanation of what congenital heart disease is. And um, yeah. Interestingly, it's one of the most prevalent, um, type of anomaly that we see in, in, in, in terms of congenital malformations, which is super interesting. And then it impacts one in 120 babies born in the United States. So it's pretty common. Um, but in terms of your question of like, what is what happens, right? So you get the, how do you get this diagnosis? When do you get this diagnosis? So yeah, usually around 20 weeks when you go for [00:15:00]  your 20 week ultrasound. Um, it could be diagnosed at that time, at which point they may notice that there is something, um, different, uh, in terms of normal physiology for the heart and they'll refer out to get more testing done. So you can get a prenatal diagnosis of congenital heart disease. There are times that. it can get missed completely and that can be, um, something that can happen because of potentially it, it got missed because it was a fluke, but it could also be because there wasn't great prenatal care, um, for the mother. So it is something that you can catch postnatally. A lot of times you'll clinically see this in the child, if it's especially a postnatal diagnosis, um, where we don't know, of course, prenatally and the patient is born clinically. There are going to be signs that the patient is in distress and they'll really quickly figure out that it is congenital heart disease. Um, but yeah, so it can be prenatal, postnatal, really both ways. [00:16:00]  And what causes it? So in the majority of the cases, there's no known cause. There are certain things that have been shown to increase the chances of having congenital heart disease, like a family history of congenital heart disease, genetics, environmental factors, or a combination of all. And, um, it, when we talk about congenital heart disease, it can really be broken into two different categories. It's the easy, I think it's the easiest way to really understand that you have a cyanotic defects and cyanotic defects. And I've kind of talked a little bit about that, but an a cyanotic defect is when you have too much blood going to the lungs. Meaning that you have a so remember, let's talk through that physiology like we talked about. So you have the blood that goes from the right side of the heart and makes it to the left side of the heart. Um, and say that there's a hole between the two atriums, um, or between the two ventricles, the blood that's oxygenated then goes back to the right side of the heart to then get re oxygenated. So what we like to call it, that is left ventricle. to [00:17:00]  right shunting, right? So that blood that was already oxygenated has gone back to the right side to then go back through the system again. So clinically, this patient is going to have a lot of endurance issues. They're going to show clinically, they're going to show work of breathing there. And clinically, as a speech language pathologist, our interventions are going to be based around that. So that's an a cyanotic defect. And cyanotic defect. Um, there's also so cyanotic defect. There's also there's decreased blood to the lungs. And the reason is because what's happening is that the blood is going from the right to the left side, meaning that it's not all getting oxygenated. And these are the babies when we look at their oxygen saturations. Prior to any interventions, they're not going to be at 100%, right? They're going to be at 75 or 80, 85, somewhere around there. Again, this is going to depend on the type of cyanotic lesion that they have. Um, and we like to refer to this as right to left shunting and some examples. Um, you'll see this a lot, um, In the [00:18:00]  literature, and just in when you're talking about congenital heart disease, we talk about the five T's, and there's more than the five T's of cyanotic lesions, but um, there's truncus arteriosus, there's transposition of the great arteries, there's um, tricuspid valve abnormalities, tetralogy of fallot, and then TAPBR, total anomalous pulmonary venous return. But that is kind of the two different types of congenital heart disease.  Amy Wonkka:  And you mentioned that if you have one of these cyanotic injuries, you may see oxygen levels like in the seventies. Can you remind us what is normal? What should we be seeing? If we're seeing something  Nashifa Hooda Momin:  in the seventies, we should be at a hundred. So imagine when we go to our doctor's office, you know, when they put the, um, the little. on and then they look at the rhythm. So that's supposed to be at a hundred percent or they'll put the little sticker on around your finger to check, but it should be at a hundred percent. So that's a real big difference. Yeah. And so remember when we were talking about the fetal [00:19:00]  circulation, so during, um, uterine utero, what's happening is that foramen O'Valley and that ductus arteriosus are bypassing the bypassing those pathways. But once they close after birth, that's when these complications start to really pop up for critical infant with critical congenital heart disease. Um, so at that, that's why, that's why we have to try to optimize keeping that ductus arteriosus open so that we can balance that circulation. We're getting, we're getting blood to our lungs, but we're also getting blood systemically, um, until the patient has their type of intervention.  Amy Wonkka:  So this is something that's affecting the whole baby, you know, I mean, the oxygen level across their entire body, their entire system, what are important things for us to be thinking about if you're working in an environment like that? What are things that you need to be thinking about if you have a patient like this  Nashifa Hooda Momin:  going on? Absolutely. So when we're thinking about working with this population as a speech language pathologist, I think it's important for us to think outside of the box. I think that, you know, we can sit there [00:20:00]  and treat the symptoms as it goes. But like I mentioned, I really think it comes down to physiology and really understanding what's going on to the patient. fully to then be able to provide the specific interventions that they need. So again, I am giving a very inpatient acute lens because that's where I work. We'll talk a little bit about outpatient as well. Um, but in my head and I, I like to break it down into four categories. I like to think about post surgical complications, airway considerations, GI considerations, and comorbidities. And those are all medical things, but they really truly impact oral feeding success. So when we talk about post surgical considerations, many of these infants, um, after they have any type of intervention, they're going to be on sedation and pain medications. And this can cause nausea, constipation, drowsiness, and that can impact oral feeding. So a great example is think back to when you had a procedure or any, or know somebody that had a procedure or surgery, think about how. they felt or [00:21:00]  you felt weaning off medication and it can make you feel really out of it and nauseous and I obviously can't say we're 100 percent that's exactly how a baby feels but it's a consideration you don't feel great right um and and then when you have a speech language pathologist that comes Right right after they have surgery and they're nauseous. We have to make sure that we're not just like giving them a recommendation and that is the single recommendation. We have to remember that it's that this their journey is going to be very variable. It's going to change. They're going to feel better soon and then we need to be very adaptable and our assessments need to be ongoing because oral feeding is going to be changing very rapidly or especially post operatively. And then we also may see withdrawal symptoms, um, this can be in response to the medications that they have. Some infants are more sensitive to this if they've had in utero drug exposure. Clinically, these patients may, we may see tachycardia, tachypnea, hypertension, irritability, tremors, decreased alertness, and all of that is going to play a role on our clinical assessment for feeding, right? So [00:22:00]  making sure that we're adaptable and knowing that our plans are going to be consistently changing. Um, chylosuffusion is another post op consideration or chylothorax. Um, and what that is, it's a buildup of fluid in the space around the lungs, um, in the chest cavity. And this happens because of injury with. To the thoracic duct, um, and this results in the buildup of Kyle in the plural space. And this is a Kyle is a fluid that's made by your intestines when you eat that. Um, so the reason why am I even talking about this? It's because if a patient has a, um, a Kyla suffusion or Kylo thorax, they're going to be recommended to be put on a low fat or nonfat diet. So imagine a patient maybe who'd been orally feeding with breast milk or formula who then now has this complication. They have to be on this low fat, non fat diet. So that could be the introduction of formulas like Toler X or Infopor, which are okay, but for a patient that's been having yummy, delicious formula or breast milk, and then you're [00:23:00]  introducing this new formula, it's not as palatable, and that has definitely impacted oral feeding success. On the other hand, I have seen patients completely chug a full bottle of Toler X, but it is just another consideration that we have to be thinking about. Um, And then there's also a high risk of stroke, hypoxic brain injury, cardiac arrest, secondary to any type of medical intervention. We know that when we're thinking about, um, the physiology, there are a lot of neurological complications we see after cardiac surgery or after cardiopulmonary bypass. So that's the first category.  Kate Grandbois:  Um, yeah, I know you have other categories that you want to walk through, but I just have a quick sidebar question. I'm thinking about my experience feeding my own children, what I know about infant development and how important fat is. And how important from a nutritional standpoint, so I know we are not nutritionists, but in this moment, when you have a baby who is now having a, you know, a nonfat diet recommendation or other feeding specifications that [00:24:00]  could impact their nutrition, how much of that is a balance and how closely are you working with nutritionists and pediatricians to make sure that they're getting the nutrients that they need for development? Nashifa Hooda Momin:  Absolutely. So I will say that the diet is temporary. It's not, um, something they'll be stuck on for a whole year and nutritionists, um, are so critical. So just to kind of give you a little layout of how our teams are set up, especially in the ICU setting, we have the physician, we have a nurse practitioner, you have maybe an advanced practice, um, advanced practice practitioner. I think that's APP. Um, and then a nutritionist there, a pharmacist there that are, you know, All rounding on every single patient every single day, and that similar model is also there in our step down unit. Um, and so I, like, it is a huge consideration because we are watching their weight game very, very closely. I will say that it's usually temporary and, um, You know, pediatricians or cardiologists that they get discharged to are also kind of keeping an eye on it. I [00:25:00]  think the big thing is making sure that that Kyle stops building up. And once we, that resolves, then you can kind of resume back to your normal diet. Yeah, that's helpful. Um, so the second category that I wanted to talk about is airway and respiratory considerations. Some of our kids will require prolonged intubation. Um, and that can place a lot of strain on the vocal folds. We may see this after extubation. So usually I'll be able to assess this with vocal quality. Um, if especially If I've seen the patient preoperatively and done feeding with them preoperatively and I see them postoperatively, operatively, and I can usually be like, wow, their voice doesn't sound like their baseline. A lot of times their caregivers are great about saying, no, they're definitely not as loud as they used to be, um, you know, picking up on if they have, obviously, if they're crying and they're not vocalizing, then we know there's some aphonia. Um, dysphonia and hoarseness, really assessing that, so that can be a consideration. Another thing is that infants that are super [00:26:00]  critical may end up, um, in a situation where they may require ECMO, which is extracorporeal, extracorporeal membrane oxygenation. And for our cardiac patients, we usually use VA ECMO, um, but it's a temporary solution to offload the heart and the lungs. Um, but we have also seen that ECMO can, we've seen right sided vocal fold paralysis, and I think that has to do with the placement of the catheters for ECMO, so that's another consideration we have to be thinking about, especially when we're doing our clinical assessments and working with oral feeding. And speaking about vocal paralysis, a lot of our infants with congenital heart disease will, especially the ones that have surgeries near their aorta, like a PDA, um, and Norwood and aortic arch surgeries, they all have a really high risk of recurrent laryngeal nerve damage, um, and that is going to impact vocal paralysis. Vocal fold, you know, closure and can cause vocal fold paresis or paralysis. Um, so that's another consideration. And just to kind of review the recurrent laryngeal nerve, um, it [00:27:00]  supplies most of the intrinsic muscles of the larynx. It functions for speaking, breathing, and the opening of the vocal fold. So if an injured, we're going to see that vocal fold paresis and paralysis. And again, clinically, what I'm going to be looking at is this patient is, has dysphonia or aphonia. They may have some stridor. Um, or and then that's going to put them all at an increased risk for aspiration. So definitely a lot of airway considerations. There's a few more. Um, so phrenic nerve damage is another thing that can happen. Uh, the phrenic nerve originates around cervical vertebrae four, um, and it goes over the heart. And if there's any type of damage post operatively, sometimes we'll see these kids where their respiratory rates are really high. So say, You already have an infant that, um, preoperatively, their respiratory rate was in the 70s, which is high. Um, and then postoperatively, their respiratory rate's in the hun in the hundreds. And just to kind of put that into perspective, that's like per minute. So imagine, like, 70 breaths per minute, now bumped up to 100. And you're asking them [00:28:00]  to take an oral, like, orally feed. Like, take a bottle. It's a lot. to do right in terms of coordination. It's really hard to coordinate your sex while breathe coordination when you're breathing that fast. And so in that particular population, these kids may require a diaphragm implication, which is another type of intervention that they'll have to do to help kind of help with that phrenic nerve damage that could have happened with surgery. Um, other considerations are subglottic stenosis. This was something that I, um, came across recently, maybe It's not as common, but it's something that popped up for one of our cardiac patients, and it's interesting because this is something that, you know, you may not even be thinking about, but it's a patient that like, for example, they get extubated, and they're actually doing well, going along in their post op course, and then they start to get worse with their feeding. They have Schrader, you're noticing that, Um, they're more noisy. They're having more signs of aspiration, almost where you would have seen more improvement. Um, and so this happened with one of the patients that I was working with and we [00:29:00]  ended up doing a fees on the patient and noticing that there was subclotic stenosis. And so then they had to go to the OR for a dilation. But again, it's something that you would, it's in our head that like after surgery, we're only going in the pathway of improvement, but as speech language pathologists, especially in this type of setting, You just kind of have to be on your feet and being able to read and advocate for your patients and knowing that, hey, this is, this doesn't sound right, um, because you get so close to your patients. And then finally thinking about respiratory support. So that is something that a lot of our patients are going to need. And so think about an infant who is on five or six liters of high flow. Um, and then you're again, like the same concept, you're requiring, you're asking him to take a bottle of water. when they're already have this baseline work of breathing and then they have all this extra flow that there's no research to say like, hey, you can't feed babies on five liters or less or five liters or more, six liters or more. But like, you have to look at the infant as a whole, right? If they are. are really to Kipnick [00:30:00]  and you're asking him to take a bottle without strategies or, or with strategies, like the plan is going to be very dynamic in the sense for that baby. So those are some airway considerations.  Kate Grandbois:  There are so many considerations. There are so many considerations and the whole time you're talking, I'm thinking this is a tiny little person. Yeah, I know.  Amy Wonkka:  Well, and it's, it sounds like it's, it's just, it's a lot, it's a lot of problem solving in a very fluid, in what can be a very fluid environment, right? So you're thinking about so many different variables. I know you had mentioned gastrointestinal considerations. That's like a system, a system we haven't gotten to yet. What are some of the gastrointestinal considerations?  Nashifa Hooda Momin:  Absolutely. So there's, um, there's a, you have to think about reflux. Um, obviously a lot of our babies have reflux. Some are symptomatic, some are not. There has been some literature to show that infants with CHD do have a higher percentage of having reflux. Um, another consideration is necrotizing intercolitis. Um, so necrotizing intercolitis has been a little bit more prevalent in infants with congenital heart [00:31:00]  disease. More specifically, um, Our single ventricle population. Um, so again, just in the reason we talk about these things, why is this important? Why does it relate to oral feeding? If you are having issues GI wise, it's going to be hard to push through oral feeding. And if you're not addressing these issues, you're kind of going to be dealing with another slew of issues, like. oral aversion in the long run, right? So like being able to clinically look at your patient and see that they're having signs of reflux is something that you need to be pick, you pick up on and tell the team so then we can adjust medications or adjust strategies, whatever needs to happen, right? But if you power through with oral feeding, then the patient's eventually going to clinically not be interested to eat. And then you're going to have another issue. Um, and then finally comorbidities. So how do existing comorbidities impact the patients? Um, we know that there are underlying genetic syndromes like Trisomy 21, Kabuki, Turner's, DeGeorge, that are often seen with CHD, and we also know [00:32:00]  that they Um, and so, um, you know, with baby can impact feeding. We see, like, poor muscle tone with them. Oral motor dysfunction, structural abnormalities. And so with an infant with CHD, it just adds, like, another layer of complexity to oral feeding. Um, some other comorbidities are cleft palate, trach and bent, tracheal malaysia, laryngomalasia, vascular rings, vocal fold paralysis, um, and again, there can even be congenital subglottic stenosis. So it's, it's something that, you know, We have to also be putting into the picture. I almost like to think about it as a formula. It's not a formula, but like there's a lot of things you have to think about to make a feeding plan for a particular patient.  Kate Grandbois:  I have another question and I know you have some, you're giving us so much. important information. I am, I'm, I'm just, again, I, every time I talk to you, I'm kind of floored by how fluently all of this comes out of your mouth because it's so much information and it's so helpful. And I have a question that is a little bit of a sidestep and maybe we'll get to this in more detail and you can, you can push it off, but. [00:33:00]  Yeah. As you're talking about comorbidities, I'm thinking about the parents. I'm thinking about, you know, they've, they've just had a baby. Maybe they knew ahead of time that there were going to be some genetic issues. Maybe they didn't. Maybe they knew they were going to, there was going to be a congenital heart disease. issue. Maybe they didn't, but there's so many professionals involved. There's so much triaging. There's so much coordination. It sounds like you're, you know, just constantly trying to put out fires is, is, is what, depending on, on what's going on with the kiddo. And at what point do you have a conversation with the family and really put your counseling hat on to feel, see how they feel about what to do? component of this is more or less urgent or, you know, long term implications for some of these things. This just feels like a very complex issue where counseling would really have to be at the forefront of all this. Is that a, is that a reasonable assessment? [00:34:00]   Nashifa Hooda Momin:  Huge. Yeah, absolutely. So a lot of things I think in this, in this career or in this, um, job that I've been in, I guess for a while now, one, the importance of learning how to effectively communicate with the team and that multi, we talked about multidisciplinary, interdisciplinary, Transciplinary like buzzwords all the time, but truly how important it is to have this conversations with the team to come up with a plan that's very patient centered, but in terms of counseling with caregivers, it is at the forefront. So when we're meeting caregivers, sometimes. Um, if it's a baby, like I mentioned with critical congenital heart disease, they may be transferred over to our hospital and there may or may not be a caregiver on the first assessment because a lot of times we are consulted immediately when they're admitted for babies under three months. But as the minute we meet the caregivers, it is, hey, we are speech language pathology. Most of the time they're like, well, my baby's not ready to speak right now. Um, and then, you know, kind of explaining what the role is that we're [00:35:00]  here to really work on feeding and swallowing and What we're anticipating. What are common complications? How are they feeling? What have they done? How is a lot of it? It's also even like, Hey, how mom are you pumping? Is that how's that going? And what can we get for you and, and advocating for them as well as like a unit, um, and then providing that education. And the great thing is because we are consulted preoperatively, we've established those relationships. very, very early on and then follow them through the surgery and then follow them through step down. Um, and then make sure that we plug them in right into outpatient. We have a rehab, um, outpatient case manager who helps them, plugs, plugs our cardiac patients right into outpatient therapy. So there is a lot of, um, Treating the patient and assessing the patient. But it's like, like you said, you have to have your counseling head on at all times when you're interacting with caregivers. Um, and I will say, thinking kind of about long term implications. I think that I will say that [00:36:00]  I've. I've learned that you never know, and I'm kind of on that boat of, hey, by the time they get to step down, I'll have a general idea of kind of what the next steps are going to outpatient, but it's hard for me to meet a baby on day one and know what's going to happen, so I'm usually very transparent on, hey, like, Let's take this one step at a time. These are kind of my goals for, for your baby. Um, and, but I also want to hear what you're thinking and, you know, what, what your goals are, um, for feeding, because I think that's important to understand, especially when we're thinking about breastfeeding and, and how that can be sometimes challenging for an infant with multiple lines and, um, you know, just the complexity of where they are, but listening to that. So then you can advocate again to the team that this is kind of what the caregiver is thinking. I hope that answered that question.  Kate Grandbois:  It did. And I appreciate you. I appreciate you taking a second to hold space for that only because it just, again, it just feels like such a complex work environment, a complex baby, a complex patient, you know, [00:37:00]  family dynamics. So I, I appreciate you answering that question. All right. Let's talk about the feeding part. Yeah. What? Okay. So why? Why? How is feeding related to all of this? I don't know. It seems like a dumb question. There's so much going on.  Nashifa Hooda Momin:  There's so much going on. Um, so outside of all these considerations, now you have all of this to think about. These infants are going to have an increased cardiopulmonary load, which is going to result in decreased endurance. So they're going to be very easily fatigued. So that cardiac output that they have is insufficient to meet the metabolic and energy demands of the body, especially. Especially when it is related to oral feeding. So oftentimes, what we see as their clinical presentation, we'll see, um, I mean, depending on the age of the infant, we may see poor state control. And the reason I'm even mentioning that is, remember that they're already, they already are very easily fatigued. And then imagine how that impacts their state control, especially as a newborn infant. Um, they are going to have baseline tachypnea with reduced baseline saturations, [00:38:00]  especially if you're a cyanotic. Maybe you're going to see that poor coordination of oral feeds again because of that underlying tachypnea, underlying fatigue issues. You may see oral aversion. That oral aversion can happen for various reasons. It could be the fact that this patient was intubated for two, three weeks, we have to be thinking about, like, how long they had that endotracheal tube between their vocal folds. And then, and then now, we're gonna come on and try to be like, hey, let's take a pacifier, hey, let's take a bottle. And it's a lot of negative excitement. and we're trying to like add the oral feeding component. It could also be, oral aversion can be because the patient has a, is a single ventricle baby and they have poor blood flow to their gut and that's gonna result in feeding intolerance. So every time they eat, they may throw up, because we're trying to figure out that nice balance of what they can tolerate. And so then now they've associated every time that I get food in my belly I throw up and I don't want to eat so That can be a reason for oral aversion. They may have decreased hunger cues because they're on continuous feeds because of that poor feeding intolerance. We just [00:39:00]  talked about, um, also dysphagia. Dysphagia is extremely, extremely prevalent with this population. Um, to kind of take it back to literature, there was a study done in 2022 by Nirwana et al, um, and they looked at 374 patients retrospectively. Um, and I encourage you guys to read it. It's a great paper, but really they found that 70 60 percent of these patients had oral dysphagia and 64 percent had pharyngeal dysphagia. And there are specifics in terms of like aspiration and silent aspiration and vocal fold involvement. And so like, it's a dysphagia is extremely prevalent with this population, which obviously explains why speech was so involved. Um, but, What are we thinking about as speech language pathologists with these diagnoses? We have to be thinking about the patient clinically. So again, we come to bedside, and if they have increased work of breathing, then we're working with our skills to give them the strategies to help kind of work around that work of breathing while also orally feeding. Um, but say if they're a cyanotic baby, they may still have that work of breathing, but in our heads, we also have to be [00:40:00]  thinking about, okay, so they're cyanotic, How is the blood flow going to their gut? Do I need to be kind of thinking about that, depending on their physiology? Okay, what about their brain? Are they getting great blood flow to their brain? These are the things that I like, like to be thinking about, even though they may not be at the forefront of our treatment, um, because long term we're going to be thinking about this, right? So like, again, like advocating for, educating our caregivers, but advocating for the patient and then also thinking about next steps, right? Um, And like to kind of think about that blood flow that that might be blood flow to the brain thinking about neurodevelopmental delays down the line.  So as SLPs, other things, other common strategies that we think with this population is what position are we going to use to feed them, right? Cause these are, most of the time I'm working with infants, um, nipple selection and then the use of pacing, right? So babies under three months, I think my go to is elevated sideline. My preemie flow nipple, like a Dr. Brown preemie nipple or, um, an extra [00:41:00]  slow flow nipple and then offering pacing, meaning. Offering a breath between, because remember, these are babies that are going to be potentially feeding for the first time, especially if it's a newborn, and they may not have that successful abrief coordination, and then you're kind of supporting there, but also that underlying CHD where they already have endurance issues and fatigue issues, so offering pacing for that. And then a huge, huge part of, uh, speech language pathology with feeding is making sure that the bait feeding is very cue based, meaning I, I feel like sometimes, um, it feels. You know, when a baby can't speak, right? But the way that they communicate is through cues, right? And I think there's so much you can get from, um, feeding a baby with their cues, with the way they move their hands, with the way they move their, um, with the way they make grimace and like, you know, Have gaze aversion or have stopped feeding and changes in vitals. I think there's so much going on in a feeding that is not with words, but you can pick up on. And as a speech language pathologist, it's a dialogue, right? So as a feeder, I'm watching those cues, and I'm [00:42:00]  adjusting my strategies to make sure that I'm supporting the feed. And then really empowering our caregivers to do the same. So yeah, that's a little bit about like, what yeah. What is feeding with this particular population and what a speech therapist may do with this particular population? Um, yeah.  Amy Wonkka:  What if PO feeding is not appropriate at that time? Like, how, how are you making those determinations? How, how are you working with the team to help identify some indicators that might be telling you, Hey, Not quite ready for this just  Nashifa Hooda Momin:  yet. That's a great question. Um, and so as our role, it's, um, important for us to look at those cues that we talked about and then seeing, Hey, can I offer strategy? And if that strategy doesn't work, then really knowing when to stop. And then, like you said, advocating for them to say, Hey, like that, we may not be ready because of X, Y, Z. And oftentimes what all often see is like breathing difficulties, meaning that. Maybe, um, their respiratory rate is in the [00:43:00]  90s or 100s, and they're really not even with strategies and everything that I'm trying. It's just not going well, and I'm seeing a lot of stress signs. They may have decreased alertness where they're not even participating. They may be medically unstable. For example, that could be, um, Changes in color. I might see like a desaturation event while I'm PO feeding or signs like I'm like I feed them and they're gagging and hiccuping and turning away and pulling back and shutting down gaze aversion like I mentioned, or they're extremely disorganized despite all the strategies. Another one that I have seen is like fingers playing where they're going to try to stop and put the stop sign up. Um, so what is again? What does all that mean? We have to stop. We have to support Um, and advocate for their needs promoting safe feeding so we can prevent long term issues down the line long term issues like over time. Um, so, yeah, those are some of the strategies.  Kate Grandbois:  And how does that conversation go with the family, especially for maybe moms who really want to [00:44:00]  have that skin to skin breastfeeding time? You know, there are so many emotional components to feeding your child. I have to imagine that if you are seeing signs of distress or any signs that PO is not an option at the moment, that could be a really difficult conversation to have. Nashifa Hooda Momin:  Yeah, absolutely. And I think that that does come up quite a bit. Um, and I, one thing that we promote a lot of is non nutritive breastfeeding, as long as the infant is stable and not showing signs of stress with that. And what I mean by non nutritive breastfeeding is if the mom is interested, um, Having her pump prior, putting the patient to skin to skin and then eventually to breast to really just work on those oral skills, um, and have that bonding time with mom and the infant. And again, it really just depends on the infant. So if the infant is showing signs of stress, if the infant is showing medical instability, I think like, hey, like, what if we just do skin to skin, right? We don't even have to do non nutritive breastfeeding. Let's do skin to skin. Um, and it is, it is a little bit of a culture change too, [00:45:00]  right? Because I feel like. A lot of times our focus can be very hyper focused on the medical things and so kind of taking that step back like you mentioned and really seeing where we are, what we can do what we can control and a lot of times when we can't control, we can still promote that bonding experience and and do the skin to skin and. Give room for that. So yeah, it's again a very much like you've mentioned It's very counseling very reading the room reading the situation and promoting and advocating for your patient And it's interesting because I do feel like that's one perk of being a rehab therapist PTOT or speech is that you really get to know these families, um in a different level and understand kind of what the dynamics are of that family and Provide that insight to the medical team and, and our medical teams are fantastic and have been so supportive and, um, are 100 percent like on board to support, like make sure that care is very patient centered  Kate Grandbois:   [00:46:00]  now. So what happens next for these families?  