EPISODE 251

[INTRODUCTION]

[0:00:14] MD: Hi, folks, and welcome to First Bite: Fed, Fun and Functional. A speech therapy podcast sponsored by SpeechTherapyPD.com. I am your host on this nerd venture, Michelle Dawson, MS, CCC-SLP, CLC, the All-Things PFDs SLP. I am a colleague in the trenches of home health, and early intervention, right there with you. I run my own private practice at Heartwood Speech Therapy here in Columbia Town, South Carolina, and I guest lecture nationwide on best practices for early intervention for the medically complex infant, toddler, and child. First Bite's mission is short and sweet, to bring light, hope, knowledge, and joy to the pediatric clinician, parent, or advocate.

[0:01:01] EF: By way of a nerdy conversation, so there's plenty of laughter too.

[0:01:05] MD: In this podcast, we cover everything from AAC to breastfeeding.

[0:01:10] EF: Ethics on how to run a private practice.

[0:01:12] MD: Pediatric dysphagia to clinical supervision.

[0:01:15] EF: And all other topics in the world of pediatric speech pathology. Our goal is to bring evidence-based practice straight to you by interviewing subject matter experts.

[0:01:25] MD: To break down the communication barriers so that we can access the knowledge of their fields.

[0:01:30] EF: Or as a close friend says, "To build the bridge." 

[0:01:34] MD: By bringing other professionals and experts in our field together, we hope to spark advocacy, joy, and passion for continuing to grow and advance care for our little ones.

[0:01:45] EF: Every fourth episode, I join them. I'm Erin Forward, MSP, CCC-SLP, the Yankee by way of Rochester, New York, transplant who actually inspired this journey. I bring a different perspective, that of a new-ish clinician with experience in early intervention, pediatric acute care, and non-profit pediatric outpatient settings.

[0:02:05] MD: Sit back, relax, watch out for all heart's growth, and enjoy this geeky gig brought to you by SpeechTherapyPD.com.

[DISCLAIMER]

[0:02:21] MD: Hey, this is Michelle Dawson. I need to update my disclosure statements. My non-financial disclosures: I actively volunteer with Feeding Matters, the National Foundation of Swallowing Disorders (NFOSD), Dysphasia Outreach Project (DOP). I am a former treasurer with the Council of State Association Presidents (CSAP), a past president of the South Carolina Speech Language and Hearing Association (SCSHA), a current board of trustees member with the Communication Disorders Foundation of Virginia, and I am a current member of ASHA, ASHA SIG 13, SCSHA, The Speech Language Hearing Association of Virginia (SHAV), a member of the National Black Speech Language Hearing Association (NBSLHA), and the Dysphagia Research Society (DRS). Additionally, I volunteer with ASHA as the topic chair for the Pediatric Feeding Disorder Planning Committee for the ASHA 2023 Convention in Boston. I hope you make it out there. 

My financial disclosures include receiving compensation for First Bite Podcast from SpeechTherapyPD.com, as well as from additional webinars and webinars associated with Understanding Dysphasia, which is also a podcast with SpeechTherapyPD.com. I currently receive a salary from the University of South Carolina in my work as adjunct professor and Student Services Coordinator. I receive royalties from the sale of my book, Chasing the Swallow: Truth, Science, and Hope for Pediatric Feeding and Swallowing Disorders, as well as compensation for the CEUs associated with it from SpeechTherapyPD.com. Those are my current disclosure statements. Thanks, guys. 

[0:04:18] EF: The views and opinions expressed in today's podcasts do not reflect the organizations associated with the speakers and are their views and opinions solely.