Nashifa Hooda Momin:  Oh, outpatient, right? So let's so there I know I'm more inpatient, but I do, you know, interact with a lot of our outpatient providers and, um, and it's an important factor and these patients come back and we're always in constant communication, like I've talked about, but when these patients get discharged, we have to think about where that patient is at that current time. Okay, so, okay. One thing is, like, I always come kind of back to, like, where, where is the patient? Are they repaired or are they unrepaired, right? So you may have a patient that is Let's just say it had a prenatal diagnosis. They come to the hospital. Let's say it's a cyanotic defect, like Tetralogy of Flow. Clinically, they're doing well. The medical team decides, hey, you know, the patient is stable and we can send the patient home. And then we'll, that patient will follow up with cardiologists. And then when they're will kind of determine their plan for surgical intervention when they're a little bit older, because [00:47:00]  again, sometimes we know that literature has showed that a baby when they're bigger and healthier, um, and have kind of some more meat on them, they're going to do well, right? With surgery. So sometimes that's the option, right? So these patients may go to outpatient therapy and clinically, these patients are going to be unrepaired. So they might have that baseline worker, breathing, working really hard. And in fact, that might actually get them Get worse as they get ready, getting ready to need the surgery. And so as a speech therapist, it's going to be more like, Hey, I need to provide strategy. So the patient may come in and say they're using a level one nipple, and they're feeding in sideline. They're not really using pacing. It takes them 20 minutes to feed. They're doing fantastic. Okay, well, week three, they come in and you notice that the patient's actually really struggling. They're pulling, they're tugging. Okay. Okay, let's kind of go down to a newborn nipple or a preemie nipple and offer some strategies, maybe a 10 minute rest, like a break at 10 minutes, give him a rest break and then start over again, maybe adapting the plan. And it can even be that the, and this has happened in the past where [00:48:00]  the outpatient speech therapist is the one that reaches out to the cardiologist. And it's like, hey, this patient is not finishing their feeds. They're really tugging. They're really not doing well. And then they get followed up. And usually right around that time is when they need that surgical intervention. So it really is a lot of communication and being in that setting, knowing that, hey, this patient is struggling and we need to advocate and do something about it. On the other side, you may have a patient who's repaired, right? So the patient comes in, say this is a, um, a, a cyanotic defect. We were talking about a cyanotic defect before, but, um, they come in, say they're a. BSD. Um, and they have their, initially they had endurance issues. They worked in the inpatient, had some strategies. They get to outpatient. And this is the kid that might actually do great. And this is the patient when you might be like moving up along the totem pole, right? You might be making their, maybe their nipple was at preemie. You're going to go to a level one. Maybe they'll go from elevated sideline to cradled upright. And we're kind of moving them along the process of like, Hey, like. Let's get [00:49:00]  them fully orally feeding if they aren't already and supporting the caregivers as they need them. So those are kind of the two things that I feel like generally we're thinking about as they get to outpatient. Um, but one of the major challenges that I hear, um, is the, How, navigating recommendations from various providers, so, you know, say the patient, an inpatient had, um, we found that the patient had vocal fold paralysis, so ENT was following them, and say they were discharged with an, with an NG tube, so you have GI following them, um, and then you have cardiologists, then you have the pediatrician, and then you have the speech language pathologist, right, or, or OT, PT, whoever is involved. Say the patient comes to, so, therapy, and as a speech language pathologist, I feel like I'm ready to push them, but I'm not sure, and I can't really get in touch with everyone because I'm in my outpatient bubble, and it's hard to get, walk over, and just ask someone a question. So I feel like that's a really big challenge, is to kind of navigate these, Recommendations from the so many, many [00:50:00]  providers and then trying to see documentation and then making a plan and feeling confident about, Hey, can I make this plan on this particular patient? Because it seems a little complex. So I feel like that's a big challenge that I hear a lot, um, from a lot of our outpatient colleagues. Um, and I, I'm hoping that there's a better way at some point that we can, we can support these families. And instead of this, I feel like working in a little bit of a silo, even though we are multidisciplinary, but we are in our individual islands when we get to outpatient. Um, but yeah, but I feel like that's a big challenge. And then lastly, um, I kind of do think that, um, one of the big things that I, I, I want to kind of highlight is that even when we talk about repaired and unrepaired, we really have to be thinking longterm, right? So remember, we were talking about, you know, Cyanotic and like thinking about, um, blood flow, right? So how is the blood going to their gut? How is their blood going to their brain? And thinking about, like, long [00:51:00]  term implications. So even if you have a baby that's doing well, PO feeding, um, and say they have a cyanotic lesion, again, like, how are we making sure that they're plugged in to getting assessments and thinking about neurodevelopment and thinking about the long, um, term implications of that? So I think that's another outpatient thing that we, I mean, I think it's an inpatient and outpatient consideration, but it's something that we all need to be thinking about. So I feel like those are some things that come up when I think about outpatient.  Amy Wonkka:  Yeah, just monitoring for those referrals to early intervention when they need to be made. I wonder if you can bring us back just thinking about the infants and the families who you're working with. Um, what are some of the, some of the helpful things that you have learned in your time in this position?  Nashifa Hooda Momin:  Yeah, so I will have to say that, um, My lens changed quite a bit when I became a mom myself, and I think realizing how it's much more [00:52:00]  than just a b c d. These are the things that we're going to do. This is how, um, feeding works in this inpatient setting all the way to outpatient. It's really, um, as kind of Kate mentioned, thinking about the family and putting them in the center of the care, right? So, um, one of the things that I feel like that I have learned is Being being more mindful about the recommendations I'm making. So, for example, making sure that the plans are feasible for our families, um, thinking about what are their social determinants of health, thinking about health equity, thinking about what are the logistics of going home, like, um, one thing that came up was a we had a family recently that had nine Children, and we were recommending, um, thickening for this particular population. The mom was not at bedside. So yes, the patient needs thickening. But how do how do I make sure that this is going to be a feasible plan? Right? Will they have the resources? So really, getting that time to talk with mom and seeing like, [00:53:00]  Hey, what can I do to make this work? And will this work? Because what's the point of making a recommendation if we're just if it's not going to work? So I think that's been one of the biggest things that's changed is to think about feasibility. Um, yeah. And really take a minute to understand what the caregiver's goals are themselves. Um, so that's been a huge, I feel like, change. For me, um, that I am, and I think I still have a lot to learn and a lot to grow on, but that's been something that I've been really trying to focus on more recently. Kate Grandbois:  I also have to assume that cultural competency comes into a play quite often as well in terms of cultural expectations for a, you know, for the postpartum period for the mother. I mean, there's just, there are so many layers to this population that I can't imagine Cultural competency not also being a consistent consideration as you're making recommendations, engaging in [00:54:00]  counseling, all of those kinds of things. Nashifa Hooda Momin:  Absolutely. I think that, um, and that's, that's another, uh, big factor is this was like years ago where we had a family wanting to really focus on breastfeeding, um, and, um, Making sure that the plan was around that because culturally that was what was going to work and it wasn't even it was culturable. It also came down to resources and kind of their where they were and how the feasibility how they could do things in their current setting. So I think realizing that, hey, I can't keep recommending a bottle to you if that's just not going to work. And that's not culturally what you've done where you've come from, right? So I think taking that into consideration is huge. Um, so yeah, I, again, like very learning one of the biggest things that I've learned. Um, and that's been more at the center of my attention, I think, has been thinking about putting the patient at the center and making sure that plans are feasible, making sure we have caregiver buy in. And we talk so much about this when [00:55:00]  we talk about adults, right? Like we're like, Carryover. Like, how are we going to make sure the adults have carryover? But for our kids, it's the parents, right? Like, it's, how are we going to make sure carryover happens? It's getting that buy in from the caregiver. Um, and so I think that's, that's been huge. Amy Wonkka:  This is sort of a tangential question, not super related, but I was just curious, how often, I know you mentioned in the case of the, of the patient who you've had, who had the subglottic stenosis, that you did a fees. Um, how often are you using imaging? To help aid in your choices that you're making as far as like, maybe whether a baby is going to be PO or not, or, you know, what, what  Nashifa Hooda Momin:  some of your strategies might be. Yeah. That's a great question. So the two types of instrumentals that we can do are, um, fiber, uh, sorry, fiber optic endoscopic evaluation of swallowing, which is a fees. And we can also do swallow studies, um, video fluoroscopic swallow studies, um, and both of those, I feel like it's interesting. I like to, I will do a swallow [00:56:00]  study when I. need to get more information. So clinic, so the thing is when you have a patient that's post op in my head also, I feel like they're recovering, right? They're recovering. They were intubated. Um, and so if I can clinically assess and I see clinical signs of aspiration, I don't know for me, if I would jump to a swallow study right away, but if I'm answering a question, so for example, The patient is fully PO feeding post operatively, no clinical signs of aspiration, but they're there every time they eat, they're having changes in their vitals to me. I'd be like, okay, hey, let's get down to fluoro and find out, am I missing something? Or is this something related to their physiology? What's going on? Let's, let's get more information. So I feel like that's kind of when I would want to do a swastika again, it's variable and I think it's patient specific, but that's a good example. Um, A fees is also extremely helpful because, um, so for that patient that we talked about with the subglottic stenosis, we did do a swallow study. And the swallow study, what, there was no penetration, no aspiration. And it was so [00:57:00]  alarming to myself and other, um, colleagues because clinically we were hearing Strider and clinically we saw signs of aspiration. So we were all floored. Um, and then when we ended up doing the fees. To get that different view, it was, like, we didn't even get to the fees because the minute that the ENT passed the scope, we immediately saw the subglottic stenosis and immediately they were like, this patient's going to need to go to the OR and, you know, um, next steps from there. But I think that I like to, I think it's like, where, how will these tools help guide my plan? Right? So I don't want to, and that's another big consideration is like, when we think about Swallow Studies, it is thinking about radiation. So like, if I'm just doing a Swallow Study just to check a box, that's not, that's not the best for the patient. So where can I add this in to clinical care that's going to help me change my clinical plan? Um, That's kind of how I feel like our institution does it for both of those [00:58:00]  assessments.  Kate Grandbois:  And I think that, I mean, that sounds very much in line with our evidence based process for a lot of other things in the field. That was really helpful to hear. I wonder in our last few minutes, if you have any advice for our audience members listening who are maybe working in a hospital, working as a med SLP, working in feeding and swallowing, but not necessarily with infants or in NICU or with congenital heart disease. What advice do you have for those individuals who might be interested in getting into this field? Nashifa Hooda Momin:  I think that I would, I think when I first started, and one of the greatest things was just being able to learn and shadow, um, from all the SLPs that were in my area. So I think starting there, and if you don't have like an ICU or, um, an ICU setting, um, then I would try to see if you could potentially, one of the things that I've had other colleagues do is PRN, and if you're, if you're interested, just to kind of get your feet wet and [00:59:00]  learn what, um, Kind of an inpatient setting is and then, and really just gaining experiences and seeing and testing it yourself. I feel like a lot of times you just have to put yourself in that situation to see, hey, like, this is something that I thrive in. For me, it's a lot, and you probably can tell from our conversation today, I'm big on problem solving. Um, I, I like to look at all the pieces of the puzzle and come up with something. Um, and that to this kind of environment, I feel like is a great Good fit for me. And that's not to say that, you know, the same personality wouldn't be somewhere else. But when I, when I'm in the ICU setting with high stress, lots of moving parts, it works great for me. So I think that shadowing and putting yourself out there is one recommendation. And I think learning, I think like just constant learning is an, um, Putting educating yourself on different areas and topics like for me, I feel like when I first came into the field as a speech language pathologist, I didn't want to do peds. I was very actually pro adult neuro. That's where I started. And that's where I thought I would end. [01:00:00]  And I took my position here. And Again, cardiac was not even in my radar, and I trained in the pediatric setting, and I found myself kind of like inching towards cardiac over time, but I think that it's just that learning and exposure of different areas and different topics and different people and their expertise and kind of be a sponge and soak it all in, um, and I, I think that would be my advice is just keep yourself learning, um, and, and I'll say 11 years in, I'm still I like love to just, um, in the mornings when chart reviewing with colleagues, just to say like, Hey, like, what does this mean? Or what do you think this is? Or, um, and I, I just like, love to learn. I love to like, learn new things, which I feel like is, um, yeah, I think it's a great thing to do and a great. Right for SLP intercast.  Kate Grandbois:  Thank you so much for being here. This was just a true wealth of information. I know I've said it twice, but again, I'm just [01:01:00]  astounded with how really this information flows out of your brain. You're clearly an expert in this content area and we're so grateful for all the time you've spent with us. Um, we will put all of the references that you've given in the show notes for anyone who is listening while they are driving. folding laundry, what have you. Thank you again so much for being here Neshifa. Really, really wonderful.  Amy Wonkka:  Yeah, it was awesome. Thank you.  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 [01:02:00]  email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

[00:00:00]   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 and welcome to SLP Nerdcast. We are here today with a totally brand new, different kind of episode. For those of you who have been following along with us for a while, about six months ago, we announced the launch of [00:02:00]  something that we call SLPD On Demand, which is an opportunity for our members to write in. with their clinical questions and our resident doctor of speech language pathology, Dr. Annapala Moomy, is going to walk us through the case study. She's done a little bit of research to, um, basically answer your clinical questions. So welcome, Annapala. Why don't you start by telling our audience a little bit about yourself?  Ana Paula Mumy:  Follow me and a program director and associate professor at a small private university in East Texas. And I've also been in SLP for nearly 25 years. It seems crazy to say that, um, and I just love clinical work.  Kate Grandbois:  Well, we can tell because you always, I mean, I'm just looking at all of the research that you've done for this clinical problem. Uh, I'm really excited to get into it. Today's question comes to us from [00:03:00]  one of our members. Lauren P. Um, and B, the question in and of itself was related to childhood apraxia of speech and how that intersects with eligibility criteria in the schools. Um, so we're going to read the question, unpack everything, but before we get into that, I am going to read our learning objectives and disclosures. I will try and get through that quickly so we can launch right into the good stuff. Learning objective number one, list at least two potential adverse impacts on educational performance for children with apraxia of speech. And learning objective number two, Describe the role of specially designed instruction on dismissal criteria. Financial disclosures. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I am a member of ASHA SIG 12 and I serve on the AAC advisory [00:04:00]  group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Thank you. Ana Paula, how about your disclosures?  Ana Paula Mumy:  Yes, I received compensation from SLP Nerdcast for my work as ASHA CE Administrator and as the SLPD on demand. I'm also employed at East Texas Baptist University. In my non financial disclosures, I'm the co founder and president of Sparrow Stuttering. I'm a member of ASHA and TISHA, and I serve on TISHA's University Issues Committee. And I'm also a member of several special interest groups. with ASHA fluency and fluency disorders, issues in higher education, administration and supervision, and cultural and linguistic diversity.  Kate Grandbois:  Excellent. All right, well, why don't we start by Reading this clinical problem. So what did Lauren P have to say about one of her students and how can we help her?    [00:05:00]  Yes, so I'll first share the a little bit of information about the student She has a first grade student in an elementary setting who was diagnosed with Childhood apraxia of speech, and she does really well with, um, their target lists in blocked and distributed practice, and is demonstrating carryover of those words into conversation. Ana Paula Mumy:  And Lauren also says that Um, let's see, their difficulty is that they'll randomly come across curricular or random words that she'd like to be able to say, so they go back to working on sequencing them. Is there a better way to approach this, and how do I know when we're ready for discharge? Um, she's obviously always going to have apraxia, so at what point do we know that we can exit from therapy? And so here's her, um, more formal question that came from this little blurb here. Just when do I [00:06:00]  end treatment for students with childhood apraxia of speech that are intelligible but still have occasional difficulty with novel multi syllabic words? If they respond well to traditional CAS interventions and quickly are able to sequence the novel words with carryover, when do we say that our skills services are no longer needed? Kate Grandbois:  That's a great question, and I wouldn't even know where to begin finding that answer. So I know that you went to the literature to kind of figure out what the research says about that. Maybe we should start unpacking this clinical problem by leveling the playing field a little bit and talking about like what characteristics of childhood apraxia of speech are present that we then kind of need to work with. Go for it.  Ana Paula Mumy:  Sure. So I'm just going to start with a working definition of CAS, uh, which is essentially a motor speech disorder where children have difficulty learning and [00:07:00]  carrying out the complex sequenced movements that are necessary for intelligible speech. And when we think about speech, I was actually just, fun fact, I was looking at just some of the, um, information about speech movements, and I'm also teaching phonetics, and so this is really interesting to me, um, that speech movements meet some of the most exacting coordination demands of any human muscular system. So I think we know that intuitively, but just, you know, Good reminder, right? There's just a ton of coordination that's happening, not just the placement, right? But just that, um, coordination of movement. And so, that's really where children with apraxia of speech, um, break down, is being able to sequence those complex, uh, movements. And we'll see things like, um, inconsistent errors, so not saying words the same way every time. Uh, we may hear issues with stress on wrong syllables or words. Um, You might hear distortions of sounds. [00:08:00]  A lot of times vowels are impacted, which is different or, um, unusual in the sense when compared to phonological disorders. They also tend to struggle with longer words. So that fits Lauren's case where the multisyllabic words are a problem for this child. Um, and then it also may co occur with other language issues, reading issues, and so on. But. There is a really good, um, leader article that talks about, um, discriminative characteristics. So I'm just going to do a quick overview here. Um, this article talks about the often present, but not necessarily discriminatory characteristics of childhood apraxia of speech. So those would be things like, A limited consonant and vowel repertoire, which you could also see, of course, with phonological disorders. Um, the use of simple, uh, syllable shapes and frequent omission of sounds. So again, it [00:09:00]  could also mimic phonological disorders. Uh, numerous errors, um, so they'll score poorly on articulation tests and then poor intelligibility. So those are kind of the Um, you know, maybe more umbrella or kind of like the overarching things that you would hear, but then if you really want to discriminate, um, between childhood apraxia of speech and a phonological disorder, you would be looking for things like, um, difficulty moving from one articulatory configuration to another. So. maybe they're, you know, clumsy in how they articulate things. And that's why you hear some of that variability in how they might say something one time versus another time, right? Um, you might also see, uh, groping, um, or trial and error type of behavior where they're almost like searching for the position for that sound or, or how to, um, you know, place their tongue or whatever it may be. So you see some maybe facial, um, Uh, groping behaviors. [00:10:00]  Um, I mentioned the vowel distortions. So these are not necessarily substitution errors, but just distortions of the vowel sounds. Um, because maybe. how they're shaping their tongue or their mouth, um, you know, is just different. And so you're, you're hearing those differences in their vowels. And then the prosodic errors, hearing either, um, lexical stress differences, um, maybe even phrasal stress. So you hear some like intonation patterns that maybe sound different. And then the, um, last one is inconsistent voicing errors. So the child might use, um, Corrective voicing inconsistently, and that's one I think characteristic with CAS is that inconsistency that you, you know, because with, phonological disorders, you know, there's a very distinct pattern of error. And you can pretty much count on like, okay, they're going to be, you know, fronting their K's and G's, or they're going to be [00:11:00]  omitting final consonants, you know, and it's a pretty consistent pattern of error. Whereas with CAS, there's just a lot more variability and inconsistency, which makes it difficult. Kate Grandbois:  Okay. So all of this, all of this kind of tracks with, you know, what I think most of our audience is speech language pathologists who. You know, remember this at the bare minimum from graduate school. I think what's really interesting about this clinical question is the intersection of eligibility criteria, because in a lot of districts, at least in my experience, you know, I have heard the argument, well, speech sound disorders don't prevent access to the curriculum, right? They might not impact reading or writing, um, which we know doesn't feel good, but I'm curious to learn what The actual literature says about CAS and how that intersects with like IDEA and, and our general requirements for eligibility in the schools. What did you learn when you went [00:12:00]  a digging in the literature? Ana Paula Mumy:  So because eligibility for this particular child was already determined, what I'm going to zone in on really is the question at hand, which is essentially, is there continued adverse impact, right? Which is. The other thing that we looked at because, well, let me back up. So, of course, when we're thinking about eligibility, thinking about, you know, does the child have a disability, right? Is there something, um, that is impaired? And then is there impact? So does disability adverse, adversely affect, um, the child's educational performance? And then we have also, um, instruction where we look at the, does that student require specially designed instruction in order to access the curriculum and, um, thrive educationally? So, so for this child, we know She's eligible. She's been receiving therapy. So now we want to know, is there a [00:13:00]  continued impact? And then is there a continued need for specially designed instruction? So when we think about impact, we have to look at, is there a relationship between the child's speech difficulties and their academic achievement when it comes to, of course, reading, writing. We could also think about Phonological awareness is that speech difficulty translating into difficulty with phonological awareness, um, or even spelling difficulties. So those were, would be questions to potentially ask it or things to look into, um, through, You know, teacher interview through, um, looking at maybe samples of the child's work and those kinds of things and really just asking the right kinds of questions to determine, um, is there something happening, you know, beyond, um, just the intelligibility piece, which we know based on Lauren's little blurb that she's [00:14:00]  saying she is intelligible, but there's still times when communication is breaking down, right? So, the, the second question might be, you know, are there persistent errors, or if there are persistent errors, are these errors limiting that child's participation in the classroom? So, for this child, if she is largely intelligible. Maybe it's not impacting her or limiting her participation, but maybe, um, there is still significant awareness of those challenges, or maybe the child's afraid to speak up, right? She's afraid to maybe, um, contribute to a classroom discussion, or read out loud, or maybe Or those like  Kate Grandbois:  awful oral presentations that they made us give, or like the terrible book reports that they made us do in the front of the classroom.  Ana Paula Mumy:  Right. And of course, for this child, she's a first grader, so I'm not, uh, she's probably not doing any kind of like formal presentations, [00:15:00]  but they're still having to maybe, um, I think even love situations like if they do, you know, show and tell, or maybe it's a more social like, uh, type of participation in class where they're just talking through things and, and, or showing something and, and having to, um, explain or describe or, you know, whatever the case may be, but is. Is the child or the continued difficulty that she's having with particular words, is that impacting her to, in a sense that she's becoming withdrawn or maybe not, uh, willingly participating. So that would be something to look into. And then is this, um, or is the difficulty still noticeable across settings? So, um, and if it is, is it drawing undue attention to that child? So thinking about, you know, maybe she's. relatively comfortable in the classroom with her classroom teacher, but in other, [00:16:00]  uh, types of class room settings, like maybe art or P. E. or, you know, there's maybe other areas where the student is Um, participating throughout the day where there are more significant communication breakdowns potentially, right? So just looking further beyond just that regular classroom. And then, um, is the student consistently intelligible to all the adults, significant adults in their lives, right? So parents, teachers, other professionals, um, and peers, of course, right? Um, without knowing. All the detail about this child, she's reporting intelligibility, um, and just difficulty with more complex utterances or in multisyllabic words, um, but if the child is still feeling an impact from that, it could potentially justify additional [00:17:00]  work, right? So I wouldn't just say, well, just because there is intelligibility, most of the time that it would just completely erase. any potential impact that could be present. So we would just have to dig further. And again, I would just talk to the teachers and talk to the parents and talk to the child and just try to gauge, um, how is she feeling? Is she, you know, talking openly and not feeling, you know, some kind of, um, barriers there?  Kate Grandbois:  Would you also maybe think that in that instance, it could be, um, Good practice to check in with the school counselor or, you know, if you don't have a lot of counseling skills to maybe have a conversation with them about questions you could ask to kind of, you know, I'm just thinking of a small child, if they're having a negative social impact or not speaking up in the classroom or feeling, you know, that they're hiding their communication in any way, that might be a really difficult thing for a small child to handle. communicate about maybe they might not [00:18:00]  even be aware of it. Just, just given the nature of their age. So I would also imagine that there has to be some counseling that's happening and not all of us have had counseling training. So I'm, I'm wondering if like, you know, there's a room, there's room here to kind of have a conversation with the school counselor and get some tips. Like what are some things, what are some strategies to kind of best measure and best gauge this level of social, emotional impact?  Ana Paula Mumy:  Sure. I think absolutely. If you. feel less ready to do that or to have those kinds of conversations. I think the counselor definitely could, um, help you figure out how to elicit more from the child. Um, I would say because of my background with working with stuttering and having those vulnerable conversations sometimes with children or teens, um, I, I feel fairly comfortable whether it be through Um, maybe utilizing a storybook that would kind of open up the opportunity to talk about it, right, or maybe it's through [00:19:00]  drawing or, um, you know, just whatever the case might be, but, but definitely I think if you feel less capable to approach that, um, I think the counselor could be a great, um, source of help, so for sure. So moving into specially designed instruction, I would say. The two questions that came to mind were, does the student know what to do most of the time? So do they know how or what strategies are needed in that moment? Or can they? relatively independently, um, figure it out, right? So like if I'm struggling through a word, um, do I know what to do with my tongue? Do I know what movement or do I know if I slow down enough or if I articulate with more precision or what does that look like, right? So if the child is able to cue themselves relatively, um, Like, or was just minimal, [00:20:00]  uh, excuse me, minimal support, um, then I think maybe that specially designed instruction is no longer necessary because they're showing that they're capable, right, of doing it on their own and maybe just need some periodic reminders, right? Um, Um, then if that, those periodic reminders are needed, if they need maybe some cues or modeling or explanations or whatever it might be, could it be provided by the teacher or a paraprofessional or somebody else, rather than it still needing to come, you know, from me as the SLP. So if you feel like the child. knows what to do and has the skills that are there and just needs maybe an extra boost here and there, then maybe there could be someone else, you know, that is providing that reminder or providing some kind of minimal instruction. But if they're still needing, I would say, you know, moderate to significant [00:21:00]  levels of prompting or instruction, then that's going to be more our role and reserved for our Specialized instruction that we can provide, you know, for that child, and it's also making  Kate Grandbois:  me think of, um, service delivery, because, you know, if you're thinking about possibly transitioning out of direct service and making sure that other communication partners are trained, maybe shifting to that 3 1 model where you three sessions of direct instruction and one session of consultation to kind of talk to the classroom teacher, make sure they know what prompts to give or what the history is there. Just kind of like leveraging some of that indirect service that we don't tend to see very often in our field, but we know from lots of different research studies across the entire span of our field is very, very important and effective.  Ana Paula Mumy:  Right. In thinking about, for example, if you use any kind of tactile cuing or, or even if it's just [00:22:00]  verbal cues, does the teacher know what those are, right? So the video can be that continuity across what you're doing with what they're doing. And of course, if you're doing it from the get go, the teacher is going to feel very comfortable being able to provide those occasionally if they're needed, right? Whether it's a tactile cue or verbal cue, um, or, or a sign, or whatever it is, right? And so I think, um, definitely if we're doing, I would say if we're doing our job well in terms of collaboration with teachers and really preparing them to essentially support what we're doing. outside of the classroom, then when it is time to move maybe towards more of a consultation model and them maybe, um, helping you along to maintain that carryover, then I think they'll be, you know, ready and there won't be a huge need for a lot more. So it's almost like they're already doing it anyway, right? They're just [00:23:00]  continuing essentially what they've been that we've already been doing in a sense.  Kate Grandbois:  Mm hmm. So I know this, you know, concept of service delivery and indirect service provision is also making me think about our service delivery. And I know you found a really interesting research article on dosage. And I'm really excited for you to share that because I'm very curious.  Ana Paula Mumy:  Yes. Um, I think we've always known, uh, well, I shouldn't say we've always known, but I think it's relatively known at this point that we need high frequency. Um, of repetitions to affect change, right? When there's any kind of motor, speech motor concern, um, whether it's phonological or CAS, I, I think the, the research shows intensity being really important, um, and high number per session, um, and ways to, uh, so that. you're essentially doing a lot of drill play or [00:24:00]  drill type of activities to get as many repetitions as you can. So I think that's a relatively known concept, right? I don't think we struggle with that. And I think too, we've seen more research pointing toward, um, having maybe shorter, um, more frequent sessions, right? So I can get a hundred repetitions in 15 minutes. That would be much more useful to do over two to three days than just trying to do one session that's 30 minutes long. Are you really accomplishing more by doing that, right? Not really, because I can get 200 reps pretty quickly and have a relatively productive spin that way. Um, so what, what I found when I was looking is that for the, um, phonologically, uh, disordered. Child or the child with a philological disorder that the, the research is pointing to an average of 29 individual treatment sessions for at least parents to come, uh, [00:25:00]  begin to rate a change where they're perceiving a difference. Okay.  Kate Grandbois:  29.  Ana Paula Mumy:  29.  Kate Grandbois:  That's a very specific number.  Ana Paula Mumy:  It ranged from 21 to 42.  Kate Grandbois:  Oh, okay. Average. Yep. I can do math. Some. Yeah.  Ana Paula Mumy:  So average 30 ish. Right. Interesting. This was, and this was 45 minute sessions. And again, I don't tend to function that way. I tend to say I would much rather work with that child twice in the week for 20 minutes and get 40 minutes that way versus one long session because I can achieve a high number of trials fairly quickly. So that's my own personal. Uh, bias or, or preference, and I think that the research does support it, but when it came to the, um, the children with childhood apraxia of speech, it actually required a hundred and fifty sessions, an, an average. So it ranged from 144 to [00:26:00]  168 for there to be a noticeable change. Um, in intelligibility. And again, this is based on parental, 150, 150 sessions. I  Kate Grandbois:  just grabbed my calculator. I'm doing 150 divided by 20. That's five times as many sessions.  Ana Paula Mumy:  So 81 percent more individual treatment sessions are needed. Um, for childhood apraxia of speech than for a child with a severe phonological disorder. So and we're just talking about, you know, achieving games across, um, and again, this is based on, you know, parental perception of speech change and intelligibility.  Kate Grandbois:  But that's functional change in their, in their everyday environment. That's very important. It's an accurate measurement.  Ana Paula Mumy:  Yes, so I, I was like, wow, this is really impressive, um, or, or just really impactful information because I think if you think [00:27:00]  back, so I'm looking at Lauren's question again, right? And she says, she's been working with this child for what, a year or so, um, she's in first grade. Have they achieved what they want? a significant number of sessions for there to truly be this change that's going to last over time, right? And of course, we're seeing that she's responding well. Um, she reports she's responding well to CAS interventions. She's quickly able to, um, sequence, novel words with carryover and so on. So this child, of course, is responding to treatment, right? And there's been marked improvement based on what we know. Um, but at the same time, we also know that kids with childhood apraxia or speech are going to need a way more, um, contact, right, with us, um, than a child that just has a severe phonological delay. So I just think that's really important to consider when we're thinking about dismissal, that we don't [00:28:00]  do it too early, um, and that, that child really has achieved some solid gains and has a clear, um, Understanding of what are the strategies that they're utilizing to be able to be more intelligible, to achieve the consistency, right, to, um, work through those prosody, um, differences, you know, so I think it's just really important to, um, not to quickly arrive at, oh, they're good, right? Kate Grandbois:  Right. Right. I mean, that's a tremendously high number of sessions.  Ana Paula Mumy:  It is.  Kate Grandbois:  I mean, in comparison, that's, I mean, it doesn't, I guess, doesn't surprise me. We know that I was always told that, you know, the number of trials that you need for motor speech is way higher than what you would need for, or for apraxia specifically is way higher than what you would need for, let's say articulation. Um, so it doesn't surprise me, but I think I'm, I'm still taken aback by how that. [00:29:00]  Level of intensity would fit into a school model and would intersect with all of these other variables as well,  Ana Paula Mumy:  right? And so if you think about it, you know, I did the math too and thinking about 36 weeks of school right in one academic year Um, if sessions are occurring twice weekly, we would say we need about 75 weeks, which would be at least two academic years, right, for that child to really, um, for you to see those measurable gains. Um, if sessions were occurring three times weekly, we would still need about 50, you know, so it is still a big chunk, right, of time where we are very intentionally working with this child. And, um, of course, um, Aiming for a lot of repetitions, and so just a high number of trials, you know, per session.  Kate Grandbois:  And that doesn't even touch all of those other social emotional components that you mentioned earlier. I mean, that's another, that's another big factor.  Ana Paula Mumy:  Yeah. [00:30:00]  One thing that was interesting too, there was another study that showed that the continuation of novel word challenges is to be expected. So that does. seem to align with what Lauren is seeing, right? So that difficulty with those multisyllabic words, it could persist over time. So this one particular study, uh, Lewis et al in 2023 showed that it may persist into adulthood, um, for individuals with CAS. So that is not, um, Maybe a shocking thing that she is still struggling with those. Um, so just something to consider there. The only other thing I would add is then looking at, you know, is there any potential impact on literacy? Right. There is some research that shows that. Sometimes kids with CAS are at risk of being placed back on an IEP by fourth or fifth grade because of learning issues or because of some literacy related, um, [00:31:00]  aspects, you know, uh, whether it be because of phonological processing or language or reading difficulties. So just something to be, again, just aware of, um, in considering that an impact on literacy and not being too quick to dismiss without looking into those components.  Kate Grandbois:  That's so interesting. This was so, so helpful. I didn't know I could learn so much in such a short period of time. What I love so much about unpacking Clinical problems like this and case studies is looking at the intersection. So this is not just necessarily about childhood apraxia of speech, right? But we've talked about everything from eligibility criteria to literacy to communication partner training. Uh, social emotional impact, um, and I think when you are in, you know, Lauren's position of trying to decide whether or not to discharge, I think it's so, it's so important to kind of take a step back for a minute and really think about how the dominoes fall or think about [00:32:00]  the, the incidental impact of, of some of, you know, these lived experiences across these different domains. So thank you so much for, Doing all of this digging for us. This was really really interesting  Well anyone who is listening who would like to write in with their clinical questions There is a link in your SLP nerdcast dashboard for members to write in clinical questions for our SLPD On Demand, our resident doctor of speech language pathology, Ana Paula, to dive into the literature, and we will unpack it on the show. So we hope to hear from more of you moving forward. You can look forward to more of these SLPD On Demand clinical cases to be published in the future. Ana Paula, thank you so much for your brilliance and expertise, and we will be back again soon.  Ana Paula Mumy:  Thank you.  Kate Grandbois:  Thank you so much for joining us [00:33:00]  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 Why Language Development Matters in AAC [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois:  Welcome to SLP Nerdcast everyone. We are very excited for today's episode. We've We're already laughing. It's going to be a really great episode today. As most of our audience knows, Amy and I have worked as AAC, quote, [00:02:00]  AAC specialists for the majority of our career. And we are here today to talk about this topic, AAC, which is a real passion of ours. And we are here with two researchers and content experts, Dr. Kathy Banger and Nancy Harrington. Welcome Kathy and Nancy. Thank you  Cathy Binger:  Thanks. It's great to be  Amy Wonkka:  here. Thanks very much. Glad to join you. We're so excited for this conversation. Um, we had, we had some really nice chat before we hit the record button. Um, but for those listeners who aren't familiar with your work, uh, you're here to discuss AAC and developmental norms. And before we get started, can you please just tell us a little bit about yourselves?  Cathy Binger:  Nancy, why don't you start us off. Nancy Harrington:  Okay. Um, I am a speech language pathologist, um, clinician and a researcher, um, from the University of Central Florida. I have been, um, working in the AAC field [00:03:00]  for nearly 40 years. I started my career in New York, um, and also worked in Ireland for about 20 years and have been at UCF since 2013, where I was very happy to join the research team of Dr. Binger and Dr. Kent Walsh. And we've got a lot of exciting stuff going on.  Cathy Binger:  Great. Thanks, Nancy. And I'm Kathy Binger. I'm at the University of New Mexico, where I'm a professor. I'm also an SLP, and I want to make sure we give a very firm and loud shout out to Dr. Jennifer Kent Walsh, who's working at the University of Central Florida with Nancy, um, who's also, we're going to be talking about, um, her work as well, because it's all of our work together. So, um, yep, she couldn't be with us here today, but she's with us here in spirit. So,  Amy Wonkka:  shout out to Dr.  Kate Grandbois:  We're so [00:04:00]  excited to get into everything. Um, for our listeners who are not aware, we actually have. hosted, um, Dr. Bringer and Dr. Kent Walsh on the show before to talk about AAC and language development. Today's episode is definitely not a replacement of that. It is very much an extension of that, but if anyone's listening and would like more information about AAC and how it intersects with language development, we will link that episode in the show notes as well. Uh, before we do get into the good stuff, I need to read our learning objectives and financial disclosures. I will try and get through that as quickly as I can. Learning objective number one lists three reasons to use a developmental model in planning AAC intervention for children. Learning objective number two, describe aspects of a developmental language framework when planning AAC intervention. And learning objective number three, describe the benefits of ensuring access to both core and fringe vocabulary for aided [00:05:00]  communicators. Disclosures, Cathy's financial disclosures, Cathy is employed by the University of New Mexico and has funding from the National Institutes of Health. Kathy's non financial disclosures, Kathy is a member of ASHA and Special Interest Group 12. Nancy's financial disclosures, Nancy is employed by the University of Central Florida and has funding from the National Institutes of Health. Nancy's non financial disclosures, Nancy is a member of ASHA and ASHA's Special Interest Group SIG 12. Kate, that's me. I'm the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosure is I'm a member of ASHA SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy.  Amy Wonkka:  Amy's disclosures. 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 financial disclosures are that I [00:06:00]  am a member of ASHA. I'm in Special Interest Group 12, and I participate in the AEC Advisory Group for Massachusetts Advocates for Children. All right. Let's get into the exciting stuff. Um, our first learning objective talks about the developmental framework. And I think, you know, I work in a public school. I work in AAC. I'm working with a lot of people who don't necessarily have an understanding of typical language development. Uh, and I would love to hear you both talk a little bit about how important that is. Cathy Binger:  Well, it's very important. So, um, I, you know, just as a starting point, I'll tell you, and this is Kathy, that, you know, I go back. Over and over and over and over and over and over and over and over and over again to the developmental model when I'm trying to figure out goals and [00:07:00]  objectives for kids who use AC and also for kids who have developmental language disorder, kids who have whatever I go, I go back to that model. All the time and teach my students, um, hopefully teach teaching and learning are two different things, but at least try to teach my students the importance of of doing that, because it, it helps us figure out where the gaps are. Um, so that I know where this child I'm working with is doing relatively well and where their holes are and for me to figure out where their holes are, I need to have an understanding of typical development. Um, and am I going to make sure they're on track with all of the domains, pragmatic, semantic, syntax, et cetera, all at the same point at the same time. That's probably not going to happen with our kids, but I want to know. Where their relative strengths are, as well as their relative weaknesses are, so that we can help boost [00:08:00]  those things up because, um, in language development, all of those things develop at the same time, right? And in applying a developmental model paper, um, Amy, you were saying before we, before we recorded that you really like the graphic that's in there. So I just want to call attention to that. If anybody wants to see that, um, you can look at a paper and look at that graphic. And it really tries to demonstrate. the, how simultaneously these things are coming, right? Kids start to develop their pragmatic skills before they ever speak, and then they say their first words, and that's when semantics comes in. And then at about 18 months in typical development, that's when two word combinations start, right? So by the time a typically developing kid is 18 months old and has 50 words, They're putting words together. That's syntax, starting to work on their syntax. So that's really early in development. 50 words isn't very many words. Um, I mean, it's many words for kids with [00:09:00]  certain impairments, but, um, you know, for a lot of kids, that's not that many words. And so that's the beginning of syntax. That's the beginning of grammar. And we want to make sure That we're not ignoring one domain like syntax or morphology or grammar as a larger whole, um, while we're only working on something else, like semantics, where we're, for example, in AAC, trying to teach a kid how to find 500 words on their device, but meanwhile, we're not really focusing at the same time on helping them learn how to put those words together in a structural way, which is What we do see happening with kids who have, um, kids in typical development. So we want to make sure we're supporting all those things at the same time because that that model really teaches us that kids can do that and kids do do that and kids are cognitively ready for that if you're looking across these different stages. So, Nancy, you want to add anything to that?  Nancy Harrington:  Yeah, um, [00:10:00]  and I think for all of you who are speech language pathologists, um, providing language intervention, this doesn't sound very different, does it? To what you do with your children using natural speech to communicate. It's what I tell my students all the time. We're still doing language intervention. It's just that we're using, uh, additional tools and additional modalities to communicate. And I think that's so important for all of us as clinicians to remember.  Amy Wonkka:  I think one, one other piece that As somebody who's, who's working in the field and working with people who possibly didn't, you know, I'm thinking of my like BCBA colleagues who I've worked with over the years, um, or maybe even, you know, OTs or PTs who don't get the instruction in developmental language that we do as speech language pathologists, is Also sometimes see that we're working on skills that are too many steps above where we've, we've busted out of the zone of [00:11:00]  proximal development. If we're like way down the hill and then we're like, Oh, why, why isn't this student able to do this? They can do these other things. So I think that's something else that, that for me, at least has been very valuable in using that sort of developmental language lens to think about what the students I'm working with are doing or not doing. Um, and, and often. When I see we have somebody who's not achieving these objectives that we've set for them We're missing there are gaps like you were saying like there's gaps that need to be filled in and if we didn't kind of Zoom back out and take a look with that lens Could have easily missed it.  Kate Grandbois:  I want to Make it a comment. That's an extension of that and In, in terms of working with AAC, like Nancy, when you said it's, you know, we're still doing language intervention. I think it feels very different for a lot of clinicians because there's this thing, right? There's this like thing. And [00:12:00]  you're supposed to, and when you start working in AAC and Amy and I, you know, we were trained in this years ago, but you know, one of the first things you have to learn is like, how do you program this thing? Like, what do you do physically with this thing? And. I think that that thing ends up inadvertently influencing what we end up doing in therapy and it might even end up influencing the targets that we choose or the goals that we write. And this is, you know, where I think we're going to kind of navigate into talking about this, you know, this concept of vocabulary within this developmental model. I want to just give an example real quick. So a lot of the high tech devices that we see often, you know, they have, you know, boards that are full of core vocabulary and they might have a Fitzgerald key. Anybody who isn't familiar with that, you might be color coded where the verbs are green and the nouns are color and, and it's organized in this nice, you know, in this beautiful [00:13:00]  way. And It's very tempting to leverage what the device can do or what the device can look like and try and map it onto our student or our client. Um, and I think that there's a really interesting intersection there between this thing that just happens to be in the room and how it. accidentally in or might inadvertently influence the way we're thinking about our language intervention. I don't know if that's kind of like a, a springboard into talking about this, you know, how we end up choosing what, you know, what we're working on in therapy or, or if you agree or disagree, feel free to, to tell me that I'm completely wrong. 10, 000%.  Cathy Binger:  No, Kate, I'm really glad, you know, you brought all of that up and something that, um, we've done a lot of talking about. Over the years is exactly what you said is just, um, getting over the thing, right? That's it's just a thing. [00:14:00]  It's a mode. That's all it is. And I think, especially when we're when we're talking to SLPs who know language and sometimes, you know, need a reminder of this or that. But, you know, we were all taught typical language development at some point. And if you have this scary experience of, oh my gosh, there's this kid on my caseload now, and they're using this device, and they don't know what to do, blah, blah, blah, blah, blah. To me, it's really comforting to think that my job is to go back to language, which is something that I know, right? So, you know, one of the first things I always used to do when I was working in the schools or wherever I was working was, of course, going to the file to look at the IEP and look and see what goals and objectives are. I expect the, by and large, the goals and objectives for a child who's using AAC to be the same as a child who's using spoken language. Um, the communication modes are expanded. But the objectives need still need to be language [00:15:00]  based in general. I'm not saying you're never going to have one that's not but that's what that's what we do is we help focus on language and that's what AAC is supposed to do and should do is help build language skills,  Nancy Harrington:  but I think we also have a role as clinical educators and within the profession to help everybody to understand that and get over the thing as we're calling it. Um, I recently had a student, um, talk about her experience, um, in clinic with me because she was seeing an AAC client, um, in the university clinic. And she talked about how initially she was, you know, fearful because of the technology and, you know, learning all about that. But then she came to realize. It's just about teaching language. It's not so different than what she's doing with other children. And I think that's something that we really need to hit [00:16:00]  home hard in as many different ways as we can. I think, um, and now I have, um, a bit of scope to look back over because I've been in the field for a number of decades, um, across, um, A couple of continents. But, um, I think it's improving to some extent because people are more familiar with technology than they were years ago. Um, but we still have to get over it. And maybe it's very timely as people are more familiar with technology to help them really see it as just another modality.  Cathy Binger:  Yeah, and it's never about at the end of the day, there's no such thing in my view. And in my experience of the perfect device or the one perfect solution. A lot of these solutions can do very similar things. It's all about what we do with it and, um, you know, what we focus on and using that, going back to that familiar, at least again for [00:17:00]  SLP, that a familiar developmental model to help us figure out, you know, Um, what we, where the child is, where their strengths are, where their relative weaknesses are. It helps guide me, helps tell me where to go next and what to focus on next. Oh my gosh, we've been doing so much with building single word vocabulary. We've forgotten to work on syntax and work on these early word combinations and these rule based combinations and. Gosh, you know, so we need to, you know, we need to make sure we're doing also doing something to help facilitate that at the same time. And I just use that as one example, but I think that's a really common example that we see, or, or we're focusing so much on pragmatic skills or so much on request, even within a domain, maybe we're focusing so much on requesting that we've forgotten about commenting and question asking and, you know, other very Yeah. Yeah. You know, early developing communicative functions that are really important. So both within our domains as well as across our domains, [00:18:00]  um, using a developmental model can help remind us of the other components of language development and communication development that are happening.  Amy Wonkka:  And in, in one of the papers that we're going to link on, on the website, you are talking about the developmental approach and you talk specifically about some of the different types of intervention approaches. Um, you know, I agree with you, Nancy. I think, I think the, the thing is at least a little less scary now because we all carry computers in our pockets, but Some of the intervention approaches are, are, do feel a little different. They do feel a little different than if I was just using my oral speech. So maybe you could both talk to us just a little bit about some of those approaches and, and how that might look incorporating the thing as we've called it. Cathy Binger:  Yeah. Nancy, do you want to start with that?  Nancy Harrington:  That's fine. So there's, you know, there could be. various approaches in terms of looking at vocabulary. How are we going [00:19:00]  to choose the vocabulary? You know, in the, in the early days, you might've had, okay, we're going to have a whole bunch of nouns so that somebody can request, they can finally ask for what they want. Isn't this exciting? This is amazing. AAC is just so wonderful. So you might have, um, A grid, you know, whether it's a communication board or a static display device or a dynamic display device where you have a whole bunch of maybe familiar toys and food and people. And isn't that wonderful. They can finally request things and, um. So it's all that fringe vocabulary, looking at all those, all those things that are within your, the environment that are important. And then maybe you'll, you know, you. Add in then your verbs and your descriptive words and all those words that are associated with the context that you're playing in. So maybe we'll have an activity specific display, which, um, we've used a lot [00:20:00]  in our research where we'll create a display that's set up with specific vocabulary. Thank you. for the routine. Now, it could be a play routine. It could be a mealtime activity. It could be a specific storybook. It could be any of those specific activities, but it's set up with diverse vocabulary across different parts of speech, but with the relevant vocabulary that's For that activity, so that, um, rather than presenting the child with a really complicated setup initially, where they have to think about the operational demands of navigating through lots of different pages, they have the vocabulary there, but it's Many of these are sentences, but we're going to talk about some of the syntax that's set up in a way that they can create sentences. So, we're looking at syntax they can use varied vocabulary [00:21:00]  across different parts of speech. We have pronouns. We have nouns, we have verbs, we have adjectives, we have prepositions, we have. Morphological endings because, you know, think about it, even, you know, an 18 months to two year old, an early two year old is starting to add an I N G to the end of their, um, verbs. So we want to make sure that there's access for all that. So we're teaching it. In a little bit of an easier context so that the vocabulary is there for them, but they can, in fact, um, build sentences, build that syntax, use some more diverse vocabulary within their lexicon, and also talk about What's happening, you know, during the play routine, whether it's to request something, whether it's to comment about on something, whether it's, you know, [00:22:00]  to ask where something is, you know, whatever it might be, there are different options available. Now, that's not the be all to end all. We have, you know, what happens when they want to talk about something tangential, and that grid is up there, so we have to think about that as well. So there's, you know. There are different approaches, and there are pros and cons to each of them, but we need to be thoughtful and think about how we apply them so that children have the opportunities to not only have access to vocabulary but To communicate their most basic needs, but also to learn how to build that language to learn how to, you know, move from single words to two word utterances to increasingly more complex utterances with diverse vocabulary. Cathy Binger:  Yeah, and I want to go back to a [00:23:00]  2nd for a 2nd, you know, back to that noun based vocabulary. We're talking about Nancy. So, you know, I think for a lot of the kids we work with, um, when you're using a developmental model, um, going to a almost exclusively noun based, um, kind of an approach, that's not really warranted based on typical language development, right? Kids never go through a period of development where they're only using nouns. Um, if you look at the first 50 words, again, using a developmental model, we go back to typical language development. Um, the first 50 words that kids use, only about 50 or 60 percent of those words are nouns. They still have 40 to 50 percent of their words that are not nouns. They have social words, they have, um, action words like up, they have, you know, they have all kinds of different, they have adjectives like hot, um, and big. So, you know, they have this diverse vocabulary and you need that diverse vocabulary if you're ever going to combine words. You can't make sentences out of nouns. Um, so, you know, one of the things, things that we talk about in our developmental [00:24:00]  model paper. Is as Nancy said, the pros and cons of each of these approaches. Some of them have more more cons. Um, if you're only using if you're only using that approach, and this is something I'd love to hear from you, Kate and Amy, about what you think about this and you're what you've been exposed to with this. But, um, in my world, um, and giving some of the sort of getting I've heard a lot of, you know, Back from a lot of SLPs and what I seem to hear a lot with, um, kids who use AAC is that they tend to be getting just one approach. Um, and so that's when I think. You know, and I understand why some, you know, it's life is hard and they're like, there are all these real world complications that we need to be taking into an account. And that's another topic. We probably shouldn't get into because we still have way more progress to make in the world of intervention to bring all these things together. But anyway, where I was originally [00:25:00]  headed with this is that, um, you know, when you, if we put ourselves in a box and we only take one approach. And only that approach, so only noun based system, or, or almost exclusively noun based system, or exclusively an activity, um, specific kind of display or, you know, that Nancy was talking about where we have a page for playing with cars and a page for playing with cooking or whatever, um, if that's the only thing they get. Then we're going to end up in trouble at some point. Um, so I think, you know, really, the next phase, I hope of where we're going is with doing a better job of taking this developmental model into account and finding solutions where we can bring these things together. We can be working short term, for example, on building those early sentences and phrases and clauses like we do [00:26:00]  with our activity. Specific displays in our research, which have been around forever, by the way, like, we didn't create these. They've been around forever. And then people threw them out because it's have to, you know, go to a page for vehicles every time they want to say, um, crash. But maybe they're talking about crashing something else, right? Like, it doesn't make sense. Um, but. you know, so you can't just have, if you just have one approach, then you're going to get stuck. If you only have a really complicated display where there are thousands of pre programmed words, and from the start, you're trying to teach a kid to put words together using that, it's going to probably take them quite some time because there's a, there's a very real cognitive load there. Um, so I don't know if all of this is making sense or not, but there's just, There's a way to go with what we need to do. And then we also need to be making some decisions right now before we have all these better kind of solutions that are out there. And right now, I think the best that we can do is, you know, make sure that we [00:27:00]  sometimes are focusing on syntax and, uh, Um, grammar and building those utterances and Nancy and I just finished two randomized controlled trials where we've just spent the last five, six years working on that with priests with a couple different groups of preschoolers. And at the same time, we need to be building vocabulary and we want to be putting vocabulary in a permanent place where kids can find it over the long term. Right, like all of these things are going on and trying to figure out how to do it all isn't the easiest thing in the world, but knowing and being honest about, you know, where we are and where our gaps are going to help guide us in terms of filling in those gaps. Nancy Harrington:  And it goes back to diagnostics. What do we look at when we see a client walk into our clinic? Where are they developmentally? What do they need to communicate about? What context do they need to communicate in and [00:28:00]  with who? And how are we going to assist them with that? And we should, that all has to be looked at within the context of where the child's at developmentally and that's really what we have to think about and be thoughtful of considering all the different approaches and different, um, types of vocabulary selection. We need to make sure that the children we're working with have access to the rich vocabulary that, um, Typically developing children have, and that we're not limiting them based on the thing, as we said earlier.  