[EPISODE]

[0:04:27] EF: Hello, everyone. Happy Tuesday or Monday for those of you who had Labor Day off. We're excited to have you guys here for part one of our four-part series. For those of you that don't know, this is Karen McWaters, my OT, partner in crime. Today, we're talking about sensory and regulation. I'm going to be honest with you, I made up the title and I can't remember exactly what it was. But SLPÕs and OT's role in sensory and regulation, which we wanted to start here because I think it creates a good foundation for everything that we're going to be talking about the rest of the week and next week. But I will let Karen introduce herself first for those of you that don't know who she is, or I can introduce her. What's your title at Ð 

[0:05:24] KM: I'm a clinical assistant professor at Georgia State University in their OT doctorate program. Recently turned academics from clinician and still navigating that transition. Financial disclosure-wise wise, I'm paid by Georgia State University, and that's it currently. I do maintain a couple of contract roles with some clinics though in order to stay in touch with clinical practice, including the clinic I just left. Erin and I are very much excited to be here talking about sensory and regulation.

[0:06:00] EF: My financial disclosures, I'm paid by Cincinnati Children's Hospital and IÕm paid by SpeechTherapyPD for these presentations, for which Karen is also compensated. Non-financial disclosures, I volunteer for Feeding Matters, sometimes Dysphagia Outreach Project, and I'm a contributor to Michelle's book, Chasing the Swallow, and I think that's it. So, we got those.

[0:06:22] KM: Yes. I think Erin and I are going to talk to our experiences tonight as relate to sensory and regulation across multiple settings. Because the longer that Erin and I have gotten to know each other, the more settings we have worked in, and the more content we have to talk about. So we're excited to kind of talk about that and talk about OTs, speech, and how we can play a role.

[0:06:48] EF: If you didn't listen, so Karen Ð and I can't remember what podcast number it was, I want to say it's like 167. I don't know why that sticks in my brain but around that. Karen and I did a podcast and talked a little bit about our story too, of how we connected. We shared a couple of patients, specifically, we shared one patient who we treated twice a week back and forth. I would see him first one day of the week, and she would see him first the other day of the week. We would have conversations that I'm grateful for because they were just easy to have with Karen, to ask questions, to collaborate. We kind of were connecting ideas at a very similar pace, and we were seeing the patients that we were working with have these developments that really pulled from both of our disciplines. It allowed us to see these bridges that maybe we couldn't have seen as well in isolation.

A lot of these topics that we're talking about in the next few weeks may feel very OT-based. But in reality, they are just as much based in an SLPÕs role. It's just something that we may not have learned about as much from the beginning. Thankfully, I have Karen to bounce these ideas off of, and to grow, and develop my practice with. That's why we're better together.

[0:08:27] KM: Yes. The intent behind this four-part series as we already talked about was to sort of stack topics on each other so that, if you tune into all four, you have this cumulative learning experience, rather than it being discrete topics.

So, we really encourage you guys if you're tuning in tonight to come back because we really do intend these to sort of stack on each other. You may find some clinical questions become answered by the next layer, or if you go back to the last one, it may kind of inform you about like where we're coming from, what the literature says about where current practice is, and where current gains really can be made collaboratively. But then also, understanding our role as a larger Ð both OTs and SLPs in context of the larger picture, in context of family systems, and healthcare systems, and school systems that serve these children all at the same time. It's important to know your role, and then also how you fit into that in order to enable and promote the highest therapeutic gains, the best outcome potential for your client.

[0:09:42] EF: We can see all of your questions if you have any. So if you have them throughout, feel free to put them in the chat, and we'll either answer them if we can answer them in the moment, if we can answer them at the end. But like Yumi said in the chat, we want to make it as interactive as possible, and as beneficial from a continuing with that collaborative standpoint because that's how we were able to learn from each other was by that collaboration.

What we wanted to start with is a topic that Ð you hear about regulation all the time now, which is great. But I don't know if we're always all talking about the same thing when we talk about regulation. There's a misconception that regulation means that a child is calm, which is I think, what sometimes we want it to mean, because it's a little bit easier if regulation always means that they're calm if we're working on something specific. But what we know is that when you are regulated, your body is ready for the task and the activity that you want to complete, that you want to engage in, that you want to interact in.