Cathy Binger:  Yeah, so Kate and Amy, what, what are your thoughts?  Kate Grandbois:  I was, I was just about to say, I, I think that, AAC is one of these scopes of our practice. It's an area that is complex, right? I mean, it's [00:29:00]  assessment, you know, the, the variables that we have to look at and the questions that we have to ask are intertwining. Um, a lot of the, you, the individuals that we work with in AAC, not just myself and Amy, but just, you know, Generally speaking, you know, we're talking about complex communication needs. We might be talking about complex bodies. We might be talking about a lot of complexity. And for me, and this is my opinion, this is just my opinion. When I hear I'm going back to your earlier question, Kathy, you know, do we see kids who get just one or the other? So do we see kids who tend to get just core or just fringe? Um, My in my experience the answer is yes. I I do see that happen, uh happening. Um, I think the opinion that I Very quietly just put on the shelf, but I'll put I'll pull back out is that any time in intervention, if you're approaching the problem with a one [00:30:00]  size fits all approach, there is a, I'm going to hold my breath, you know, like, I don't, this is a red flag for me. Right. And I see it. I do see it in the AC, but not just with, well, we, you know, we're just giving a core approach and we're just giving a, uh, a fringe approach. I also hear, well, we just, we do touch chat here. This is just what we do here, right? So there is a lot of status quo, uh, culture that I find, and this is my opinion, you know, comes into play when people are making decisions about intervention strategies, targets that they choose. Um, and I think it's, you know, not necessarily the fault of the speech pathologist, it could be the professional workplace culture. It could be, uh, lack of resources for training, um, because this is genuinely a complex, um, area of, of, of clinical expertise. Amy, I don't know if you have a different experience or, you know, Agree or disagree. [00:31:00]   Amy Wonkka:  I, I agree. I agree with a lot of what you're saying. I mean, I can say personally, like I started off in the field. I was, we were talking about this before we hit record, but I started off in the field as a teacher's aid in the nineties. Uh, we used packs. It was exactly what you described, Nancy, which was like. Oh my, isn't this amazing? Now we can ask for all the things. This is huge. And it, and it is. It's huge to see somebody go from not having access to any of that to being able to request all of these specific things. Um, but then I, you know, I was in school at the time I was going back to school for speech pathology. Uh, it, there are inherent, uh, Weaknesses when you try and map an all fringe or all core system onto developmental framework. It's very hard in reading your paper. You know, it's very hard to generate a simple narrative with a very limited subset of vocabulary. Right. Um, so then I, I went to conferences, I learned about core vocabulary. I was like, yes, this is the answer. You, you can't make a two word combination without [00:32:00]  core. This is key, you know? Um, and I sort of got really enthusiastic in the other direction. And. Kate, to come back to your point, yes, obviously it, it is one, one approach is never the best approach for everybody. And finding a more measured place in the middle is obviously where I have settled, you know, in, in my current practice. Um, I do think, you know, there's also this other layer, which is wanting to give people access to To a really robust system and Nancy Cathy's you guys were talking about the activity displays, you know, I think sometimes we feel like on the one hand it's complicated by Time and people having time to do these things and create these, create these different displays. Um, so that's a limiting factor there, but I'm just thinking, you know, we, we really don't do that. And it doesn't have to be either or like, it doesn't have to be, you have access to word power and all this vocabulary. So we can't, we can't try an activity based display [00:33:00]  to give you an opportunity to like, relieve some of that navigational burden and work on morphology. Like it doesn't have to be one or the other. And I think That's a piece that every time I read something like your paper, I'm like, ah, that's right. You know, it's, it's the combination of all of these things. Um, so yeah, I don't know if that answers your  Cathy Binger:  question. I have a slide that I put up when I, you know, whenever we give these talks of, it doesn't need to be one or the other. It can be both. And I'm not, and again, like it's complicated. Everybody doesn't have, no one has all the time in the world, you know, blah, blah, blah, blah, blah, blah, all that stuff. And. Like, you can use for a child for whom it's appropriate, a more complicated kind of system with lots of words, blah, blah, blah. And, you know, as you can. develop some activity displays in specific motivating activities where somebody can be helping to facilitate those word combinations, the clausal development, the phrasal development, [00:34:00]  you are in all likelihood going to see that kid make way more process, way more progress. With their syntax development and their grammar development and their morphological development, if they can just have sometimes, not all the time, but sometimes for certain activities, an activity specific display where they don't have to be hunting for other things. Um, they can just focus right here. And as I mentioned a few minutes ago, we just finished, you know, two long studies where, um, we're getting both of them out the door now, right now. And, um, so we'll come back on if you want at some point to talk to you in detail about those 2 very large studies. And, you know, we just saw kids, not only kids. with typical receptive language, which I know is the minority of kids who use AAC. We did do one study with kids with typical receptive language and also a study with kids with Down syndrome. And in both cases, um, we saw them make substantial gains [00:35:00]  in their length of utterance, um, you know, over a four month period of time, um, where, you know, they really Probably pretty stagnant with that beforehand and they didn't have access to any before that for most of them. So, so, yeah, we can, we can do a lot, but it doesn't have to be all day every day. They're doing 1 thing.  Nancy Harrington:  And I also want to note that, um, you know, we can consider this too with, um, you know, many of our users who use alternative access. Yes, it might take more time. It might be slower for them to select the vocabulary that they want, but even though they may not be able to produce so many different symbols with at once within a set period of time, we still have to consider developmentally where are they? What vocabulary do they need access [00:36:00]  to? How can we set up their devices and their displays so they have access to the lexical and vocabulary diversity so that they can produce A range of utterances, um, and learn to use syntax and grammar.  Amy Wonkka:  I think that's such a, such a good point too. And, and it makes me think about, you know, just, just back to this, what did you say? Yes, and, or both and, but I, but both and so, because there are also times when that's the purpose of the activity, right? So back to operational demands, whether that's because you are using switch scanning or something, it's a more cumbersome access method, or because you're learning to navigate your system and that's a cumbersome Access method for you in the moment. Um, sometimes the focus of the activity is to work on that [00:37:00]  morphology and sometimes it's not right. So I think also being flexible within kind of what areas, I mean, back to that figure that I really like in the paper, but just thinking about, you know, there's, there's different things that are happening at the same time within those different developmental bands. And it doesn't mean we have to be working on the highest level of performance of all of those things simultaneously. Either. That's right.  Cathy Binger:  That's right. Like to have, you know, a couple activities a week where you're really honing in on the sentence development, the phrasal development, the plausible development, whatever, you know, putting those words together in a rule based way. But that doesn't mean you're doing that all all day every day. Right? Yeah. There are times and places for these things and different access methods, even, you know, that you may use for, um, to make things easier so that they can focus more on. The learning of this rather than this in a particular in a particular moment, Nancy Harrington:  and that's the. Um, [00:38:00]  beauty of a lot of our new technology is that burden can be more on the technology and less on the user. Um, and then back to your point as well that we also we need to consider all aspects of language. We need to consider the The semantics, the pragmatics, the, you know, I think back to years ago when I first went to graduate school, I remember learning about, um, Bloom Leahy and form, content, and use. Those three circles that intersected, it all went together and we, it's still relevant. We have to be thinking about that all, you know, with our, um, clients that we're working with. We have to think about all aspects of language. From a developmental perspective. Amy Wonkka:  I wonder if now is a good time for us to talk a little bit about the other paper that we're going to link in the show notes and just talk a little bit more about kind of that, [00:39:00]  that division between the core vocabulary and the fringe vocabulary and how that's used now that intersects with the developmental piece. Cathy Binger:  You betcha. Let's do it. So, um, before we go down that road too much, I made a little note. I want to come just cut touch back on something that's related. Um, as I'm shaking my clothes pin at you, um, I know we all have our sensory things that we do. So anyway, Kate, you had mentioned, you know, that anytime you see like everyone taking the same approach that sets bells and whistles off for you, right? Um, if everybody's doing the same thing, um, I, I just, I want to say, I don't know where we're heading with all of this, but I do. Also understand that sometimes that happens because, um, you know, sometimes people don't know what else to do. [00:40:00]  Um, sometimes people have a whole classroom that's a really complex kids with, um, you know, not necessarily a whole lot of help or a whole lot of background in what they're doing. Um, and it's not necessarily a C, isn't there a huge specialty? Like, there are all these things that are these very, very, very practical real world pressures that are out there on working clinicians, working educators, educational assistants, you know, all these folks who are trying to. Just do the best job they can with what they have. So, um, you know, looking down the road, I really hope see think that the next phase of what we're going to be looking at is taking those things into more into consideration than we are right now with most of our interventions and so that we can be doing the kinds of things that we're talking about today and doing it in a practical kind of way. So, um, yeah, so that, that then takes us, [00:41:00]  do you want to ask us a question about the, the paper we wrote on, um, foreign French vocabulary, or do you just want Nancy and I to launch into it?  Kate Grandbois:  I think it would be really helpful to hear what the data is showing and what. What the what direction the science is is pulling us in if you know, I love that that vignette that you just painted of like, where are we headed with this, knowing that looking backwards, you know, we started in a place with a AC where it was like, Oh, my gosh, we can use symbols. Oh, my gosh, people can request things. This is amazing. And then it was Oh, my gosh, look at the power of core. And we've gone all the way into core. So where is the I would love to know, like, where the science is taking us next. And I think that's a really important conversation, not only because of the real world limitations that people face in terms of resources and time and knowledge gaps, but also I find that this topic gives people a lot of feels. [00:42:00]   There are a lot of fields that come with Talking about how to choose vocabulary with AAC. And that is not a judgment. That is you, everybody's allowed to, I hear I'm here to validate everyone's feelings. Everybody's feelings are valid and it is, it is okay. Um, I feel okay, Kate. Okay. Okay, good. But you know, I, I think that knowing what. Taking a look at what we know versus what we don't know is a really nice way to unpack those feelings.  Cathy Binger:  I, I could not agree with you more, so I want to start really zoomed out here, which is, um, something that I, I just see and hear, you know, here and there in the AAC world is that, quote unquote, we know so much about core vocabulary. And that's a place where I will take a firm stand and say, no, we do not. We do not know much at all about core vocabulary. We know how to create word frequency lists. We're really good at that. There are lots of word frequency lists out there, and [00:43:00]  people are constantly publishing more and more lists. And that's what core vocabulary is, and the way that we define it in AAC are words that are used frequently, um, across a group of people, right? So preschoolers in home settings and in, um, daycare settings or, you know, or in school settings or whatever it is, right? So that's core vocabulary. We have a number of research papers that are out there on establishing core vocabulary lists, but, um, we don't, I have many empirical research studies beyond that. So that was really the, um, the impetus for the paper that we just recently published on, um, core, what like core, core vocabulary, fringe vocabulary, the combination. So the context for the paper is that we decided to look at fairly young kids, They're two and a half years old. We got our hands on an online. They're wonderful online databases. [00:44:00]  Now of transcripts that you can do to do all kinds of analysis. So we found a good set of transcripts from kids who are two and a half years old. Um, we had. I want to say about 60 kids and about well over 100 transcripts that we analyzed. And these kids were at daycare settings and in home settings. And they were talking both with a parent as well as with, you know, in the classroom. So they had, you know, they were doing all day record, they were doing recordings of them. So, not all day recordings, but, you know, they were doing recordings in both places. So, anyway, so it was a really nice pool of language samples, and what we did with these typically developing kids, our question, our big question was, how is core vocabulary and how is fringe vocabulary being used in the real utterances of these kids? Right? So if you just take a say, um, then we ended up with 10 over 10, 000 utterances that we did our initial [00:45:00]  analysis on and we looked at, um, the percentage of utterances that of these 10, 000 utterances, what percentage of them consisted only of only core vocabulary, what percentage of these utterances consisted of only fringe. and what percentage of these utterances consisted of both. And then we looked at six different four vocabulary lists. They're all English. We didn't look at any other languages. We just looked at English to see what was in the, our samples were all English, English speaking kids. And what we found was that, um, well, first of all, with these six Stop me if I'm like going into too much detail and wave at me or something and I'll take it back off. But to give you the context, there are six lists that we looked at. Two of them were very, very short. Two of the lists were the Banerjee, Banerjee list that has 23 words that's frequently used. There's another list [00:46:00]  that's universal core that's being used for, um, especially for kids who have very significant multiple disabilities in some classrooms. And that list only has 36 words on it. And, you know, that list in particular was made with the thought that. You know, it's used for whole classrooms. These are the same 36 words that are given to all the kids is my understanding. And, um, you know, these kids don't, there's not a lot of real estate they can get access to. So how do we make the most out of the real estate that they have? Right. But the thought behind it is an excellent one for sure. And then the other four lists were much longer. They were at least 250 words. Okay, so what we saw with what percentage of these 10, 000 utterances consist of only core vocabulary for that 36 word universal core, it was only 5 percent of their utterances. consisted of only that universal core vocabulary. So very, very, very few utterances, and those utterances tended to be very, [00:47:00]  very short. We also did MLU, um, we have MLU figures on all this stuff. They were very short utterances, and they didn't have a whole lot of content in them, as you might imagine, because, you know, 36 words. The other short list, the Vonagee list, Vanagee, sorry, I'm so sorry. I never know how to say that name. I, my apologies. Um, That list was 22 percent of those 10, 000 utterances were core only, but. Over 85 percent of them, or it was 85 percent of them, were made up of yes and no. Um, so almost all of them were yes and no. So basically, you know, those lists perform very similarly in that there are very, very few utterances that those kids were saying outside of yes and no that consisted of only core vocabulary. Which, the take home message there for me is, kids are not using only core vocabulary when they're talking. Even at two and a half years old, they're not just using core vocabulary. They're using the fringe too. So, you know, I won't [00:48:00]  get into the details of all the graphs, but, um, you can see in our paper that, you know, you get, you know, there's some utterances that are only core, some are only fringe, and some are both. And then you can look at the samples of them and what those utterances look like are dramatically different. Depending on if you're looking at a core only utterance, a fringe only utterance, or a core and fringe. And no surprise, the ones with core and fringe were way longer and way more complex than the utterances that were made up of only core or the utterances that were made up of only fringe. So it's kind of a flashback for those of us, all four of us have been around in the field for a long time. Like I learned back in the nineties that, you know, we need to be using core vocabulary and fringe vocabulary. But To my knowledge, nobody has really looked objectively. Um, at what that really means and what our kids utterance is really made out of, um, Emily Laubscher and Janice Light did a nice study. They compared, they looked at core vocabulary [00:49:00]  through the lens of the MacArthur Communication Development Inventory and had, you know, they found, you know, of course, like, there's not enough content if you're just looking at the core lists, um, and this is just looking at that same issue through a different lens where, um, where we see that. And if you look at the mean length of utterance, Um, I mean, for the samples that we took, it's, it's what we really expected, which is again, that, that those utterances that have both core and fringe are way longer and way more complex than the utterances that are only consisting of core or only consisting of fringe. So the table message is, guess what? Kids need both core and fringe, um, if they're going to be making the most of, of their language skills. So that's my, my intro to all of that. Kate Grandbois:  So what I'm hearing you say is that kids need more, your study was on. Non AAC users, so children, typical children using [00:50:00]  oral speech and kind of circling back to our previous conversation looking at the importance of Pinging our clinical thoughts and questions back to a developmental model and sort of you know Really embracing this developmental model what we now know based on this study and it sounds like the data was pretty clear What typically developing children who use oral speech are producing by far and large are utterances of both core and fringe? Cathy Binger:  Well, percentage wise, so for the longer vocabulary list, the ones that were at least 250 words, the core list that were at least 250 words, um, about 50 percent of their utterances were made up of only core vocabulary, but they had a lot more words to pick from. Right. Like if you have a much larger corpus that you're starting with and that the kids, I mean, I shouldn't say have access to because you know, these were typically developing kids, but if you give, if you give a kid all 250 words on the [00:51:00]  Cleman list, he's gonna have a much better shot at putting together some decent utterances, right? Like two, three word utterances. You're gonna get what we end up with an MLU of, you know, 2.2 to 2.5 with those longer lists. Okay, so you still get, you get a substantial number of utterances that are only core. But contrast that, MLU wise, right, mean length of utterance wise, with that Buchelmann list we saw, okay, on average the length of utterance for the, if they have just, are made up of just the Buchelmann core vocabulary, they have an MLU of 2. 2. Well, if you look at the core and fringe. utterances, right? The utterances that had both core and fringe vocabulary in them, their MLU was at 4. 6. So we went from 2. 2 to 4. 6, and that was consistent across all the longer lists, like we saw exactly the same pattern, the numbers changed a tiny bit, but exactly the same patterns where, you know, a typically [00:52:00]  developing two and a half year old has an MLU of two and a half or three, um, they're getting way higher when they have, they're using all those different words versus just a small, uh, Subset of that, that core vocabulary. So, um, yeah, it did, it did depend on the kind of list, but it was really like, what's going on with those longer lists versus what's going on with those shorter lists. Those shorter lists, especially one of them was really doing the kids no favors at all. Like, they couldn't say anything. With those that we have a whole list in the article. We have a very long appendix that has samples of has all the samples that we used to analyze the MLU data and you can see for yourself what those utterances work that we randomly sampled from that big 10, 000 utterance corpus and they're very stark. And if you want, I can read a few off to you if that's of interest, but, um, Okay. So anyway, it varied depending on the list, but the message was still the same. Well,  Amy Wonkka:  and it makes me think [00:53:00]  back to our earlier conversation just about the developmental language component there. And if we're thinking of 50 or fewer than 50 words, and then you had mentioned that of those first 50 words, about 50 to 60 percent of those are, are nominals, they're fringe words. And then the remaining 40 or 50 percent are core words. I mean, it, it. The research doesn't, research doesn't always make sense and like jive with what seems logical, but in this case, it sounds like it does in the sense that if you're going to have, because our students are all individual and I, you know, you may have motor access or visual complexity that, that necessitates a smaller amount of vocabulary, at least to start off. But I think, you know, for me as a clinician, hearing you talk about that, it makes me think it's almost more important. Is it important to have that balance the smaller your vocabulary is? Yeah. I mean, if,  Cathy Binger:  if all you [00:54:00]  have, like, let's take this as an example. You said, Amy, earlier, you were so excited when you learned about core vocabulary initially because kids had different parts of speech that they need to build sentences, right? But some of those lists, especially the tiny ones, some of them have no nouns on them at all. Like, so you may have the word and. Like, as an article, but you need a noun to attach it to, like, and you may have, um, he or she or it, but it doesn't do you much good if you don't have a reference that you can first refer to. And maybe you can do that by pointing, right? Maybe there's a, there's some multimodal ways, but from a developmental perspective, um, And for Nancy, I promise I'll give you a chance to just like, wind me up and off I go. Keep going. Words like this or that. Um, which are very common on even the very, the shortest core vocabulary list. So those are very, very useful words, [00:55:00]  right? What do you want? I say this while I'm pointing at something or touching something, and I say that while I point at something that's across the room. Those are incredibly useful words. They're very powerful. They are also indicative. In kids with spoken language disorders of a language disorder, because they use those words to cover all kinds of territory. They point to, you know, the pink monkey, when they want the pink monkey, what do you want? That. I want that. Like you hear kids with, you know, preschoolers with language disorders say this stuff all the time, but what they should be learning to say and need to learn to say is the pink monkey. Right, like that's part of development. So, um, you know, we don't want to be teaching our kids to overuse those things. We don't have to, um, in terms of language development, you know, it [00:56:00]  teaches us that. We need to be filling, helping them to learn those words and fill in and using those more precise words so that they can develop again those, that phrasal and clausal and sentence kind of development. Nancy Harrington:  Absolutely. And we also need to think about the different types of words because what we do often with core is perhaps we might have the verb eat. And there might be something very specific that the child wants to eat. Maybe they want to eat cake. No, maybe they want cookies. Maybe they want chicken nuggets. Maybe they want pizza. Maybe they want applesauce. Or maybe they want to eat somewhere else. Maybe they want to go out to eat. But there's But all they have there is eat. They have nothing else. And that's not what we do with typically, how typically developing children learn language and express themselves. And what we're doing is we're, we're kind of almost teaching these metalinguistic skills to try to [00:57:00]  figure out how you can use one word to say lots of different things. But we're, and we're not giving the, providing the vocabulary to. Or those building blocks of language.  Cathy Binger:  Yeah, I think that's something that goes overlooked, and I'd love to hear what Kate and Amy think about this too. That, you know, if you give kids a very, very, very limited set of vocabulary and that's all they have, they're, they're often taught to use that vocabulary in ways that no one else uses that vocabulary. Right, um, and to cover all, like, let's take the word go, right? So I use the word go not just for, as I normally would, but I might use it for, you know, it being in a car and moving forward. I might use it for, I don't know, all, you know, all kind, walking. I might use it for running. I might use it for sprinting. I mean, everything is go, and if everything is go, It's so imprecise that and it's used it. We can teach kids to use it in ways that nobody else [00:58:00]  really does. And then, as Nancy said, like, that can potentially really create a linguist metalinguistic demands on them. And it's not, it's not part of typical development. So, have you, Kate and Amy, have you experienced, like, that kind of thing and this kind of very odd use of vocabulary that you see sometimes when kids only have access to very limited vocabulary?  Amy Wonkka:  I feel like yes and no. I think, um, one, one area that I'm thinking about is just the descriptive teaching approach. So using, you know, maybe two tier two, tier three curriculum vocabulary, and then recasting that back using core or, you know, tier one type fringe vocab. I think that can be helpful. I think that that's a helpful intervention approach. Um, yeah. Not only just to shift sort of the, the way that we're teaching, but also to get people to really think about the definitions that they're, that they're giving students who, who probably might not have room on their [00:59:00]  AAC system for that, like tier two, tier three vocab. I do think. You know, back, back in the day, back in the day in the nineties, early 2000s. Yeah. I mean, I think that that, that sort of what, that was my takeaway and it could have been, you know, I took away the wrong message from some of the, the PD that I did. Um, but my takeaway was sort of, you're better off teaching that, uh, sort of less. Typical phraseology because it could be more versatile. And I think now the more nuanced way that I would look at it, particularly through the developmental lens would be like, okay, but is that something that is that a clinical choice that I'm making? Because we have actual real limitations on system size for this particular person. Because I do think that is true. That is true for some communicators and that might be where you think about that. You know, like you were saying, Kathy, with the, this and that, like, okay, if this person, okay. I mean, one thing that pops up on systems is like high and [01:00:00]  by, well, if you, if you are able to move your body and gesture like that, perhaps we can give that real estate to something else. Kate, I don't know if you've seen sort of that. That funny funny utterances as a result of of limited access to vocab.  Kate Grandbois:  I definitely have and I I think I've seen it play out in a couple of different ways. Um, One of the things so I tend to work with, you know, emergent communicators and One of the things that I have seen quite often is an over reliance or a clinician over relying on core when the situation that you've just described and, and having the concern that these are very ambiguous terms, right? So the go looks different, running looks different when even just a verb, running looks different when you do it, then versus core. Then when I do it, when it's slow or when it's faster and within different contexts. And I think that there, you know, is [01:01:00]  definitely. I've seen some issues growing out of this limited approach where we have, you know, we're not really acquiring a lot of, you know, there's really, really slow progress, if any progress at all. And then the recommendation is, well, we're not modeling enough or there isn't enough immersion. Um, and, you know, there might not be enough attention paid to some significant executive functioning components or sensory need, you know, sensory needs that are, are kind of mapped onto this. I also see. The limited vocabulary, um, and rigidity play out in terms of making almost the swinging in the complete opposite direction, making things entirely too specific. So, you know, choosing vocabulary that means something to that particular individual, but outside of this educational context, no one is going to know what this one tiny thing is. I think that the decisions that get made for [01:02:00]  vocabulary Um, they tend to be like going back to the beginning of our conversation, really heavily influenced by so many other variables, um, based on the context and the environment and the workplace culture and knowledge gaps and, and all kinds of stuff. And it's not great when it's limited in either direction.  Cathy Binger:  Well, and there's another factor we're talking about variables that that all that made me think about, which is motivation. Um, what little kids learning language is really exciting. They love words, you know, kids who we're talking about, you know, kids who are symbolic and kids who are, are have that, um, cognitive ability and blah, blah, blah, who are, who are learning more words and, you know, being able to say, Hey, Again, let's go back to our vehicles routine and saying go for everything every time you're moving a vehicle is one thing, but being able to say crash is another thing [01:03:00]  altogether. Right. And then laughing, you know, you see kids like, you know, just being able to talk about that. Um, and, you know, Even to little tiny things. Well, yeah, so I'll just put a put a, um, ending on that, like that, looking at how motivating, um, vocabularies in different contexts, I think is, is something to remember. If you ever get a chance to just look at typically developing little kids in the vocabulary that they, that they're using, and they're so excited about. And that reminds me of another point that we haven't talked about yet, which is grammatical morphemes. Nancy mentioned earlier that we give kids access to those early on, depending on where they are in that developmental, um, using that developmental model again. And I think we tend to think about grammatical markers as fluff. Right? Like why would you take up real estate with something like an ING and Amy, I see you nodding your head very [01:04:00]  vigorously. Yes. Vigorous nod. The fact is, um, at least the part little kids. Start using grammatical morphology so early because it's really useful like even take something like a versus the write something indefinite versus definite there's two very different meanings to those two words or Plural versus singular. There's a big difference between cookie and cookies Ask for cookies That's right. It's a lot more fun to ask for cookies. So, um, you know, that, that using that developmental model helps remind us. Um, the, the, when that comes in and how early that comes in. So what were you thinking, Amy, when I was talking about that? Amy Wonkka:  I was just thinking it was a good example of one of those funny gaps I was talking about. We might be working receptively on find, find the plural, find the cookies. Find the crayons, [01:05:00]  but we've never worked on it expressively so that so that student didn't even have access to play around with that concept. Yeah, like they would have if we had. So yeah, I just had a big, big head nod feeling, head nod feelings. But, um, I think it's, I think because so much of it is also tied to bigger concepts, right? It's tied to when we think about verb tense markers, that's also tied to ideas about time. And that's such a, that's such a big, that it's such a. Piece about narratives and, and being able to talk about something that's happening already happened is going to happen. Like there's all these funny, and I'm guilty of the, like, that's fluff and shouldn't take up space by the way. So like, if anybody's listening.  Cathy Binger:  Right. We don't want to Nancy and I've been very spoiled, at least in our research. And this has been a choice of working with kids who are direct selectors and who don't have, you know, who, who, who can access a number. Of symbols using direct selection, and a lot of you out there [01:06:00]  are working with kids for whom that is not the case. So I don't want to in any way, um, minimize the, the challenges of working with kids who have really significant access issues. Um, and you do have to maximize use of that real estate. I just. I think that, um, we're not, well, I'll save this point till, well, I'll make my mic drop moment now. We're not done, people. I love it. We're not, we're not done. We're like, we, I think about the, um, quote all the time about looking at things with this passionate objectivity, right? Like, where are we as a discipline? Um, as soon as we think we're done growing and as soon as we think we know everything, um, we're toast. So we have there's so much we don't know about how these things work over time and how to best facilitate what's going on with his kids and how to merge. All the real life [01:07:00]  issues of working with kids in whatever setting, um, that are very challenging and very challenging and that we need to be working with our instructors and our teachers and our educators and our speech language pathologist to help develop interventions and have their input. Um, so that what we are meaning researchers are developing is truly useful for them because we built it with them and we have so much growth to do in that area. So I don't want to gloss over all of that. That stuff is so profoundly important. And so is using a developmental model to help us know where we're best supporting these kids and and where their gaps are. Kate Grandbois:  Well, I don't, I mean, I think that was a wonderful way to kind of tie it all up. I think that you just nailed it. Mic drop. We're done. I think that's it. I really just appreciate this entire conversation. And I, I want to second the importance of [01:08:00]  not, of just acknowledging that we don't know what we don't know. And that research is, you know, You know, sometimes it's limited. Sometimes there are practices or things that we're doing where, you know, there isn't, you know, it's, it's evidence informed, but we don't have 20 years of empirical data yet. Right. Um, and I, I really appreciate just pointing out that we, you know, We're going places, right? Oh, the places will go that, you know, we're not done.  Cathy Binger:  That's right. That's right. And we're just figuring out what questions we should be asking about some of these things. You know, we just can't get complacent.  Kate Grandbois:  Well, thank you both so much for being here. This was a really wonderful conversation and we hope you'll come back. Cathy Binger:  You know, I'll always come back. What about you, Nancy?  Kate Grandbois:  No pressure, no pressure. Thanks again. This was really great.  Cathy Binger:  Thanks, guys. Appreciate everything that you do. [01:09:00]   Kate Grandbois:  For sure. Thanks so much for helping to get the word out.  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 Sponsor 1 Announcer:  This episode is brought to you in part by listeners like you and by our corporate sponsor, Ventris Learning. Ventris Learning's culturally and linguistically responsive teaching resources help speech language pathologists, reading specialists, and teachers more effectively meet the assessment and instructional needs of [00:02:00]  all students, including those who tend to become underserved in language and or literacy. To learn more, visit www.ventrislearning.com .  Episode Kate Grandbois:  Hello, and welcome to SLP Nerdcast. We are so excited For today's episode. We are here to talk about a topic that is very near and dear to our hearts. Collaboration is something we talk about on the podcast all the time. And today we have the pleasure of welcoming two expert guests. Welcome, Becca Sylvia and Christy Stearns. Kristi Stearns:  Hi. Thank you for having us. We're thrilled to be here.  Becca Sylvia:  Hello. We are.  Amy Wonkka:  Now, Becca and Christy, we're excited to have you with us here today, and you're here to discuss, like Kate said, how to effectively collaborate with other professionals as a speech language pathologist. But before we get started, can you please tell us just a little bit about yourselves? Kristi Stearns:  Sure. So this is Christy speaking. Um, I am a speech language [00:03:00]  pathologist. Becca and I, um, well now I'm bringing Becca in, but Becca and I met, um, I think that's important to the story, Becca and I met as, uh, First year grad students in Massachusetts, and that's how we became friends and also co founders. Um, but as for me, I'm originally from Florida, um, went up to Massachusetts for grad school. I did some work up there, um, worked at schools for, um, autistic children and individuals with developmental disabilities. Um, did a high AEC concentration. I really enjoyed doing that and also working with, um, that upper school age. So like 14 to 21. Um, and currently I'm back in Florida and, um, Yeah, I have a little three year old and, um, back where my husband and I are from. So it's been, it's been very enjoyable and it's been really nice to be able to maintain such a nice friendship and collaboration [00:04:00]  with Becca once we started communication community. So happy to be here.  Becca Sylvia:  Yes, so I am Becca. I was born and raised in Massachusetts. As Christine mentioned, we met in grad school. After grad school, I moved out to Colorado and started my career in speech language pathology, doing a lot of AAC, high tech AAC. And then moved over and did some stuff in the schools and, um, Christie and I started communication community, our blog originally with the main focus on a C, but then kind of a little bit of everything. And so it's been awesome working together in this kind of professional capacity for a number of years while also being really good friends too. Just great.  Kristi Stearns:  I'm sure the two of you can relate in a way, you know, working with a friend and also, [00:05:00]  um, you know, someone who holds you accountable, at least for me. Yes,  Kate Grandbois:  definitely. There is nothing better than having a partner in crime, a partner in nerds. A nerdy kindred spirit. It's good. Yes. Yes, to keep moving, you know, moving things forward and having another brain in the room. It's just so great. And we're So glad that you have agreed to share your, your hive mind, your, your knowledge, your shared knowledge with us today as it relates to collaboration. Um, I do need to read our learning objectives and disclosures before we get started, so I will do that as quickly as I can. Learning objective number one, list the six competencies for interprofessional collaboration. Learning objective number two, describe generational communication styles. And learning objective number three, describe collaboration through personality awareness. Disclosures. Becca's Financial Disclosures. Becca is a co-owner of Communication Community, LLC, and an employee of a health tech [00:06:00]  company, Becca's Non-Financial Disclosures. Becca is a member of ASHA and Co-managers, the Communication Community blog, the Circle, community and Social Media Accounts. Christie's financial disclosures. Christie is a co owner of communication community LLC. Christie's non financial disclosures. Christie is a member of ASHA and co manages the communication community blog, the circle community and social media accounts. Kate, that's me. My financial disclosures, I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and 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. Uh, my financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast. And my non financial disclosures are that I'm a member of ASHA Special Interest Group 12, which is AAC. Uh, and I [00:07:00]  participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right. Learning objectives done. Disclosure done. Um, Becca and Christy, why don't you start us off by telling us just a little bit about why you're here? interprofessional collaboration is important for SLPs? Why is this something that we should care about?  Becca Sylvia:  Yeah, I mean, I would say there's a lot of reasons why you should care about it. But I would say the number one is like collaborating effectively can lead to better outcomes for clients. So that's kind of what we're here for. We want our clients to have good outcomes. And there's lots of things that go into having good outcomes. And one of those things is that collaboration with clients. the clients, their families, but also like the team and other professionals. And so, um, we believe that by understanding different communication styles, collaboration methods, different things like that, can improve collaboration and then [00:08:00]  therefore outcomes across disciplines. Kristi Stearns:  And I think that's reflected in some of the studies that we'll reference today as well. You know, the objectives that Kate outlined at the beginning of the podcast. You know, we will talk about competencies for interprofessional collaboration, generational communication styles, and collaboration through personality awareness. We pulled from different research that, um, hit. Several different collaboration areas. Um, so yeah, the competencies generation, then also, you know, those personality assessments and we thought it was an interesting area to explore because for such a. deeply personal field where we have, we're on so many different teams. I don't know a lot of other professions where we're operating in so many different groups. [00:09:00]  Even though you have these, uh, other professionals that you work with day in and day out, and whether it's a healthcare setting, school setting, you also, there's that component of adding, you know, a whole other client and their caregivers and families. And so, operating in a very healthy, constructive team environment, in a collaborative environment, is so, so important, I think, for our, for our clients. Um, professions specifically. Becca Sylvia:  All right. So we can start by talking about the six competencies for interprofessional collaboration. Um, this was, um, there is an article by Bainbridge et al that discusses essential competencies required for, uh, effective interprofessional collaboration in healthcare settings. So, um, there was a framework developed by the Canadian Interprofessional Health Collaborative, also known as the CIHC, that basically their [00:10:00]  goal was like, we want to enhance teamwork among healthcare professionals so that care is efficient, coordinated well, and patient centered. So all those things that were like, these are all. Great things, you know, um, and so frameworks can be helpful sometimes because it could really kind of lay out very specifically like here are some kind of areas to focus on, um, and, you know, they're kind of can be refined over time. But I think it's we thought it was really helpful. And we really liked how they kind of laid it out. Um, and so we can talk about each of those six ones. So, Chris, if you want to start with the first few Okay.  Kristi Stearns:  Yeah. Um, so as part of, um, as part of these competencies, one of the main competencies, um, is role clarification. So, um, you know, with your team, what is each person on the team going to do to support the client's overall goals? So what are. Essentially, what out are your, [00:11:00]  um, roles and responsibilities on this team? Um, so it's incredibly important that while you understand your role and what you will bring to the team, um, and those, and those responsibilities clearly, clearly outlined, you're also aware of the roles of others, kind of like the, Okay, once you know your role, you know what lane you're staying in and you know if maybe you're getting too close to someone else's lane. Um, so that gives you the ability to recognize boundaries and, um, the scope of practice for each professional. And I think when those are outlined, um, we can perform our best and, uh, our strongest for our clients.  Kate Grandbois:  I just want to make a quick comment based on something you shared earlier about how unique our field is because we're touching so many different aspects of student care, client care, patient care, whatever word you're using. We also have such a shared scope of competence. We share our [00:12:00]  scope with, uh, special educators. We share some scope with literacy specialists, with behavior analysts, like it or not. Um, if you're working in a hospital setting, you might share, you know, some aspects you might be having. disagreements with your ENT over, over something that you're seeing or whether or not to recommend a bedside or I don't know, I'm not, I'm at SLP. So I don't really know what I'm saying, but my point is, you know, we share our scope with so many other professionals that understanding your role, I have to assume is a critical piece of being able to collaborate effectively without getting grouchy because sometimes you feel grouchy.  Kristi Stearns:  You're, I mean, yeah, you're absolutely right. And I think that, um, also considering that each setting may be doing something different. Um, and those roles may look a little bit different within each setting. Of course, we have our, you know, our specific clinical roles and responsibilities that we can't waver from [00:13:00]  too much. But, you know, you think about some of that. Um, I know you were mentioning the feeding and swallowing piece. You know, there is. There's a lot of overlap in health care settings in that, um, in that space. So making sure that whatever setting you're in, that those roles, um, are Very explicitly clarified and that can that's also a prevention measure for some of the that conflict because maybe in another setting you were way more hands on with that particular role that maybe the O. T. is taking more of a lead on and that's more of the general team expectation. Um, so making sure that that is clearly outlined is what's going to be. Healthy for collaboration with the team and then also, um, that it obviously reflects on the client as well.  Amy Wonkka:  I'd imagine too that when you're clarifying your role, that in and of itself could be promoting collaboration because hopefully [00:14:00]  you're having a conversation with these other providers and talking about the overlap and talking about what's going to happen. So just by the nature of that conversation, you're sort of setting the stage for some collaboration there.  Kristi Stearns:  Exactly. Um, and then that kind of leans into, um, another competency, which is team functioning. And that's essentially looking at how will the team function together to support one another. So we definitely need that role clarification to be able to understand how the team as a whole is going to operate. Um, So this is very important for working effectively within those all of those different team environments for all of those different clients and families. Um, and when you have those roles in place and when you understand the different team dynamics that fosters more of a sense of mutual respect and promotes, um, that positive [00:15:00]  collaborative atmosphere.  So in essence, um, having the role clarification contributes to team functioning and that continuous collaboration that it's important to check in, um, on a continual basis versus just establishing those roles at the beginning of the school year, so to speak. It's important that we continue to check in, um, to ensure that continuation and the team, the maintenance of the team functioning.  Becca Sylvia:  I also think, too, if you have good role clarifications, it can be helpful on a team if, say, someone is out, then you can know, okay, well, this person normally is the one who makes sure that this student's AAC device is out and charged in the morning, but I know that they're absent today, so someone else can kind of fill that team member's shoes for this instance, and so that's a way to kind of, you know, support the team, support each other when [00:16:00]  someone Can't fulfill their role for a day for a specific reason. Kristi Stearns:  Um, and another area of, um, the six competencies for interprofessional collaboration is that interprofessional communication. So we've covered the role clarification. We've covered, you know, roughly how the team is going to function and check in with one another. Or I guess more of the frequency, right? We want it to be continuous, so that interprofessional communication, that's what that collaboration is going to look like in essence. How will the team collaboration be maintained? So, um, whether that be You You have a meeting at the beginning of the year and outline what that might look like for you and your team. Do you want to meet on a weekly basis? Do you want to meet in person? Do you want to have, um, email, slack, [00:17:00]  messenger, whatever? You're using check ins, um, but making sure that that interprofessional communication, everyone is on the same page with as well. So making sure that, um, this communication is clear, respectful, um, you know, there are timely exchanges of information, um, because this is, you know, timing is everything in our profession in a lot of ways. Um, I think I was listening to One of your podcasts earlier this week, and, um, I know that in different states, certain evaluations have, uh, uh, one time frame, and then in other states, it may be a longer or shorter time frame, so making sure that those time markers are also there because, you know, say you're submitting information for an IEP, for example, um, okay, well, if you're submitting that information on the last day, But you have five other members of the team who also need to look at that documentation and make their, um, [00:18:00]  edits or revisions or what have you. Um, that's incredibly important.  Kate Grandbois:  I want to make one comment about interprofessional communication. And wanting to make sure that one of the things that I found to be most successful is bringing humanity into those conversations and into that communication. So the colleague that you're communicating with is a human first and a professional second. Um, I've had, I have found that a lot of friction in interprofessional communication can stem from not having that human connection, so not understanding that someone is having a really bad day, or maybe didn't sleep, or is having a crisis at home, um, or even approaching communication with this underlying sense that your objectives are more important, or your objectives are more urgent, and you, you might end Talking about this later. So I don't want to, I don't want to put the carpet for the horse, but I just think I, I so value you bringing up the competency of [00:19:00]  inter interprofessional communication because it isn't just about timeliness of, uh, your workplace or, or, you know, the word, whether or not you use an exclamation point in your email. I mean, there are so many layers to making sure that that goes well. And I think so much of that is rooted in, in being a person, just being a human being, connecting with a human being.  Becca Sylvia:  Absolutely. Absolutely. You know, there's so many times where, like, you might get an email that's like, you're like, are they being a little stucky? Am I reading this the wrong way? And as much as you want to say, like, it's fine, I'm just going to, you know, forget about it. It can impact you when you're going into your next session, you're thinking about it. And so, and that. can impact, you know, outcomes in general. So yeah, having that like frame of mind of like, let's have strong communication because that does touch everything, whether it be directly or indirectly. Kristi Stearns:  Yeah. And approaching. Yeah. [00:20:00]  Like Kate was saying, um, each person as another human, you know, you're not just this bot on the other side of your email screen, you know, they entered this profession to what I would like to think it You know, to, um, you know, care for clients and make sure that they receive the best outcomes and care. Um, and a lot of this too, I know that these six competencies are a little bit more, um, uh, I don't want to say the drier area, but these are a little bit more clean cut guidelines, so to speak. And they're very important, but I think the big picture too, with all of this discussion about collaboration is that, um, All of these objectives that we're going to discuss require perspective taking. And it seems so, um, it seems so basic, but it's not, you know, it's important that we have that awareness and we can perspective take [00:21:00]  not only, you know, have that knowledge for teaching our clients in some respects, but we need to practice that and model that as clinicians and, um, professionals and when we're working with others. So,  Amy Wonkka:  well, and I have to imagine that perspective taking also. Slides into the next component when you're thinking about your actual clients and their caregivers Um, I don't know if you wanted to talk to us just a little bit about what are some of the components there That come into play when we're thinking about this interprofessional practice. Becca Sylvia:  Yeah, I mean A big one that I know people hear about, we talk about is that patient or client or family community centered care. So at the end of the day, like the, the needs and the preferences of the client, like that is what's most important. And so understanding their perspectives and their values. In this decision making process is [00:22:00]  really important. Um, and that may mean that like roles may shift a little depending on a client themselves because of their situation because of their preferences. Um, different, you know, different scenarios and so understanding what like their goals are cultural considerations their interests. Um, you know, if say for example. They are, they primarily speak Spanish at home and there's one member of the team that doesn't do a lot of the daily communication, but they speak Spanish and they can say, you know, I can take on this role for this family because it's important to that. They have we have daily communication with them because we know that's important for this family and I can. Do it, and I can speak to them in Spanish or communicate with them in Spanish versus another family that might say, I do not need daily updates unless it's an emergency. You know, like, I prefer weekly updates and someone else can give me those weekly updates. [00:23:00]  That is when those understanding of working together as a team of doing one person's doing one of the other. But at the end of the day, it's so that the clients are centered. Um, and so another competency, and I think this is something that is, can be difficult, but I think it is important to, to kind of have an idea about, is that interprofessional conflict resolution. Because as much as we would love to not have conflicts, conflicts, Are going to come up. And again, this might be complex within the team itself, or it could be there could be a conflict with a client because something is going on that they there's a conflict that needs to be resolved. So being able to address conflicts rather than trying to kind of sweep the munch of the rug, I think is important. Um, and then kind of also being able to understand of [00:24:00]  recognizing sources of conflicts to say like, does this happen because the communicate, we're not meeting regularly enough? Is this, is conflict happening because the roles aren't clarified well enough and there's some overlap or there's an important Job or test needs to be done and no one's assigned to this role. So it's just keeps getting missed. Um, kind of trying to figure out, like, why is this conflict happening and what can we do to address it and try to mitigate it so that it we do not deal with it again, or it's, you know, lesser, I think, can be, um, is helpful. Um, and I think kind of what you had mentioned earlier to key about like, these are humans. So like, let's try to stay positive. We are all humans. Let's be want to stay positive. We want to offer constructive feedback. We don't need to, you know, do the blame game pointing fingers all the time. Um, because that doesn't really, you know, that can hurt rapport, it can hurt [00:25:00]  collaboration. And so Um, being able to kind of find ways through conflict resolution is an important piece of being able to collaborate effectively for sure. Kate Grandbois:  What you all are saying about This these components of humanity is making me think of a little story I heard once called the baby in the backseat. Have you heard this story? I swear. I'll make it very short. No, I'm so intrigued. But essentially, Amy, have you heard the story? Have I said this to you before?  Amy Wonkka:  Yes.  Kate Grandbois:  Yeah. Okay. So hopefully our listeners and you all will get something out of this and it's not totally off topic, but essentially the story goes where imagine you're in your car, you're driving to work, you are late, you've got coffee that you've spilled in your lap and you, you, uh, you end up hitting every red light on the way to work and you're sitting at a red light and the light turns green and the car in front of you doesn't go and you're like, what is going on? And you get so frustrated and [00:26:00]  you start laying on your horn and you're like, I am so late. The light cycles to green, the light cycles to yellow, and then to red again, and you're like, I can't believe this, you become increasingly more enraged. The light cycles to green again, the car still doesn't go, you can see the person in front of you fiddling around with something in their bag or something in the back seat. And you decide that you've had enough, and you're so angry, so you get out of the car, and you storm right up to the front door, or the window, to yell at the person, why aren't you moving? And you see that the woman is stuck and can't get her seatbelt open, her seatbelt off, and her baby is choking in the backseat, and there is an emergency. And all of a sudden, in that moment, Your anger goes dissolves immediately and you are, Oh my gosh, this is a person who needs my help and you go right in to help the baby in the backseat. So the point of this little story is you never know when someone has a baby in the backseat. And I, I carry this with me as a little story of if someone is being grouchy at you, if there is a conflict, if someone is being snarky, You never [00:27:00]  know what someone else is dealing with in their personal life and trying to remember that there could be a baby in the backseat. There could be something going on instead of taking it immediately personally and retaliating or talking to your supervisor or. Sending a snarky email back that doesn't have any friendly exclamation points. You know, there are so many ways that we can handle ourselves in conflict, holding space for what someone else might be experiencing that we just don't have visibility to. And that's my story. I won't take up any more airspace, but hopefully that was helpful. No,  Becca Sylvia:  I think that's good. And it made me think of a time when I had a supervisor who said it in a different way, but basically was like, You're there are going to be times where you can't give a hundred percent. So, or like your team members can't give a hundred percent. And I think of it in the sense of number one, okay. Recognizing yeah, that my coworkers or other people I work with, they, because of what's going on in their personal life, they have a baby in the backseat. They can't deal with it. I guess for me, and we'll go into, I guess, like personality [00:28:00]  styles a little bit later. It gives me permission to also to say, okay, sometimes I have a baby in the backseat and it's okay if I can't. Give my a hundred percent because we are humans and like, that's okay too. Kristi Stearns:  Yeah. The, the lack of, uh, you know, I'm putting quotes around this, but the lack of effort, so to speak, is not coming from a place, you know, I don't want this client to succeed, or I want our team meeting to start 10 minutes later. Um, you know, when we can stop and pause and think about, um, like the two of you were saying, you know, think about, okay. I don't think that this is an attack on me. I think maybe, maybe they had a stomach ache. Maybe they needed to take a little bit more time before the meeting and that's why they were late. Um, I've had stomach aches before. I'm sure other people have too. You know, I, I think it's important to stop and actually consider like, how involved are you personally in this matter, for sure. Becca Sylvia:  And [00:29:00]  that leads well into the final competency, which is collaborative leadership. So the idea that leadership roles can be shared within a team, it's not up to one person to be the leader. And so that way, if that one person is, you know, Can't give full effort for whatever reason or has a bigger role to fill one day, other people can kind of take the lead. So, you know, an example of this is if you do have a standing, you know, weekly meeting or monthly meeting where you talk about the clients, the plans, You know, action steps, all of that. Different people on the team can kind of be the person who leads that meeting and, you know, organizes it together or kind of summarizes the meeting minutes at the end and leads out to say, you know, after the meeting, you know, it's my job today to say, okay, [00:30:00]  Christy's going to do this, and Amy's going to do this, and then the next month comes around, and Christy's that person who does it. So kind of understanding that leadership roles can kind of change, and other people, people can take different leadership roles or different times, I think is also helpful to know that like, yeah, we're not stuck in like a, we made this decision once, and now it's going to stay like that. Until the end of the year or the end of whatever. All right, so those were the six competencies, the kind of that overall framework. So the next area we're going to talk about is the generational communication styles. And so it's important to understand that generational differences can affect communication. With the caveat caveat that like we're talking about generational trends, not like prescriptions of saying this is what it's Gen all Gen Xers are like this or all boomers are like this because that's not true. And we know that, but there are [00:31:00]  trends and these trends come from, you know, surveys reports, um, based on things like significant global events, cultural, cultural shifts, development of technology. You know, we're saying that a lot of. You know, the Gen Z population is really into technology versus maybe boomers aren't well, guess what? Like the technology wasn't around when boomers were growing up. So it's not that it's not that they're choosing it's that they just, it's kind of based on cultural and life. Um, but that being said there, you know, certain trends and we think just kind of having that awareness of that. There are some generational trends can be helpful. So again, seeing that humanity. And the people you're working with, um, is helpful and kind of understanding why they may think things a certain way or might approach things a certain way or have different opinions may be impacted. By the generation that they grew up in. Um, [00:32:00]  so, you know, we'll talk about kind of the overarching trends of the generations that we would see in the workplace today and kind of their, you know, rough age. We also know that like, if you're kind of right on the cuffs, you might feel like, Oh, I really belong to this generation or whatever other generation, but more or less. Um, the first two we'll talk about are baby baby boomers, which are around age 60 to 78. Um, and for communication styles, they tend to favor the face-to-face communication. And then like more, um, you know, like formal. respectful interactions, more of that like traditional communication style. Um, the next generation, so generation X or Gen X, roughly ages 44 to 59, um, less of that like face to face traditional communication and tend to perform more of the concise [00:33:00]  communication, efficient communication, let's kind of like get the job done. Kristi Stearns:  Um, yeah. That's about right. What would you say,  Amy Wonkka:  Amy? That resonates for me as a, as a, as a Gen Xer.  