Sometimes regulation may mean that we're calm, and sometimes regulation may mean that we're ready, and we've stretched, and we're going to go for a run. That's not going to be that same arousal level necessarily. I think arousal and regulation can sometimes also get misconstrued as being the same thing. Karen and I are trained in Floortime, which uses these functional emotional developmental capacities developed by Stanley Greenspan. The first capacity is regulation. Because you need to be regulated to learn and to Ð your body needs to be in the right place to do whatever activity you want to do. It is, you need to be regulated to learn. But also, you need to be regulated to be successful in the task, the idea, or the activity that you want to engage in. Karen has taught me a lot about regulation from that standpoint, very much, though.

[0:11:54] KM: My perspective, so when I was in OT school, I thought I wanted to be a brain and spinal cord injury therapist. I really loved the brain and how it worked. Then, I got into my pediatric rotation and I realized everything that I loved about neuro was in pediatrics. In fact, you got to explore that a little bit more because it was called sensory. My big talking point to students often is that we act as though sensory and regulation is like the redheaded stepchild of neuro and nobody really knows what to do with it. It's really one and the same. It's just a behavioral explanation of what happens neurologically in a child's body.

The literature in the technology is finally catching up to that point, there was an article released a couple of years ago about the neural foundations of air sensory integration. And it really goes through fMRI and MRI studies, talking about which regions of the brain and how that relates to your sensory systems.

Erin, I think that might be a good place for us to kind of jump in and talk about it. I'm just going to tie in what the audience may already know about neuro, and tie that into some sensory language, and kind of connect some of those dots. Because you're right, regulation and arousal get conflated, and it's really easy to think that one is the same. In fact, if I can share my screen, I'll show you what I sometimes use with students. I know that those of you who are live will get to see this. I can provide this to be linked into the audio version if people are interested in it.

This is just my summary for students of the sensory pathways in the brain and how that relates to neurological functioning. This was just like a basic sketch that I put together because I think it really helps paint the picture of what we're talking about and also paints the picture for when we get into these words that are so sensory-specific. These sensory system words that you hear thrown around all the time, like enteroception, or proprioception, or vestibular. It kind of helps put it in context of what we're really talking about. So I'm going to do a little fly by neuro review really fast, Erin, if that's okay.

[0:14:10] EF: Perfect. Can you make it bigger so that Ð

[0:14:12] KM: Yes. I had to put it in a slideshow. Okay. So, again, this is just a basic sketch, and I can give this Ð

[0:14:21] EF: We can put in the show notes.

[0:14:22] KM: Yes. The first step in the sensory neural pathway is that, when you're talking about sensory, the first thing to know is that there are a lot of terms that get used repetitively when you start talking about this body of literature. One of the terms that commonly gets used is the word threshold, which is really confusing to those of us who've sat through neuro classes. Because we learned the term threshold as refers to the peripheral nervous system where your nervous system is an all-or-none system if you guys remember that. Where it fires or it doesn't, and there's a certain amount of electric potential that has to be fired in order for a nerve to shoot an impulse down its axon. We learned this stuff as it relates to the sensory system peripherally.

When we start talking about sensory processing and integration, please know that we're actually referring to the central nervous system, not so much the peripheral. We're talking about what happens to that information as it gets closer and closer to your brain. This is kind of some information about that. The first step is your spinal cord, all this information comes into your spinal cord, and then they crossover, they bundle together, they get sorted according to type and area of information, and they go up your spinal cord. That's why I wrote on here, recall decussation and tracks. There are different tracks in your spinal cord that carry different types of information. 

Your spinal cord also does this really cool thing called a central pattern generator, or a CPG, which means that it has some control over functions in your body without referring to higher brain centers. Then it goes up to your brainstem. All of this information, all of the somatosensory information from your skin, and your proprioceptive systems is fired up to your brainstem, and your reticular activating centers. That's the home of the cranial nerves, which I will totally own up to you guys. SLPs know way more about the cranial nerves than OTs do. We learn them and then we lose them because we focus on other parts of the body. So you guys are really the experts on those cranial nerves and their sensory-motor functions.

Brainstem activity is really linked with arousal. Please remember things like your Glasgow Coma Scale or your Rancho levels. That's really what they're testing, is brainstem functioning. The other important thing to remember about your brainstem and your RAS or your reticular activating center, is that there is no direct input. All input to your reticular activating center, which governs arousal is indirect. So pain is an indirect sensor that then refers to your reticular system to say, "Oh, I need to become more awake, there's something that hurts,Ó or light touch is also very alerting. All of those are indirect inputs. 