Kristi Stearns:  Yeah. Well, and it's, it is interesting because the information that we're reviewing and these communication styles that we're discussing across, you know, boomers, Generation X, Millennials and Gen Z, this is polled, what was the survey? It was like over 400, 000, um, individuals. So like, these are self reports of, you know, um, You know, this is my age range. You know, they're circling their age range and this is their preferred communication styles. And again, I think for me, um, you know, I would fall personally into the millennial range, but I see different, um, communication trends from other, um, generations that I, that I also, um, would subscribe to. So again, these are, these are more of just trends, but by, [00:34:00]  um. Understanding that these different preferences do in fact exist, it gives us a little bit more of that exposure and awareness that, okay, if I'm someone who only wants to chitchat via email or via workplace digital messaging, and somebody else really wants to meet with me once a week in person, I'm not taking that as, wow, This person has no respect for my time. You know, I know that this is more efficient, but, you know, why do they want me to meet in person, you know? And there's so many more layers than that. Um, and that's not really true to me because I, I love meeting in person. So, um, yeah, I actually do. Becca and I differ in that respect and somewhat. Becca can do more on, um, uh, my, I need more in person accountability and Becca likes that. Corresponding via email and in messages. But anyways, um, [00:35:00]  so yeah, Becca covered Baby Boomers and Generation X. Um, so Millennials, that's, uh, another generation that is roughly between, uh, the ages of 28 to 43. So this is the generation that's a little bit more comfortable with digital communication. Again, a lot of that has to do with cultural shifts in the development of technology. Um, You know, we tend to, we Millennials tend to value feedback, um, and collaborative approaches. Um, so this might look like, uh, higher energy collaborative environments that appreciate real time feedback, often communicated through digital platforms. So, um, I can say for myself, I really, like, I think back to grad school, and I loved the immediate feedback. I walk out of a session, and my supervisor is holding up a list of things for me to improve, like, I [00:36:00]  really enjoyed that, um, while I know that there are other individuals who want to wait till the end of their week so they can get all of the rest of their Um, documentation done without distractions, and that's not something that they need to consider. Um, so roughly that's, you know, Millennials, and then our last generation that we explore is Generation Z, Gen Z, which is, um, 27, roughly 27, um, years of age and younger. So this is more of that, um, Technology has, from a cultural perspective, has really evolved, um, for them as compared to, you know, Millennials, Gen X, and Baby Boomers. So, Gen Zs are described as highly digital, um, they're a little bit more accustomed and have the expectation of multitasking, um, Generations, you know, Gen Z might expect a little bit more of a fast digital communication is and is adept at navigating multiple [00:37:00]  communication channels simultaneously. Um, I, I. You know, I'm making a generalized statement, but, um, I know several different business professionals that they have someone who is, falls into the Gen Z generation, um, managing their social media profiles. Um, you know, I think of some of my younger cousins who are in their early 20s and they also are starting a business ventures with the interest of doing that. Um, whereas I don't. personally have that type of capacity. Um, but I love to see it, you know, and it just goes to show that within each of these, you know, uh, rough generational ranges, there is so much that each can bring to the table in different ways and to kind of highlight those strengths more than see them as differences. But it is important to be aware [00:38:00]  of. Maybe some of those preferences, whatever it may be, whether it's generalization, general consistent with the generation or not. Um, you know, it can help you with, uh, that teamwork and collaboration. And maybe, you know, maybe you're taking a, uh, approach where, um, we have one, uh, colleague who really prefers those in person meetings. We have another colleague who, um, You know, wants to do a little bit more messaging and emailing. Okay, maybe we work with a hybrid approach. Maybe we meet in person once a month and then we have those digital weekly updates at the end of each week. So again, just meeting. Your team where they're at and, um, having that mutual understanding,  Kate Grandbois:  I think mutual understanding there is key because I can already hear the voice like, Oh, boomer or Oh, God, what a gen gen Z, you know, rolling there, [00:39:00]  rolling your eyes or making the assumption that the way that someone else prefers to communicate is in a front somehow to you or disrespectful. And I think the point here is understanding. that other people have preferences and it's your job as a respectful colleague to acknowledge those preferences, maybe not accommodate those preferences all the time, but not take it personally and sort of look at it through a lens that can diffuse any of any of that conflict. Becca Sylvia:  Yeah, I know, you know, Kristi and I had talked about it a little bit, especially in, I would say, our field, whether you're in a school on a special education team or you're in like a SNF and you can have a rehab team, you may have, you know, co workers who are, you know, on the same level as you in terms of like, same degree, same credentials, same like general responsibilities, and you could have, you know, You can have an OT who has been practicing for over 30 years, and you can have a speech [00:40:00]  therapist who just finished their CF and are, you know, one year out of practice, and they're kind of, you have to, in collaborating together, in a sense, and I know, um, so my mom is, has been a school based OT for over 30 years. When she first started, like, there wasn't email. So, you know, obviously, things have evolved. She uses email all the time, but that's not her first thing. method of communication necessarily. Maybe it is. Sorry, mom. But you know, in the terms of versus someone of her, you know, newer OT or a new speech therapist who is Gen Z and is, you know, just finished, just graduated school and that's all they know. And so the sense of like this, we have to kind of collaborate and work together and know that. There are that someone what someone might prefer or go to is based on their experience rather than trying to be like, this is the best way that's just like, this is what I'm doing, what I'm [00:41:00]  more comfortable with. Amy Wonkka:  Well, and I'd imagine it really, really connects to the interprofessional communication component that you guys were talking about. You know, I think when you're building, uh, When you're identifying the roles and you're, you're identifying whose, whose scope is what, um, and you're figuring out, okay, what is the best method of communication? I think maybe having some explicit conversations just like you did about the roles would be helpful in terms of what is your preference for communication style? Um, because all of these are areas where, you know, I think, I think about some of the collaboration that I've done in, in my role in schools and in outpatient settings. And, um, Do you sort of just go into the mode? Okay, this is how we do this. This is how we do this. And I've never even paused to gather information about how the other people I'm collaborating with would actually prefer to meet or receive information or communicate. So it's also very connected to that for me and hearing you guys talk about it. Becca Sylvia:  Absolutely.  Kristi Stearns:  And I think just [00:42:00]  as a closing consideration, um, again, your personal preference or maybe a colleague's personal preference may not be consistent with their quote unquote generation, but so it's important to not generalize or stereotype entire generations. Um, but, you know, this data that we've shared is from a student. very big survey. So these preferences do exist. Um, and that I think is the most important to recognize that people will just have different preferences. And, um, just, Use respectful language, you know, use neutral, respectful language when describing generational traits. Um, you know, rather than saying older generations are out of touch with technology, you know, you can say different generations may have varying levels of comfort with technology. You know, I think of my parents, my dad has always been ahead of the curve. You know, he would fall into that boomer range, but he is incredibly, incredibly, incredibly tech savvy. And what, [00:43:00]  whereas my mom. Who falls into that range. She needs support with opening up her Outlook and email and that sort of thing. So, um, again, there's You can't just fully full on stereotype and focusing on those strengths and emphasizing the different strengths that each, um, colleague or, you know, um, each generation, so to speak, um, contributes, um, is very important than perceiving things as differences or weekend weaknesses and that, um, you know, and this also applies. We talk about, um, You know, successful collaboration. But again, this also goes back to when we're collaborating with clients and their families. We're working with, um, a very wide age range, um, of clients and family members. So, um, make sure to also include if this is something you're exploring in your workplace, um, how generational diversity can enhance that collaboration and creativity rather than just [00:44:00]  you know, framing them as differences or feeling like you have obstacles when you're working with certain clients and families. Um, so all starts with communication. Just have, have conversations about it. Yeah. Um, and I think we're ready to talk about, um, the ocean framework.  Kate Grandbois:  Yeah. I'm really curious to hear these about these components of personality awareness.  Kristi Stearns:  Yes. So I think, you know, we, we went back and forth how we wanted to structure these different objectives and I think that the personality awareness using the big five ocean framework, which is what we're going to talk about ties in nicely at the end because you can look back at some of those six competencies for inter professional collaboration and some of these generational differences. And you can. A lot of that will interweave with some of these, um, big, some of this big [00:45:00]  five framework, um, and we'll talk about what that is, and we're digging a little bit more into the, the personality of, um, different people, so that's, that's fun. Out of curiosity, Have any of you taken a personality test before you either applied to a job or during like a workplace, um, like seminar or workshop? Kate Grandbois:  I have. I'm, I'm like the rare psycho killer one. Every, every time. No, I don't  Kristi Stearns:  think  Kate Grandbois:  that one's in here, but. It's not a psycho killer one, but I, I, I can't remember the acronyms, but I'm the, I'm the, The really rare personality type that makes people look at me weird. Like  Becca Sylvia:  when I took my Harry Potter sorting and I was a Slytherin. Yeah. That I don't know how, um, valid that test that I took was, [00:46:00]  so, yeah, I think it's more valid than my, than my personality test.  Amy Wonkka:  Has the Harry Potter sorting test been empirically validated this year?  Kristi Stearns:  Wow, we submitted the wrong paper, everybody.  Kate Grandbois:  Yes.  Kristi Stearns:  Wouldn't that be fun if we were all indifferent? A different house. That would be it. That would be fun. I feel like I  Kate Grandbois:  can feel like a live podcast recording coming on speech pathology and the Harry Potter sorting tat sorting hat research. There's going to be some good research coming out of that. But anyway, I didn't mean to derail you. I have I have taken one of those tests. Kristi Stearns:  Well, maybe some of the questions or some of the findings. Let us know if any of that is consistent with some of these areas that we're describing. I know that there are, there are a lot of different workplace personality assessments. I know like Myers Briggs is a really common one, and I know there's like 16 or something. Um, but the big five ocean framework, which we are going to talk about, [00:47:00]  um, There are five personality traits. And so, um, let's talk about how some of these personality traits can further enhance collaboration. So, uh, the big five personality traits, uh, also known as OCEAN. Um, that's an acronym for each of the individual personality traits. Um, it's often used by psychologists and offer a comprehensive framework to understand individual differences. Um, again, understanding and awareness is, um, There's a theme here. Um, I believe, uh, this framework has been around since about like the 60s or 70s, but in 1981, psychologist Lewis Goldberg coined the term, um, coined ocean the big five and has been further refined and accepted over the years. So, um, the, the big five, the BFI consists of a series of statements that respondents rate on a scale, typically from strongly disagree to strongly [00:48:00]  agree. Um, I know that we've all taken, uh, little assessments or filled out questionnaires like that. Um, so this, the BFI helps to identify where an individual falls on each of the five dimensions. And, um, this can provide insights into their personality characteristics, which can be useful for personal development, career planning, and improving interpersonal relationships. Um, So an example question might be, um, uh, or an example statement would be, I see myself as someone who is dependable and self disciplined. And then you would rate yourself on a scale, um, from strongly disagree to strongly agree. Um, so the first The O in the ocean traits, um, is openness. And so that is the personality that is, uh, uh, willing to try new ideas and practices. Um, so this [00:49:00]  personality type might encourage creative problem solving and, um, Is very open to the ideas and perspectives of others. I think in our field, we all, um, it's important that we all have a sense of openness. Um, because we, you know, a big part of our, um, our ethical requirements as our cultural sensitivity and responsiveness and, you know, that requires a sense of openness. You know, not every client is going to, um, live, um, you know, Or have the same cultural values or beliefs as you do. Same thing with your colleagues. Um, so it's important that, you know, that's not something that we take into consideration when we want to provide our clients with the best care. Well, we do take it into consideration, but it's only to provide our clients the best care. Um, without any sorts of, um, judgment. So, um, that's openness. So team members and high openness, uh, I [00:50:00]  think I mentioned this, bring creativity to the table, but you know, maybe they need a clear structure to channel their ideas effectively. Um, I'll give myself as an example and my partnership with Becca. I love trying new things, changing things up. Um, maybe, you know, that's why I love to do design. I just I'm always like, should we change our logo? Should we do this? Um, and, you know, Becca's that channel for me, which we'll get into the conscientiousness. Um, Becca's that channel for me where, you know, she's very open to hear some of my ideas, but she might, you know, she's there to filter them and say, okay, well, A, B, and C look good, and we have time for that, but you know what? Maybe we can put these other on hold. Um, So, openness, as I was starting to say, conscientiousness, that's the personality trait that's a little bit more self disciplined, [00:51:00]  um, meets and exceeds expectations, that little bit more regimented personality, which, uh, Becca, thank you for being there for me. Um, while I do feel like I, um, have a, strong sense of conscientiousness. I still think that that is one of those personality traits that Becca really contributes positively to our duo. Um, so that's also the person that is establishing clear expectation responsibilities with the team. Um, highly conscientious professionals tend to be organized and reliable, um, making them ideal for the roles requiring, um, Planning and follow through. So, and that's, you know, it's very important to have that type of personality on a team. Um, and then another personality, um, in the OCEAN framework is extraversion. So, we all know those We all know extroverts. Um, you know, uh, they're [00:52:00]  energetic. They enjoy working with people. Um, they like to facilitate opportunities for social interaction and teamwork. Um, extroverted team members often excel in roles that require frequent communication. Um, again, hi, I'd love to meet with you in person, Becca. Um, and so, what was that? No, I just was laughing. Um, and, uh, appreciate social interaction, um, such as client facing positions. Um,  Becca Sylvia:  I  Kristi Stearns:  would  Becca Sylvia:  just to kind of add in and thinking about the differences and how things come together with a team and the sense of when we look at, you know, some of that role clarification or the leadership, um, trying to, you know, trying to figure out how a team can kind of work together. I, as Christy mentioned, I definitely am like high on the conscientiousness side of things. Like I can keep track of due dates and I can make sure things are submitted on time and uploaded on [00:53:00]  time and we have it all, have all of our I's dotted, T's crossed, um, what have you. But then less on the extroversion side. So if there is a role that says, okay, this person is going to check in with the client's parents every week and have that face to face conversation, I'm not going to volunteer myself for that role. I can do it, but I'm not going to volunteer myself for that role. But I will take the role of Organizing and filing the paperwork and all of that. And so that's kind of looking at like, okay, this is where my personality lies. And so this is kind of how we can decide that role and work together as a team. And as we'll go into a little bit more, Christie and I are very similar in some ways, but also very different and other ways. And we kind of have learned how we can collaborate effectively in a sense of like, We can take on different jobs because it [00:54:00]  fits our personalities better. Kristi Stearns:  And, you know, it's again, it's not something that happens overnight, obviously, you know, back and I've been collaborating for a really long time. Um, so I think that exposure is important, you know, and going back to the human piece of interacting with your team, you know. You'll learn a lot, not by just having structured team meetings, but by having conversations and learning a little bit more being open, right? And learning a little bit more about who exactly you're working with. Um, you know, we also have a sense of inferencing skills. I would like to think that we also could. You know, based on our just our casual, maybe nonprofessional interactions would be able to get a stronger sense of, um, some of our colleagues preferences and, um, you know, just their, their sense of self. So I think, uh, [00:55:00]  Yeah, tying in these ocean traits to some of what we talked about before, um, this is kind of like a, uh, tying all these pieces together can help achieve the most successful collaboration. Um, Becca, do you want to go into talking about the other two parts of the ocean framework?  Becca Sylvia:  Sure. So we covered the O, the C, the E. Now we'll go into A, which is agreeableness. So basically it is what it sounds like, getting along with others, being agreeable, um, you know, really promoting that culture of empathy, cooperation, wanting to maintain harmony, you know, all really Good things. I would say what could be difficult is if someone is highly agreeable and there is a conflict and not wanting to sort of kind of address the conflict or try to get to the root of it. And that can impact that collaboration and they had a effective work down the line. [00:56:00]  Um, but people who are highly agree. So people who are highly agreeable may not want to be the person to kind of. Address a conflict, whereas someone else who says, I. Doesn't it doesn't impact me as much to not get along with someone or to have a dissenting opinion. I am more willing to do that. They can might be someone who can kind of manage conflicts or kind of take that role. Um, when you're working together on a team. Thanks. Um, and then N is neuroticism. So this is kind of having a tendency towards stronger, let's say negative emotions, but kind of emotions such as like being prone to anxiety. Being prone to prone to getting angry easily. And, you know, this can be a situation. If we go back to the baby in the back seat, someone who is just like, I'm mad because this is not getting done and quick to [00:57:00]  being like, they're not doing this, so and so is not doing their job. And then someone who might be lower on their neuroticism scale might say, you know, that person, I'm going to let them sit through five red light cycles before I even, you know, bring it up or get angry about it. Um, but at the same time, someone who maybe is higher on neuroticism may get stressed easily. So I think that I know you can think about probably people on a team. Maybe yourself who was like, I get so stressed in these situations and I look around and so and so is not stressed or a situation where I'm not stressed that this didn't, this plan we had did not work out well at all today. Whereas someone else might be like this plan didn't work and now I am not going to sleep tonight. So kind of understanding that some people may respond to the same situation. In a more heightened way, or in a less [00:58:00]  heightened way, it can be helpful to know, okay, this is not because they don't care about it as much, or they, it's because of like, this is kind of more of their personality is they're not going to jump to that anxiety or the worry as much. And so, being able to kind of support other people is helpful so that we can kind of, yeah, move the path forward.  Kate Grandbois:  Would you recommend for anyone listening who's maybe thinking about personality tests for the first time or reflecting on how this intersects with their current team? or even how this is reflecting on themselves and what personality traits they may have. Are there certain things that in your reading of the literature and reviewing all this material, um, Are there, is there one that is more beneficial over the other? So in other words, is it, is it more helpful for a clinician to reflect on their own personality and what they're bringing into the table versus [00:59:00]  making assumptions or pigeonholing a colleague? Well, they're very neurotic. So I'm just going to X, Y, and Z. How does that, what would, what would be your thought there in terms of what a clinician can actually do with this information for themselves and for others? Okay. Thanks. Becca Sylvia:  That's a great question. I would say, I think it's been helpful to think about how I think about certain situations and respond to certain situations and might say, okay, um, you know, I, the reason why I, um, Um, less eager to get on the phone with this client is because the extraversion is like harder for me, and it's not in, you know, or, um, the reason why I'm really struggling to change my plan is because, oh, I tend to be a little bit less open. And [01:00:00]  so I guess for me, it's helpful to know that, like, just because I think see things from a certain perspective. It's not how everyone else might see something from a certain perspective. Um, I don't know what you think, Christy, but I think it's been helpful for me to kind of think about where do I fall on these scales and how I can think about other people might fall in a different place and how they might respond or act. Kristi Stearns:  Yeah, and I agree in that sense. I think that, um, where I haven't Taken one of these formal personality assessments in any of my workplaces. I think now that we've read some of the literature about it and we've Um, examined it that, you know, doing the work, so to speak, kind of starts with yourself. So I think even if I didn't have colleagues that were looking at the same information, um, but I've been able to look at this information and kind of, um, do a self [01:01:00]  assessment. I do think that, um, you know, I'm avoiding labeling other people, so to speak, but, um, it helps me understand myself and what. I have the power to change because, you know, you know what they say. You can't change other people. You can only control what you can control. And, um, I think it also helps you put into perspective what you can control. Um, but if we were, I think perhaps some of the most beneficial uses of some of these personality assessments, though, is that, um, you know, you each complete the questionnaire assessment or what have you. And then. Should you feel comfortable in your workplace. Um, that opens up to sharing and a collaborative discussion. Um, so, and then usually I would imagine if this was, uh, during some sort of a workshop that they would go into how the different personality strengths can, [01:02:00]  um, support one another or if maybe if there are certain limitations with different personalities. personality types that, um, uh, where, who can kind of, what other team members can help out in the areas that maybe someone isn't, I don't want to say performing the highest, but, um, you know, like for me, who doesn't meet like the highest bar of conscientiousness, um, You know, Becca shares her questionnaire, and she has a higher level. Okay, great. What can you do? Let's chat. What can you do to contribute, um, to what, uh, to some of the areas that I may need support with? And I think that having this framework, um, It helps take things a little less personal and it helps this whole topic be a little bit more approachable that it's coming from, um, actual literature, you know, self reporting. I think that that helps. Um, but. I think that using this framework and then also [01:03:00]  considering the other frameworks as well that we talked about the competencies and the generational differences, um, can really, can really help with collaboration as a whole. And, um, and again, the ocean traits, you're not just one. full trade and that's all that you are. Obviously these traits exist in ranges. Um, and some folks may be a little bit more on the, you know, the strongly agree side of that range, um, than others. If that answered your question,  Kate Grandbois:  no, it did, um, it, it really did. I, you know, we've talked so much about collaboration on this podcast, but we've never really looked at it through a generational lens or a personality lens. And I, I think that these two components are very helpful in terms of what we bring to the table, the lens that we're looking through when we're interacting with colleagues, um, thinking about our role on the team, what we can contribute areas where we might need more support, or we might need to advocate. For more support. [01:04:00]  Um, this has all been really incredibly helpful. I'm wondering in our last few minutes, if you have any final suggestions or thoughts for our audience.  Becca Sylvia:  Yeah. I mean, as you heard, we did, we kind of, we covered a lot of different things and we just kind of, you know, Um, and we've kind of, um, Dipped our toes into some of these things in terms of dip, the competencies, the generational trends and different personality types. So we wanted to provide a broad overview to say like, these are different things to kind of think about. Um, And when you're thinking about collaboration and you're trying to maybe establish. Good collaboration on a new team or improve collaboration. It can be helpful to think about, okay. Different areas of. You know, interprofessional competencies. Generational trends, personality types, and how they kind of all come together. Um, so our goal was to kind of, you know, increase that awareness of it. And you may [01:05:00]  find like taking bits and pieces of each of these can be helpful for you and your setting. Um, you know, and as you mentioned at the beginning, The reason why we feel so strongly about effective collaboration is that we really do believe that it can improve client outcomes. And so that's what we're here for. It's like when we, when the team collaborates together, the clients went out, um, and it also can be helpful, you know, in terms of having a more inclusive and productive work environment. So saying, you know, like, this is, you know, We can get things done. We can be efficient, but also we can be inclusive and understand that we're all different and being different is not bad. Being different is just being different, you know? Um, and everyone brings their own strengths to work together on a team, whether it's you're working with other health professionals, you're working with a client, or even if you as a speech language pathologist, you are in the same [01:06:00]  setting, and there's two or three of you in the same setting, that intra professional communicate collaboration can also be really helpful. Um, and you know, we just, we want to. As we mentioned before, like understand and respect differences, um, and think about that rather than being bad things that there are strengths that everyone has. And we can, by thinking about strengths, um, that can help with that collaboration and therefore our clients.  Kristi Stearns:  I agree with what Becca said. And, um, you know, you may find that there are certain, uh, maybe personality assessments, maybe, uh, workplace frameworks that are more suitable for the place that you're working. Um, yeah, which is why we wanted to give you, uh, a little bit of an array, but, um, yeah, what Becca said about how just, being inclusive to those differences and having some awareness, um, [01:07:00]  can, you know, just decrease you taking things personally, which can, you know, deter from you doing your best. Um, and the You know, there's a reason why, you know, in the nineties, I think about those posters that say teamwork or, um, you know, all of those like very morale boosting types of, I think of those morale, uh, types of posters on, uh, you know, workplace walls, whatever, but, um, they're reminders, right? Um, and I think that some of these frameworks and assessments Bye. Can give you exposure and reminders, uh, just ways that you can improve your own collaboration, looking inward and, um, and all in all to support, yeah, your, our clients and their families.  Kate Grandbois:  Thank you so much for sharing your time and your hive mind, your collaborative hive mind with us [01:08:00]  and our listeners. This was really wonderful. We're really grateful. Thank you so much.  Becca Sylvia:  Yes, thank you for having us. We enjoyed this a lot.  Kristi Stearns:  Yes, we really appreciate it. Thank you so much for your time.  Becca Sylvia:  Yeah, thank you both so much. This is great. Sponsor 2 Announcer:  Thank you again to our corporate sponsor Ventris Learning, publisher of the Assessment of Literacy and Language, or ALL, and the Diagnostic Evaluation of Language Variation, or the DELV. SLPs, school psychologists, and reading specialists use the ALL to diagnose developmental language disorder and to assess for emergent literacy skills, including dyslexia, for children ages 4 through 6. The DELV is appropriate for students ages 4 through 9 who speak all varieties of English. To learn more, visit www.ventrislearning.com . Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, [01:09:00]  depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon. .