It then goes to what we call your traffic conductor, your Thalamus, which basically sends all of that information from your body to the correct place in your brain, which are those sensory interpretation areas. Those are some that are topically organized, so it's organized according to your body scheme. Proprioceptive tactile inputs are really, really well studied in regards to that somatic topic organization of the brain. After it's all been, the mail has been sorted to the right place and read, then something has to happen to it. So after all of that input goes all the way up through your brainstem, through your thalamus, and is interpreted, it then goes through premotor areas that prepare the body for action. That's also somatotopically organized.

So you can already see where if you have challenges with body scheme, which is something you hear thrown out in sensory all the time, you can see where that might start to influence function and adaptability in your environment. Then you've got motor feed forward, and feedback loops, and those kind of complete the circuit on how your body handles that information. Now that is very much very, very much a flyby. If anybody has any specific questions, I'm happy to take a second and answer those. The reference for it is actually a textbook. I can get that to you. I'll make sure that it's footnoted at the bottom when you guys get a copy of those.

[0:18:26] EF: Well, we have to think about Ð and I always say that this is the tangent that always go off on, that OTs don't own sensory and that we play just as much a role in sensory, and we have to think about in that pathway. In that feedback loop, what information are we in-taking and acknowledging in regard to that communication? Because so much of a response to sensory input involves some sort of communication of telling somebody, or showing a response to what information they were getting from the environment. 

So, as communication specialists Ð which is what I think we should be called as opposed to speech-language pathologists, but that's a tangent for another day Ð it is our role just as much to acknowledge and understand what that child is communicating to us based on what's going on in the environment. But we can't just look at what they're communicating, we have to understand the environment, we have to understand their sensory systems, and we have to understand their differences in order to understand their communication correctly, and with a bigger lens, essentially, because so much changes in the day-to-day, especially for a child that has developmental differences, that has medical differences, that has sensory differences. And sometimes, it involves us taking a step back, and looking at the bigger picture of what could have changed that day, that environment in themselves. And maybe it's that why there's a difference today as opposed to "TheyÕre being bad,Ó or ÒThey just want a reaction out of me.Ó

I love how Kim Barthel always says when Ð that a child Ð instead of when a parent would say, ÒThey're being bad,Ó she'll say, theyÕre connection seeking, and how if a child is dysregulated Ð and we'll get into this later on. But this, this involves that aspect of looking at their sensory [inaudible 0:20:30] communication. We'll talk more later on about the impact that relationship can have on that regulation piece. Because the quickest way to access your amygdala with those emotions is through relationships and the oxytocin that develops in your right frontal cortex.

When I talk with other clinicians about that regulation piece, my first, most important thing is, are you taking time to build a relationship with that child and that family? Not just, are you building rapport? I don't know why, that's a pet peeve of mine. Set for a session, building rapport with a child. Like, no, you should always be building a relationship, and relationships change. And just because you got a child to like you one session doesn't mean that you're going to come in the next session, and something's not going to happen, you're not still going to have to work for it. 

We all have to work for our relationships. Every session you should go in with an understanding of what happened in the session previously, and the sessions before that but acknowledgement that you might be at a different place when you walk into that session as well.

[0:21:39] KM: Yes. I think that for me, when I connected the dots between sensory and neuro I started to really drop the judgmental glasses, and drop the behavioral glasses, and say, "Okay. Well, if your body is responding like that, maybe there's actually a reason why underneath there. You just said that Kim Barthel calls it being a behavioral detective, and it really is. You really have to integrate all of your knowledge in order to understand and form a hypothesis. We are not just clinicians, we're scientists, and we're trained in scientific thinking and reasoning. So following that methodology is also important in treatment.