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]   Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00]  professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois:  Welcome to SLP Nerdcast. We're so excited for our topic today. We are here to talk about something that is under discussed in the field of speech language pathology, and yet at the same time, something that is critically important [00:02:00]  for every single thing we do as speech language pathologists. We're here to talk about counseling, and we have two content experts here with us to make the conversation even better. We're very excited to welcome Dr. Corrie Clark and Kate Mellillo. Welcome Kate and Corrie. Hello. Yeah. Thanks for having us. We're very excited to be here. I was thinking why I listened to this podcast. Amy Wonkka:  We're so happy to have you here. Thank you so much for sharing your time with us today. Um, like Kate mentioned, you're here to discuss counseling with a focus on children and adolescents and executive functioning and relationships. But before we get started, can you please tell us a little bit about yourselves? Kate Melillo:  Sure. I'll go first. Okay. So, um, I'm Kate also. Um, I am a speech pathologist in North Carolina. Um, Cori and I co own Be a Problem Solver Services, which is our private practice. [00:03:00]  Um, and my focus is on executive functioning and social skill building. Um, and our practice is actually both mental health. and speech services. So it's a little bit of a unique combination. You don't see that a lot. Um, and I'm, I also write a lot of social emotional learning content as my other job. So I'm, I'm in this world all the time. And I'm Dr. Corey Clark. I am, um, a licensed clinical mental health counselor. Um, I specialize in working with, uh, children and adolescents and, um, I also teach, uh, a, a clinical mental health counseling program, uh, called the Chicago School and I, I am also the president elect of the Association for Child and Adolescent Counseling, um, and so a lot of my focus is on, you know, the unique work with, uh, counseling children and teenagers. Oh, and we're also married. [00:04:00]  We are also together. So if you hear us having a marital argument, that's great. That's what podcasting is the perfect platform for side chatter. Um, so that's, that's wonderful. And I, I want to circle back. I were tickled that you listened to this podcast. It's always funny for Amy and I to hear that kind of thing because we hang out in a zoom room and then we send these off into the ether. Kate Grandbois:  So it's, it's always nice to hear that. Um, and we're, as I already mentioned, we're so excited to have this conversation, it, you know, counseling touches everything we do, and your practice is unique, and it sounds wonderful blending these two areas of competency, um, and we're very excited to get started. I do need to read our learning objectives and disclosures. I will try and do that as quickly as possible. Learning objective number one. Describe key knowledge areas, attributes, and skills of child counselors To incorporate into speech sessions as they [00:05:00]  intersect from the competencies for counseling children and adolescents. Learning objective number two, describe three relationship based counseling strategies that can be easily included in speech sessions. And learning objective number three, Identify how the mental health strategies discussed intersect with executive functioning treatment in the relationship based model of executive functioning. Disclosures, Corey's financial disclosures. Corey is the co owner of Be A Problem Solver. Corey is the co owner of Be A Problem Solver Services, PLLC, which is a mental health and speech therapy practice, and Be A Problem Solver Education, LLC, a parent education service where Corey received a salary for a speaking fee. Corey is a faculty member at the Chicago school where he receives a salary. Corey is non financial disclosures. Corey is president elect of the association of child and adolescent counseling. Kate's financial disclosures. Kate is the co owner of be a problem solver [00:06:00]  services, PLLC and be a problem solver education, LLC, where she receives a salary and a speaking fee. Kate is a research strategist at 3C Institute where she receives a salary. Kate's non financial disclosures. Kate has no non financial relationships to disclose. Kate, that's me, Kate Granbois. I am the owner and founder of Granbois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka:  Amy, that's me. My financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I am a member of ASHA Special Interest Group 12, which is AAC, and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, we've made it through the disclosures and the learning objectives. On to the actual content. Um, [00:07:00]  Kate and Corey, why don't you start us off by telling us a little bit about the first learning objective? So I guess both what are some clinical competencies for counseling children and adolescents, but also why is it important for SLPs to be aware of and to develop these competencies? Cory Clark:  Yeah, so I'll start. Um, this really, for some context, this really started in the last five years where I, as a, um, counselor saw that counselors were being trained to treat adults from a more general model. And I found that working with, um, and teenagers was a very unique process. And I think that really started from working, uh, Kate and I met, uh, working at a preschool and, um, I had a, you know, background in working with kids in that way. And, and I saw that a lot of people were going into the field, just kind of treating kids like little adults, you know, and it was, there was an [00:08:00]  incongruency there. So I was really interested in what makes working with kids and teens unique because I knew there was. A uniqueness there, but I wasn't quite able to pinpoint it. And so, the last five years, I've really been focusing on interviewing experts in the field of, uh, child and adolescent mental health and identifying what makes working with kids and, and, and teens unique and what are the basic best practices and working with, with that population. And so, that is, is where I, um, published and, and, and focused a lot of my dissertation research. best practices for working with kids and teens. Um, and really what it comes down to is really the foundation around child centered therapy. And so what that means is child centered therapy is in its nature very non directive. Um, it is very much based on the Carl Rogers, uh, person centered counseling [00:09:00]  model, which is unconditional positive regard, having congruence and empathy for the, for the person. And And because of that, there's not really a lot of, like, specific behavioral goals in, in, um, child centered therapy, um, but a lot of research supports that a lot of behavioral change and, um, good, uh, coping skills and good development happens from that. Uh, play based child center therapies. So, um, that is sort of the foundation of, of a lot of the, the, um, best practices for working with kids and teens. And so, you know, looking at, uh, What kind of the model that I came out with initially, um, there's attitudes, actions, knowledge and skills. And I broke it down to those four kind of domains. Um, and so go ahead.  Kate Melillo:  Oh, so before we jump in, because are you about to jump into those domains before we jump into that. [00:10:00]   I just want to touch on why this matters for SLPs and why we see like a really big crossover with executive functioning skills. So, you know, I think like if you're listening to this, you're like, well, what does that have to do with what I do on a daily basis? Um, however, like at our practice where. Counseling and speech therapy all the time. I mean, and I think a lot of SLPs, especially when you're new, you go in and then you're like, Oh, I didn't like now a kid is crying in my office. And I didn't expect that. Right. Like, or they're dumping out like, Oh, well, my home, my mom told me this, like, they're just telling you everything. And actually, it's funny. I remember in grad school, I had this one professor who's like, you're going to be so surprised. They're going to come in and tell you everything. Cause you're like the sort of, you know, side person in their life. A lot of times, like you're like this extra [00:11:00]  support person. Who's not the parent. And there's no other, like, side person. Like, you don't have this other, um, stake in the game at, like, you know what I mean? Like, they are kind of coming to you, like, friendly, right? Like, I think, like, the SLP role tends to be really, um, warm, empathetic. The things that Corey just described, but like Kate said, like, we don't get a lot of this training. Um, even though we're doing this relationship based therapy. All the time. Um, and so in terms of where we see it a lot is this like crossover with executive functioning and that's a lot of times because, um, executive functioning at its core is really regulation, right? It's, it's how our brain can regulate itself so that it then can like plan tasks, organize tasks, um, Execute tasks, right? Like impulse control, working memory. Um, [00:12:00]  and a lot of that comes down to emotional regulation. Like I always say, like I describe to my clients, like when you're in mental health. is not in a good space, like your executive functioning skills become scrambled eggs. And so it's really hard for, for students to be regulated, right? Like cope and release emotions and then be like, okay, let's, let's work on pronouns. Like it, it, it just doesn't work like that. The human brain doesn't work like that. And I think a lot of times we go into sessions and we have an agenda where like, these are the goals. That's what you learn in grad school. You're like, these have to be like good functional goals. They must achieve them. The insurance company must approve them and you must do them like, you know, and then we skip over this other stuff. Meanwhile, like, you know. Little Johnny comes into your office and he's like, Oh, my [00:13:00]  grandma died this weekend. Like, you know, I mean, and you're like, but he's the, like, you're the person he trusts. And so he's told you this information. And then you can't be like, well, let's do some grammar, you know, like it, it, it doesn't jive.  Cory Clark:  Yeah, and I, I often say that, um, I am a, I'm the person for a lot of kids, right? And teens. And what that means, what I mean by that is, is a lot of times a kid will have a person that they deem supportive and safe to say those things to. And it might be a counselor, but it might not. It might be a speech therapist and, um, or another professional. And when you're the person, right? Or one of a few persons, um, it's a. Really big responsibility and as far as how you handle those moments where they say, my grandpa died or this and that happened, or I'm feeling X, Y, Z. And so it's important to capitalize on, on creating that space, um, for, for young people. [00:14:00]  And, you know, so, so that's where I'm, I'm going with a lot of this is these best practices, um, are not just. Really just counseling. It's cross discipline in that way, so that you can hold that space. wherever it comes as a professional.  Kate Grandbois:  I also want, I want to piggyback on some of what you've mentioned. It's making me think of a lot of the content that we've produced recently, particularly as it relates to self acceptance. Uh, for example, this has come up a lot in our conversations related to stuttering therapy, uh, or self advocacy. Um, and, You can't really work on self advocacy and self acceptance without counseling and this is what we are now considering to be best practice based on evidence in the field of speech pathology and you cannot uncouple those things. I think there's a specific. Uh, flavor to working as a speech language [00:15:00]  pathologist because you are working closely with someone who is, their existence is living with a communication disorder. That is a communication disability of some sort. That is, that's why we're in their lives. So I don't, I, I wholeheartedly, I'm thrilled to hear some of this, you know, some of these threads being woven together because it is so ingrained in the fabric of what we do. Did you like that little, that little similarity there, the threads in the fabric? I just came up with that on my own. Yeah. Yeah.  Cory Clark:  So going into kind of my, um, more into the background around attitudes, actions, skills, and actions. Um, I think. I looked through the best practices that I've been working on over the years, and there's a few that I want to highlight today that are really relevant, Kate and I feel, to the speech therapy world. Um, and so, Starting with attitude, um, [00:16:00]  specifically, there's three that I want to highlight and, and they are the, the first one is something that a lot of experts mentioned, uh, when asked about, you know, what's important when working with, with children. And that is to meet children where they are. And I heard that over and over again over the years. And I was like, what does that mean? And essentially what they're saying is. You can't go into a session, a speech session, therapy session, um, with a item by item, minute by minute, breakdown of here's what we have to do, here's what we're going to do that entire time. Because kids will come in and throw a curveball or a wrench in that plan real quick. And it's important to be able to be flexible, um, to what, flexible for what, The child or teenager needs to work on or needs to address right like Kate just said if they come in and mention something about their, you know, family member passing away. You can't just be like, well, we got to work on preposition. So we're going to move past that. Right. [00:17:00]  Um, you have to, you know, And, you know, like I say to a lot of my kids, like, think like a palm tree and say, all right, I'm going to bend to this and go, okay, uh, let's pivot. Let's hold some space. Let's reflect and, and, and be supportive and empathetic. Um, so it doesn't mean throw all plans out the window, but it means. meeting children where they are and what they're giving you that on any given day. Um, that attitude is, is very important. And secondly, um, all behavior is communication.  Kate Melillo:  Wait, I want to go back just for a second. So I wanted to say about that mean children where they are, the, you know, we said a couple of negative, really negative examples, but actually The positive example can also help propel your goals forward. So for example, if a kid comes in and they're like, Oh, I'm actually going. You know, like miss Kate, I'm going camping this weekend. Well, I, you know, [00:18:00]  we'll take that and make my examples and therapy about the campaign, right? Like it becomes more relevant. Um, and so it, it doesn't have to be like a big, catastrophic, traumatic event that you're kind of being empathetic to. You're really just like tying into the kid's life and like, great. That's a vocabulary builder. I can talk about planning, right? Like there's executive function. We're going to do working memory. Like there's so many things that can be based off those examples. And I think that, you know, interestingly, I've, I've had the experience where I explained this kind of model to like a newer clinician. And, you know, like I've had job interviews and stuff, like interviewing people to come and work at our, our practice. And they're like, I don't think I can do that. Like, I don't think yet I can, I can, like, that seems like an advanced skill. Um, now granted, I like what Corey and I are saying is, is a clinical, [00:19:00]  is your clinical judgment, like your clinical sense. And that does come with time. So I don't want to make it mean like, this is so easy on the fly. Think of 10 examples that you can use when the kid says one sentence like that. I get that that is like a really hard skill to do. Cool. But I think as SLPs, we can kind of hold this in our mind. Um, and we'll talk about at the end, some examples of how I incorporate, like how I get this going. All of my students know, um, what I'm going to ask at the beginning of every session before they come in. So they're ready and I'm ready. Right. So I've primed it so that like the structure of my sessions is ready for that acceptance, right? It's, it's, ready for whatever's snowballs come my way. Um, and we can talk about that a little later on, but I just wanted to say, I just wanted to note that I get that this is like, uh, takes a little bit of practice, especially if you're used to going in and being like, you know, this is what we're doing today. Um, it's [00:20:00]  definitely a change in that. And you're in your own attitude, which is also what Corey's found in the counseling world as well.  Cory Clark:  Yeah, I think, yeah, I think everyone has their own, uh, uh, preference in terms of how they want to go into a session. And also it's based on what your, um, specialties are and how you run your, your practice. Um, for me, being flexible is just, that's what I prefer, you know, and I, I don't have a lot of agenda in, in, um. A lot of my sessions don't  Kate Melillo:  like to plan anything.  Cory Clark:  I don't. I'm just like, I just want to walk in and say, how's it going? Yeah, I love it. But there's plenty of professionals that I work with that are like, no, I need I need an agenda. I need this. It's very structured. Um, so, you know, for some, it'll be natural. Some not as much. Um, but. The, the second thing I, I want to highlight is all behavior is communication and um, that sort of attitude and understanding is important with kids and teens because there's a, there's a saying in the, in the child [00:21:00]  counseling world, um, so it's important to listen with your eyes because when you're working with young people, they're going to be giving you a lot of information content wise, particularly when how they talk, what they're saying, um, what it's about, you know, what you're working on, but also, um, Non verbally, what are they giving you? What are they saying? Um, what is their body doing? And both of those things have to happen at the same time, listening with your ears and with your eyes. Uh, because kids communicate so much, in particular, and teenagers for sure, um, with how they're, how they're sitting. Are they fidgeting? Are they, You know, do they need to move? Um, do they need a break? Are they listening? Are they focused? Um, what is their affect? All of these things are happening in real time. And it's important to be attuned to that because otherwise you're going to miss really important cues as far as how they're able to be present with you and how they are in that moment. And if you can reflect some of [00:22:00]  that, That's really, really valuable learning for them and awareness. What does  Kate Melillo:  reflect some of that mean?  Cory Clark:  Um, I noticed that, you know, you're, when I ask you to do this, you start to fizz it around in your chair. It seems to me like you may be a little nervous. You're not sure what to do, right? That's a reflection of like, Maybe they know they're doing that, maybe they have no idea. But, and sometimes it's, you know, not accurate. Maybe it's a reflection that they'll correct me on. It's also a good opportunity for them to advocate and say, No, it's this or that. Um, but regardless, you know, listening with your eyes involves that real time kind of, interaction where you're listening to what they're telling you without words. Kate Melillo:  I also think it's ironic because it is what like we teach when we're teaching perspective taking skills, right? And social skills were like, look at the other person. What are they telling you? You know, like look at their body language. Like what did that, what did it mean when they started to walk away when you were in the middle of your sentence, right? Like it's so I think too, like [00:23:00]  we're sometimes go into the sessions, like not doing the things that we're trying to teach. And I, I, I like that, you know, in the counseling world, there is this piece of reflection because it, it, it brings everybody together, right? Like you as the clinician and the student, right? So you've got both parties being like, Oh, I recognize there's a behavior here. And I I'm, what am I trying to say or communicate to this other person?  Cory Clark:  Yeah, and the third aspect of sort of attitudes and understandings that I want to highlight is that all children must be and teenagers must be viewed holistically. And what I mean by that is sometimes it's easy to fall into kind of a The trap where you are looking at one particular aspect of development, whether it be, you know, from the counseling world, like a emotional development or something with relationships, um, [00:24:00]  but you have to think about young people in terms of all aspects of their development and, you know, in particular, I often kind of. Disregard or discredit certain things, not intentionally, but be like, oh, that, you know, looking at how they're doing emotionally at school is very much tied to their social life and their social development and also what's going on at home, right? And also physically, um, their physical development, how is that impacting their social life, especially with like tweens and teens and all of that, right? So you have to consider all these, you know, domains when you're working with, with young people.  Kate Melillo:  I think we hear this all the time. If you have a middle school student with articulation errors, you are not just like, Hey, let's fix those errors. It is impacting them socially, right? Like those friendships are coming into play. Um, and I, so I think this like core best practice of the [00:25:00]  holistic child is so important because, and I think, I do think like Some of these things are becoming more mainstream in SLP, where we are starting to look at, hey, how does this affect you in these ways? And maybe you're making, you're working on some like, um, social, like, strategies to, you know, help, not just with the articulation disorder part of it, right? So like, you're, you're, you're using multiple domains there, um, to help that kid. But I think that, It's different than what we thought of as like the traditional Western medicine model where we're like, let's just treat these one this one symptom and make it better. Like we really actually need to be looking at everything because that's going to round out a kid's mental health, and the way they interact with the world. Cory Clark:  And I, so the next. area, the domain that I want to talk about are knowledge bases [00:26:00]  and understandings, um, of counseling with children and teenagers. Um, and the first one I, I really want to focus on is, is the most common, um, issue I hear. And when people come to see me in counseling, they will say that, um, they've tried counseling before or they've tried some sort of, um, therapy service before. And the parents or guardians or caregivers were left feeling like I had no idea what was going on. Uh, they never told me, they just kind of went back into the session and I didn't know what was happening. And then they were left frustrated, like, I don't know what the goals are, what's going on, right? Or they didn't understand them. And so they come to me, like, will you let me know, like, what's going on, like, you know? And, um, I always tell them that although I'm, you know, I'm not going to say exactly what the content is of the session, like there's privacy there. You will always know what my treatment plan is and what my background [00:27:00]  is and what my training is and how I intend to use that to support your child or teenager. Um, so the, the first really knowledge base that I wanted to focus on is, um, how to involve family or caregivers or guardians in therapy services. Um, it's so important to involve. Other stakeholders in a sense, but family members in, uh, as appropriate, because kids and teens operate in a system, uh, they're part of a system, and you have to be able to translate what you're doing to, um, how it can be reinforced at home and other settings, um, so that involves communicating a lot of those goals and a lot of those things to parents and to, to, um, family members. And that can be tricky, um, depending on what the situation is in, in your service, um, but you have to be able to, to translate that, um, or else you risk losing the [00:28:00]  connection you have, um, with, with the family, um, and they'll pull, you know, maybe prematurely pull them from services or feel like it's ineffective. Or, in a lot of cases, think that you're not doing effective work because they don't really understand what, what the goals are.  Kate Melillo:  Well, and I was also going to add, because a separate, a separate best practice is also the developmental models and how to apply them, and I want to just integrate this into the sharing with the family, because the other thing we hear quite a bit is, you know, families will come and say, Like, I didn't know what was going on and not really for, for speech. I actually have a lot of parents in my sessions. I, I, I just prefer that. Sometimes if it doesn't work with the kid, I'm like, okay, you got to get out because you're, you're entering this session parent. Um, but I like the parents to hear because a lot of times I'm giving homework to the family and which is more counseling ask, right? Like, I'm like, this is how we're going to integrate this because we do hear a lot. Oh, I've tried that before, and it doesn't work. [00:29:00]  Um, Cory hears that in counseling all the time. Yeah. And the, uh, the developmental piece that I wanted to point out is, you know, we are in this field, we're experts at these developmental theories. Like, we know all of this, like, background information that a layperson parent doesn't know. So a lot of times parents will come and say, like, you know, Oh, my kid is like now climbing the bed with me. It, they don't sleep anymore, blah, blah, blah. And maybe that in that kid's life, you know, they're going through a developmental transition, which we know about. And we have other parents come and tell us like their eight year old did the same thing. And we're like, okay, now we can show that that's fairly common, but not every. You know, person is going to know, like Erickson, Piaget, Bandura, like they're not going to know that. And a lot of times SLPs, uh, we get like a little bit of that. And I feel like it also depends on your grad school program, right? Like where the focus was on those things. And they're so varied that maybe you [00:30:00]  don't know as much about that. Which is why it's like, we're talking about this because that's something to share with parents. Um, hey, let me find out more information about that for you. That's helpful. Or make a referral, which we'll talk about at the at the end here, but I I'm pointing that out because I think that there's times when families feel like they're just. navigating this alone. They're the only person that it's happened to. Um, and that it's just, that's just usually not true, actually. Like usually it's happening to a lot of people, but nobody's telling them that. And so when they come in your office, they're like, hello, professional person, do you have the answers for me? Um, you know, and so it's a good, it's a, it's always a good idea to involve the family as much as you can.  Cory Clark:  Yeah, and the next, uh, understanding that I want to highlight, I just want to have a caveat about, um, and that is, it's important to understand the basic foundations of play therapy, and the caveat there that I want to [00:31:00]  distinguish, I do not expect this. I did not expect every therapist to be a registered play therapist. I did not expect speech therapists and other professionals to be play therapists, um, that has a separate and distinct, uh, licensure and, and process and credential. But, the foundations of play are important to consider in working with kids and into teenage years, um, because they allow, um, Young people to express themselves in their natural, in the natural form, which is play. And, um, and so a couple of important points about play therapy, um, they, it's important to accept children exactly as they are and allow themselves to express themselves freely, um, and have a sense of permissiveness to do that. So, you know, thinking about where your, your practice is, whether it's telehealth or, um, an outpatient setting or a clinic somewhere. You have to think about what is that setting doing for them to be able to express themselves, [00:32:00]  um, and you have to ask yourself, like, what, what does that look like for you and your practice? Um, it's important that they have that space. They feel free to express and be themselves with whatever they're, you know, intending to do. Um, and as a therapist, you reflect what they're doing, like listening with your eyes, and um, allow them to gain insight into their own behavior. So that looks like, it can feel very, um, odd at times, because, you know, you're almost like narrating their life, like, like a, you know, bird's eye view, if you will. You know, someone's like playing and they're like, they hand you something rather than just, you know, like they're handing you a figure, you know, and they start, they want you to play with them. My instinct as like a father is to take my son's, you know, figure that he gives me and then I'm going to create like a game with it or a story or whatever. Let's play therapy a lot of times in most modalities. You're not going to do that. You're not going [00:33:00]  to direct them and, you know, say, Oh, now I'm going to create a story. You're going to say, Oh, you want me to play with you. You're really excited for me to play. No, you're giving me that. Okay. And then you sit down and you let them dictate what the play is. Because they're communicating that way. Right. And so in, in a, in a speech sense and that speech therapy, in a sense, it's being able to reflect what, um, your client, what your, your person is, is giving you in a way that allows them to gain insight into their own behavior and their own affect and feelings. Um, and that's really, really healthy and important for their development.  Kate Melillo:  Well, and I think speech therapists, speech therapists are doing this, right? Like if you think about like. the fundamentals of like early intervention really, you know, here's, you're at a kid's house and you're like, here's the farm that you have. I'll just use the good old farm example, where, you know, you're like, Here's the cow. What does the cow say? Right. So you've got a lot of opportunities there for [00:34:00]  like vocabulary building and all of that other like syntax stuff that you want to target. Um, and I, I, I wanted to point out that so play therapy gets the rap of being for little kids. Um, but court. So we haven't mentioned this yet. We didn't say this because this isn't really that relevant yet, but so we're also both trained improvisers. And so we do a lot of improv with our clients, especially tweens and teens. Because I think that the other thing about play therapy is that it's about that acceptance. And those improv games, that is what they are, right? Like if you've ever heard the concept of yes and it's, I accept the idea that you've just given me and I'm going to build on it. And that is what, that's actually what you're doing when you're in your little farm scene. That's what you're doing, right? It would be weird if the kid was like, here's my cow and the cow wants to drink. And you were like, [00:35:00]  ah, that cow's actually on a rocket ship going to the moon like that. Right. And that doesn't make any sense. That is one of the fundamentals of improv comedy. And so we use that a lot. And I think, um, it's confusing to parents, parents will, how many times have you heard, Oh, all they do, they go to that therapy and all they do is play. Um,  Cory Clark:  It's like saying, oh, I went to therapy and all I did was talk. And it's like, that's, that's right. You know, playing is communication. But, but that's not a common, I don't think, understanding that like, You know, and play therapy is very evidence based, and it's very, um, it's very clear how to do it once you learn it, um, but it's very misunderstood because we use the word play all the time, like, let my kid play, and my kid's playing in the other room, um, but, you know, I use so much improv with, with kids and teens where, you know, I'll have a figure and it looks like a superhero to me, like, But they'll hand it to me and say dad or whatever. I'm like, okay, this is [00:36:00]  dad, right? Like you accept what they're giving you and in that way They're telling you their story and you get to hear it from their lens not you know What your instinct is tell you like no, this is a figure of Batman, you know, whatever, right? So you have to be able to roll with that again be flexible and meet them where they are and reflect And I think that's essential  Kate Grandbois:  I, the only thing I have to add to that is some of my own experience. I've been trained. I had to go through this very specific training in child led play and it was hard. It was so much harder than I expected it to be because of exactly what you said. I'm like, Oh, playing. I can get on the floor. I can do some Legos. I can get out the cow and the chickens and you know, make some animal noises and make it fun. I can play. I know how to play. I'm a pediatric therapist, but really taking the child's lead and filtering your own responses and not coming up with [00:37:00]  directives and not asking a ton of questions and really letting them direct where the play goes is a Harder than you think. So if anyone is listening, and I just, I think it's a, it's a great exercise. What you're, what you're proposing is a really great exercise to really think about what play means from a therapeutic evidence based lens, because it might not be That colloquial casual. Oh, we're just playing. We're just on the floor. It's very different and it's gonna feel hard It can feel challenging. That was my experience  Cory Clark:  It's and it's so hard that I mean it's important to note There are some modalities that are more directive play therapy but You know, without getting into the nuance of that, um, there's a misunderstanding that like, oh, if I play UNO with a child, that's play therapy and that's, that's free play. That's, that's playing a back and forth game that has set designed rules. Um, so that's not play therapy. That's playing a game, right? So there's all these. You know, misunderstandings [00:38:00]  based on the language really. Um, and play therapy is, is a distinct process. Um, and I always say the most exhausted I am after a session is a non directed play therapy session because, uh, 45 to 55 minute session is, It goes by, you know, it's, it's exhausting. Kate Melillo:  Well, and I would say too, like, I don't know if you guys, have you read the Declarative Language Handbook by Linda K. Murphy? I love that book. It's a really good resource. It's not a play therapy book, but I use it a lot. And Cory mentioned terms that were declarative language. Like, I see you're doing this. What happens next, you know, um, Tara Sumter, too. She has her reflexive questioning guide. Like, those are also those reflexive questions. And it is, Kate, like, to your point, so hard to, like, bite your tongue and be like, But didn't you mean this? You know, and, or, like, weren't you going to do this with this? Or, like, you're trying to guess the kid's plan. And that's actually not teaching [00:39:00]  them the skill for that, like, future thinking, right? Those executive functioning actions of, like, Oh. You wanted to see what I was going to do. And then when they make a choice that's like, I don't, I don't know if that was what we were going for here. Then you're, you have the opportunity to discuss it and see how you could have done it differently. Whereas if you had done the directive play, you would not have gotten to that point. Um, it's also why we love those improv games because they're They're totally impulsive. Like you don't actually know what the kid's thinking. We can't know what anyone is thinking, you know, um, which is a big, that's a big like nugget there between the counseling and SLP world because we, since we do tend to go in with like, here's our strict, you know, plan that we've got, here's our goals and counseling. It's a, it's really a free for all. You're there to share what, It's going on with you. Um, and as [00:40:00]  SLPs, I think we, we tend to, I don't want to say like disregard it, but we're just not as, you know, it's not our area. We're not as skilled at looking for those clues. But when we do something like a child centered play therapy session. We open up the door, right? If we, if we allow kids to kind of lead, um, and also not tell them what they're supposed to do,  Cory Clark:  what we thought they were  Kate Melillo:  going to do,  Cory Clark:  right. And if, and if you're listening like, well, I'm not a play therapist, how would I know how to do that? And I do not expect even every therapist, every counselor to be a play therapist again. It's about. Um, understanding the foundations of what, what play can mean in counseling or can mean in therapy, um, and what it looks like and how you can reflect in a way that allows for that development, right? That's, that's incorporating play in, in therapy. That's, that's what this is about. Um, and the last kind of thing I want to mention about understandings and, um, knowledge bases [00:41:00]  is atypical versus typical child development. We all learn development of models in school and we learn, you know, the basics, but it's easy to forget some of the more kind of subtle pieces of development. For example, you know, someone will come in. And I'll hear, um, you know, uh, concerns from a parent or guardian around how their child is just so rigid about, you know, a sense of justice, like, it's not fair that my sibling gets this, or why does this peer or classmate get to do this and I don't, and it causes problems, and I'll have to kind of remember, oh, there's a very specific point in child development where that is just front and center in their development, like, I, this, deserve this, and this, and like, and there's very black and white thinking that is common, uh, as part of development. So, sometimes, you know, the therapy session involves me kind of walking through [00:42:00]  typical kind of phases that, that kids are going through that is commonly seen in certain ages. Um, and so it's important to kind of think about, okay, Is this behavior or is this issue, um, part of like common social development or is this something that's like, ooh, that they're 14 and still kind of chronologically still kind of struggling with this thing that is usually seen chronologically at age 8. And, um, we're doing that a lot as professionals in speech, I'm sure, but it's easy to kind of get lost in the nuance of that. Mm  Kate Melillo:  hmm.  Cory Clark:  All right. So, um, moving into. best practices and skills from a counseling sense. Um, I've mentioned a lot of these before, but the first one, you know, basic counseling micro skills is what, what I'll say. Um, what are micro skills? These are the little, not little, but subtle behaviors that a counselor or a [00:43:00]  therapist does in sessions to allow someone to feel heard, to feel supported, to feel that they're not judged. And so, you know, the main things I want to highlight are It's important to reflect, like I've mentioned before, um, what you're, what you're getting and, um, encourage rather than praise, uh, so, you know, I always have to stop myself from saying like, oh, that's  Kate Melillo:  good job,  Cory Clark:  good job with that drawing you made, right? And that's, that's praise. Um, encouragement is your work. You worked really hard on that. You were so focused when you were doing that, right? That is encouraging them and their behavior in the process rather than the end product. Um, so, uh, another important piece is being creative, um, and in sessions. Um, so. You know, being able to tailor what you're working on, um, as far as your goals and sessions to be, you know, being creative around how that looks. Um, we get, we settle into our, our favorites kind of [00:44:00]  activities or interventions. And sometimes we can get frustrated when we're like, oh, that didn't, it's not working. Right. And it's important to be creative, um, as far as how you. adapt to, you know, what a, a young person is giving you in sessions. Um, and, you know, staying up to date on, on the, um, at most evidence based practices in your field, I think is another piece that you have to always incorporate, um, like doing this, like staying up to date with, with your, what you listen to and, and trainings and, you know, specialties. Um,  Kate Melillo:  I would say like, so this like resonates with me for my just SLP practice where. I get in like ruts of I use the same material or there's a trend I'm seeing with a lot of kids at the same time. And so I'm like saying the same thing over and over or something like that, right? Like you're just like, you get in these like cycles of like, oh, I'm really hot on this game right now or [00:45:00]  whatever. Um, I don't know if that resonates with everybody. Maybe people are just like way more creative than me, but I don't think that it's, it's not just about like, there's some really creative, like type B SLPs. You know, like if you like a teacher's pay teachers who make like amazing materials and I'm like, wow, that's incredible. But beyond that, I think it's about creativity in the way you think like using. practices that you wouldn't normally do or even like leaving the room that you're in. Like, you know what I mean? Like just thinking outside the box a little bit, um, which again, I know is a stretch because sometimes they're so limited and what the timing that we have for a session, like the space that we're in for a session, those are all realities. So I'm not trying to like, give you a blue sky pipe dream here, but I think that it's, That's where it really resonates with me because I feel like I, I personally, I feel like I do a good job keeping up with evidence based practice. And then I'm like, how can I even implement this? Like, this is going to be hard for [00:46:00]  me to do, even though I know it's the right thing. Um, yeah. Yeah.  Cory Clark:  And that sort of leads into my, my last kind of domain around. Clinical skills, and that is, you know, actions in and out of sessions. And the first one is about, you know, again, making sure you're have the right supervisor, the right CEUs, the right education over time to match what your people are giving you, right? What they're presenting to you. Um, and then making referrals appropriately as, as you need to. Um, we see it a lot with our practice with it being a speech and counseling practice. Um, know, What an appropriate referral to counseling looks like, or to OT, or to physical therapy, or to feeding therapy, or, no, makes sense, speech therapists, but, um, other professionals. Because, you know, for example, a common kind of stuck point is, if a young person's anxiety has gotten to the [00:47:00]  point where it's so severe across settings, they can't really learn very effectively at school, or in a speech therapy session, because they're so Uh, and a heightened state of tension and anxiety. Uh, they need more support and getting to a place where they can, you know, be regulated to learn. Um, and so knowing how to, to refer, knowing where to refer, getting to know your area, I think is really important. Um, so, you know, researching that and, and kind of making a few calls if you need to, to see what's open in your area, what's appropriate referrals is important. Um, and then I've mentioned this before, but the last one is, you know, empowering others to have a larger role in their child or teenager's life. So again, that's involving family as needed, um, as appropriate. To, you know, allow them to reinforce the things you're working on, um, is, is really important in working with young people. [00:48:00]   Kate Melillo:  Um, okay. So I wanted to talk about like, we just, Corey just told us like so many things and there's actually like a billion other best practices that he researched. And those are like just the highlights. So I realized if you're like falling asleep now, you're like, okay, thank you. That's enough. Um, yeah, yeah. Sorry. You're boring. Nobody's falling asleep.  Kate Grandbois:  We're on the edge of our seats over here. We're listening  Kate Melillo:  with our eyes. Yeah, there you go. There you go. There you go. Um, but I think so taking all that I've mentioned it before. Um, I, I read this, I think it was, I'm in Tara center's community for executive functioning and I, somebody posted like something. It was like, um, once you see executive functioning, you can't unsee it. I don't know who said it. So I'm trying to give credit to the person who said it, but that, that is like, My whole life because a lot of times really every session kids are coming in and I'm like, oh gosh, like there's so many, it's not just those like surface [00:49:00]  goals, those symptom things that I need to address. It's really how the entire brain is functioning as a whole. And that's why I mentioned at the beginning that like, when your mental health is, is not in a good. space, your, your executive functioning becomes scrambled eggs, then you can't do a lot of other things. Right. So there's sort of this like hierarchy, um, where you, you're needing, like Corey just mentioned, making those referrals appropriately so that you get services in an order that makes sense to you. Like there's a lot of times where I get parents coming in and saying, Oh, I want executive functioning therapy for my kid. But then I learn like, The parents are going through a recent divorce and, you know, the kid lost a bunch of friends because he had to move due to that, right? Like, so there I'm like, Oh, let's pause this for a minute. Like, I get that. Maybe he's not firing on all cylinders, but there's other reasons for that. And so we see this crossover with counseling and executive functioning all the time. [00:50:00]  Um, You know that exact. Oh, I haven't even mentioned the word anxiety yet. I don't know. Have you, have you guys see this? I see, I, I work with a lot of teenagers and like tweens and the level of anxiety that I see on a daily basis is, is really striking. I mean, and there is also new literature about this, right? Like we know that the mental health stigma. Um, state of tweens and adolescents in the past five to 10 years has significantly, anxiety has significantly increased. So it's, it doesn't surprise me anymore, but it's almost like I immediately have to take that consideration into my treatment plan. Um, because honestly, sometimes I have to parse apart with parents, like, Ooh, this trouble with executive functioning is actually anxiety, right? And, and they go, so they're so closely related that what the behavior looks like, right, [00:51:00]  that what the kid is doing, um, that the parents like, well, What do you mean? Like if he, okay, prime example, my kid doesn't want to go to school in the morning. And I'm like, yep. Okay. So what, why is that? And they're like, well, they, because they're ADHD. And so they don't like, they can't get their backpack together. They can't do this. They can't do that. Well, few sessions in, then I'm finding out like their first period is math. They don't want to go be going to math class. They are procrastinating for that and that is actually a symptom of anxiety. And so I'm having to like really juggle like this. We have to address that anxiety piece because yes, they probably do need help getting that backpack organized. Let's be honest. Like a middle school boy backpack. I don't know if you guys have seen them, but they're a nightmare. Um, there's a lot of crumbs, unexplained crumbs and crumpled papers. As a parent  Kate Grandbois:  of two tweens, I can confirm the crumbs.  Kate Melillo:   [00:52:00]  It's a real  Kate Grandbois:  problem. It  Kate Melillo:  is a huge problem. It's not always like the kid has, you know, this like severe executive functioning disorder. Sometimes they do. Um, and every middle schooler could use executive functioning help. Let's be honest. But the, the brain regions between, um, That prefrontal cortex and limbic system, like they're going, you know, I don't know if anyone wanted a brain review today, but executive functions live in that prefrontal cortex and those emotion responses that emotional regulation lives in the limbic system and they interplay, right? And so if the kid is having a ton of anxiety, uh, or. Depression, a lot of fear, a lot of times, a lot of fear in the tween space, right? Because it's a new, you've got hormones, you've got new friends, you've got transition to middle school, like there's so many factors at play. Um, so to bridge this kind of gap, we try [00:53:00]  really hard in our practice to like, build on these relationships, which goes, this is where those best practices that Corey talked about come in. Those are all relationship building practices that I think we need to do a little bit better job of incorporating into our speech sessions so that we can parse apart. Is this anxiety? Is this actually executive functioning? Is this, you know, a pragmatic language disorder? Right? Those, those kids with, um, ASD, ADHD, you know, disruptive behaviors a lot of times, like if you have kids on a BIP, or you know, does everyone know what a behavior intervention plan? You don't know sometimes, like, what's the origin? of this, right? A lot of times, um, on my case, so to get kids who are just like simply misunderstood, uh, and some of their behaviors are, they are from ADHD, but they have never been addressed with actual executive [00:54:00]  functioning strategies. They are often just like, go in this other room, be pulled out to this other class that will help you. And then they throw a chair in that other class. And they're like, why didn't this help? You know, like, Ooh, well, what, probably if you, you can't unsee the executive functioning. So part of the relationship building is also getting that team. Corey and I just talked about this with the family. The other thing we didn't mention is like related caregivers. You know, um, we, at our practice, we have it so that like, if. A lot of times, Corey and I will see the same client for different things. And so, like, we're talking to each other with permission, right? Like, getting those, um, other providers on the phone sometimes can be really helpful. Because I've also found that when I have a kid come to me for executive functioning therapy, but they're also receiving counseling somewhere, they, a lot of times, tell me things that they don't tell the counselor. And I'm like, You know, and [00:55:00]  it goes back to what I said at the beginning, where like, the counselor seems more threatening, maybe, right, like, I'm supposed to go there and tell them all these deep, dark secrets, but if I go to Miss Kate, I'm just like, well, you know, like, I stole a candy bar, you know, like whatever it is, like, I don't know. I live in like 1955. So like, I'm like, go to the corner store. Yeah. And I love that milkshake. I don't know. Um, but we're trying to like get the everybody on the same page. Um, So when we're trying to bridge these gap in sessions, this is what one of the things that I do at the beginning of every session. I, and some people I've heard a couple of people mentioned this, like in my SLP circles, I do a high low and a Buffalo at the beginning of every single session. Um, so. My kids know that I'm going to ask this. I actually love it. It's great working memory. It's like excellent working memory. That's right off the [00:56:00]  bat, like executive functioning, and they don't even know I'm targeting it. And I'm like, what's your high, low Buffalo? So high, something good that happened to you. A low, something not good that happened. And a Buffalo's weird, funny, silly, interesting, kind of out of the ordinary. And I, you know, every single tween or teen will be like, I don't know. Whereas I've seen this kid for a year and they know exactly what I'm going to ask at the beginning of the session, I'm like, nope, we've, we've got a good thing going here. You're going to tell me all about your life. Um, you know, I've heard like there's some, there's like a rose and a thorn is another one that people use. So that's like a good thing and a not good thing. I, I tend to like the buffalo just because it makes a little more fun. Um, I like the buffalo. I've never heard the buffalo before and I like that a lot. But I set the precedent that the session is going to be about the kid, right? So like, those kids know that they're one going to be asked that question. And two, that I kind of expect them to to share [00:57:00]  something meaningful because like I said earlier, I will take that information to inform how I target those goals that day. And I, again, realize that that's, this is a little bit of an advanced skill. You do have to have like kind of a lot of things in your toolkit in order to be able to do that. But once you get good at it and make that the expectation, it becomes easier, right? You've got. This opens the door for like all of that play stuff. Like our first example of a strategy is small world play. I don't know if you guys call it small, small world is kind of like the dollhouse or the farm or in there. I've never heard it called small world play, but I like that. I used to work at, Corey and I, another fun fact, I used to live and teach abroad, and I worked at the British School of Beijing for a couple years, and in the UK curriculum, that's what they call it, is Small World's Play. So you're a little. I love it. I know, it's such a good little name for that.  Cory Clark:  Right.  Kate Melillo:  Um, that, and, and Corey too, we [00:58:00]  haven't talked about SANTRE, which is a whole other certification for, for counseling. But SANTRE is basically miniatures.  Cory Clark:  Yeah, a lot of minifigs.  Kate Melillo:  Yeah, like minifigs in the, in a SANTRE. And that is like a, cause, The reason they do that is it's a blank slate  Kate Grandbois:  like  Kate Melillo:  we were talking about earlier with play therapy. It's like a totally there's no predetermined thing. It's just whatever you're creating that sand tray. So when you're one, I start the session with this high low Buffalo. And then if we're using this example of small world play. I, this leans into heavily what we were saying earlier, you've got a lot of improvisational problem solving and perspective taking. I tend to, um, I, I really love the phrase reading the room. I use it a lot. Like, I try to give my, and we'll talk about this with social dilemmas too, but I try to make sure that like, Even if my kids like my students on my caseload don't have like [00:59:00]  glaring pragmatic issues. I'm still incorporating this in a small world scenes because they're just there. There's that is like the integration of life, right? Like that is taking the communication skills that you've been practicing and and throwing them into some sort of like realistic scenario. Um, so I love small world play for, for those social nuances and targeting some of that. And then you get that extra piece of counseling where you can reflect and empathize, right? All the skills that we just talked about before.  Cory Clark:  Yeah, and I want to talk about one exercise I love to do that's, it's more of an art therapy blend, but it's an excellent crossover between mental health and executive functioning kind of therapies. So what I do is, I saw it from an exercise for particularly with those with ADHD, but it can work well with any, any young person. Um, [01:00:00]  So I, I get a video from YouTube, just find something, a short, maybe five minute ish, uh, video of how to draw a basic. thing, right? Like how to draw a dog, how to draw an elephant, or a house, whatever. And I will put it on with the instruction, uh, that me, myself, and the, um, child or teenager are going to draw it together. Um, we each have our own paper. We're going to draw this house or this elephant together. And that's it. I'm not going to stop the video. We're just going to draw. And I, at that point, I've done it, uh, a bunch of times, right? I do it over time. And so I, can just do it, or it's, it's, I'm not great, it's not perfect, but it's, I can do it. Um, but it's their first time ever seeing this video. And so, we just draw it, without stopping, and then when it's over, it's done, right? It's simple, right? Like, we're just drawing an elephant, for example. But what we do is, in processing it, it's important to then say, Okay, a lot of [01:01:00]  kids, for example, will get frustrated because it's too fast. And so what do they do? They either quit, or they start purposely messing up, or they put an X through it, or they're scramble the crumple the paper, right? Um, or maybe they do it, but they're working through a lot of, um, frustration tolerance or a lot of negative thoughts during, right? And that mimics a lot of school, a lot of school behaviors where if they get lost in math or lost in something, um, it mimics that process. And so it allows me to work in real time to process. Okay. What was going on in your head when you started to, you know, get, get behind and drawing that elephant or, um, what do you think I was thinking while I was doing that, right? Perspective taking. Um, what kind of allowed you to keep drawing even though it was getting harder and harder to keep up, right? Um, I noticed you put the pen down and quit after about three minutes. What was going on? What happened, right? Um, it allows you to [01:02:00]  process with them. Kind of what barriers they had, um, you know, what kind of thinking traps they had or distortions, um, and kind of really make a plan for, okay, next time, what can we do that where you can work through that? And then we'll do it again, right? Um, either next session or whatever, um, to, to work on that process so they can translate that across settings.  Kate Melillo:  Well, and that's executive functioning one on one, right? That second piece of like here, next time we're going to make a plan for how to do this and we're going to apply these steps So that you can be successful because then, you know, maybe the kid has an issue with initiation, right? Like you're making a plan to get over that hump. Maybe it was the emotional regulation or making a plan to get over that hump. Those are all those executive functioning skills that a lot of times we see behaviors for, and they're misconstrued or misdiagnosed as possible language disorder. Or Pragmatic disorder when in fact, like they're really lying executive functioning. [01:03:00]  Um,  Cory Clark:  although one time I did that and uh, This is teenager. No, they drew the most amazing elephant i've ever seen in the entire world And I was just like, uh, let's process it. That was just amazing. Good job I didn't know what to I don't know how to like do my process after that. They just  Kate Melillo:  Great artists. Yeah.  Cory Clark:  Yeah  Kate Melillo:  So the last, the last kind of example here, which I think a lot of SLPs use, and there's, there are a lot of resources for this, are social dilemmas. You know, any of these like social cards, we also have, um, like some of the teen talk cards. We really liked those at our practice too, which are a little bit more open ended than the dilemma itself. Um, and I'm sure every SLP has seen these vignettes of a social dilemma. Like, what would you do? The. The thing that I think makes it a little bit lean into the mental health piece more is if you can start incorporating more of the emotional language that goes along with these, [01:04:00]  because sometimes we're focused on the problem solving outcome. And so we want the kid to quote unquote do the right thing. Um, and I know in like the neurodiversity world we're, we're, Leaning away from that and saying, like, well, what is your perspective on the situation? What was the other person's perspective on the situation? As opposed to this is the right way to do it. This is the wrong way to do it. Um, but I think that one of the important things is pointing out those emotions that come with what happens with the social dilemma, right? Like, um, There's that the concept of those like upstairs downstairs thoughts, which I think is Dan Siegel. I want to say it's Dan Siegel who it could be. I would have to check that. But I think that's because that's on the what's that workbook? Yeah,  Cory Clark:  it's upstairs and downstairs brain.  Kate Melillo:  Yeah, yeah. Um, so if you're not familiar with his work, that's a he's a really good resource. He's got like workbooks that go along with those. [01:05:00]  Like emotional thought processes, and in the SLP world, we're, we do tend to look at that perspective taking piece, um, but there's more involved in it than that, right? Like, why did that person, like, why did that person do that action? Well, they were feeling XYZ, right? And so I think that there's a really big crossover opportunity there. Um, and also we have not talked about this, which is self monitoring. And self advocacy. So self monitoring is like, well, what I would do in this situation is this. Um, and then I'm like, how do we feel about that choice? Right? Like providing that, or we can give social dilemmas, have them play them out, role play, and then self monitor. Those responses. Um, I use a scale of negative two to positive two. In my practice, I do not like a scale of one to 10 when I'm self monitoring, um, because [01:06:00]  the one to 10 I feel like what's the difference between like six and seven. Right? Like to me, there's like not really a difference. Like, how well did I do on this scale? Six or seven is kind of the same thing. Whereas in the scale of negative two to positive two, a zero is actually meeting the expectations. A one is doing better than that. A two is doing like amazing. Negative one is like, I did not meet the expectations and a negative two is like, I totally blew it. And so that scale allows a lot of my students a little bit more. One, wiggle room, right? Because they're not like judging between a six and a seven. But two, they're like, well, now I know I didn't actually do the thing I was supposed to do, right? Like, or what I did was unexpected. Um, other people might think that the, their perspective is that was a little strange and maybe that's okay for them. Like that, that's, maybe that's fine for them, but it, it is a, an actual skill to be able to go back [01:07:00]  and self reflect and then use the self advocacy to say like, Hey, next time I needed X, Y, Z, right? Or I would prefer if you said something like this to me, whatever it is, I'm in this social dilemma. So the last part is when to refer. Cory Clark:  Well, we've covered a lot of this. I don't want to kind of go too far into it that we've already done, but it's just really important to know your area. Like I said before, to know how to know where to refer. Um, for things like when the anxiety is getting too heavy to really, you know, carry out sessions. Um, when trauma has been noted that you didn't know before, you know, early on. A lot of times you don't know, um, when you start services with someone and then it comes up, you know, throughout. Um, or if, you know, someone's behavior is, you know, Getting to the point where they're so aggressive or disruptive at school or at home to where it becomes unsafe to, you know, to, um, [01:08:00]  do therapy services or, um, you know, just hearing about unsafe things at home. Um, it's important to refer. So, you know, connecting with local counselors in your area is important. Um, creating relationships, creating a referral list if your practice doesn't already have one. Um, of where, you know, you can refer to where they won't be turned away, right? And it's really hard, um, nowadays to, to. To find places that are accepting, uh, new, new clients, uh, that see kids, aren't  Kate Melillo:  full.  Cory Clark:  Yeah, they accept the insurances they need, you know, so it's important to know what's available, what's possible in your area.  Kate Grandbois:  You've shared so much with us. I could talk to you for a whole other hour. I already, I'm already thinking of all of these additional questions about how to approach this in a school environment, about, but we don't have time to go to any of these, these Avenues that my brain maybe that's my executive functioning really failing me here wanting to go off on all these tangents You've just shared so much helpful [01:09:00]  information And reaffirmed so much of of my own personal perspectives of how important counseling is So much of what we've said on this show in the past in our last few minutes Do you for? For the SLP or the special educator who's listening who might be somewhat familiar or somewhat new to this general area, do you have any, you know, final thoughts or words of, of, um, words of wisdom and, and suggestions for next steps?  Kate Melillo:  I, so I think the biggest takeaway here is to, for SLPs to like, I challenge you kind of to go into your next session and change the way you think about how you deliver the session, right? Like, change your mindset around like how you're going to approach those goals today and make it more about the relationship with that student and not about the goals. Um, because that that's really like the crux of what we're saying [01:10:00]  here, because I think you'll see things like the executive functioning stuff like bubble up, like, you'll see things like the other goals, um, come into, you know, in front of your face. If you just made it about the kid and the relationship that you have with them, which I think is definitely. A mindset shift. Um, it's not the way that everybody approaches their session. And yes, it could be your, you know, maybe it's preference, but the evidence actually does lean this way. Um, and a lot of new research and social skills and social emotional learning. So that would be my challenge to everybody after today.  Kate Grandbois:  Thank you so much for being here. We really appreciate all of your time. I have learned so much. Um, I'm sure our listeners have too. Everything that you've mentioned today will be in the show notes. So anybody who's listening while they're driving, walking, whatever, what have you, um, all of those links will be there. Thank you again so much for your time. This was really awesome. Thanks for having us. Thank you. [01:11:00]   Amy Wonkka:  Thank you.  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. .