Floortime uses the word, "I wonder." Like, ÒI wonder if." You can basically replace that with like, "I hypothesize that today, that kid is more tired." So they're going to be more reactive to alerting stimuli, because they're fatigued, and their brain does not have as much bandwidth to handle, sorting out what's threatening and what's not. So they're going to react to things as though it's a threat when it may not be. And that just has to do with fatigue and your reticular activating center. It's not that they're choosing to overreact, it's that they're tired, and their brain can't sort through the sensory input. It really does change the way that you interact with that client, because it gives you the space to hold space for them, and to hold Ð that's mine Ð 

Me and Erin feel very similarly about holding space for people and not trying to delete hard emotions because you're trying to "regulate the kid." Sometimes being regulated for the task at hand means you're sad, or you're angry, and that's because you're a human. Those reactions are valid and important to experience as a multi-sensory world and being. That's a side trail, sorry.

[0:23:45] EF: No. But from a regulation standpoint, if I do end this, I can talk about my speech pathology pet peeves, because I have some of them. What I think about transitions are oftentimes a place where children have a hard time staying regulated for the transition, because they were regulated in the moment, in the session, and now we're changing things, and we're moving, and we don't know what's going to happen. Oftentimes, a kid doesn't want to leave, and they feel frustrated, and they feel sad. I will say to them, "I'm sad too. I don't want you to leave. I had so much fun. This also makes me feel sad."

If instead of doing that, you sit there, and a child's having a meltdown because they don't want to leave, and you're like, "Let's go. Keep walking." I would want to punch you in the face because you're not acknowledging my feelings and what's happening in my body, and then you're expecting me to shift. And feeling okay, and feel Ð it took me a while to feel comfortable with letting a kid just take a moment and feel sad. Because you feel like in your session, they're supposed to be enjoying it, and learning, and you don't want them to feel sad when you're around. But sometimes, they are just sad, frustrated, angry, that's okay. And part of our job, and also, OTs learn a lot more about mental health. The language that we use, and how we use to label things, and how we model language impacts a child's mental health a lot, and a caregiver's mental health, and how they're viewing their child.

We do have a lot of power in the words that we use, both with their caregivers, and our patients. So not taking that lightly and making sure that we choose those words very intentionally, when those emotions and moments are happening, because you are labeling that feeling in their brain for them to base on what language you're choosing to use. If they feel a big emotion and you bypass it, it can reiterate the fact that that emotion isnÕt safe instead of giving them space to feel that emotion. Where now this is safe, and someone's going to be there, and I don't have to avoid it.

[0:25:57] KM: Well, Erin, we have a whole episode coming up about therapeutic use of self where we get to talk about conscientious use of yourself as a therapeutic tool. We're excited to talk about that in a couple of weeks. So yes, we're excited for you guys to join in on that conversation too. But we wanted to layer in sensory before we get there because understanding how to use yourself also means you have to understand your own sensory system. I feel like a lot of times, there's like the Ð we have to come to the realization that we're all sensory creatures. Before you go to understand somebody else, also understand yourself.

I think that's kind of where, from a sensory perspective, if there's confusion around the terminology that's being used, or what that meaning is. Then it gets really hard to communicate with other professionals as well as understand what to do. We all have those children on our caseload that we intuitively know their body just works so differently than mine, and I don't know what to do about it. That feeling of therapeutically being at your wit's end, and not understanding what to do next is so frustrating and is a recipe for burnout. I feel like a lot of times, it's because there's some miscommunication in the way we talk about sensory and motor-based learning, which is where all of this came from. 

Erin, do you want to do an SLPÕs guide to the sensory systems and talk about what they are? I think it's really valuable for an SLP to have a voice in that and not just an OT, because OTS are Ð we talk about them a lot, and we don't own them. We don't own them. It's just neurology, itÕs just brain science. It's not OT. It's just Ð I was telling Yumi right before we began that sensory itself is not an occupation. We don't get trained in this as though it's the point of our intervention. Having sensory experiences is the means to an occupation, but in itself is not an activity that's purposely like that's meaningful and productive in your life. That's what an occupation is.

Sometimes in play, sensory experiences, and sensory-motor play is that, but there's a whole lot more to sensory. Oftentimes when we talk about sensory, we're not even talking about sensory-based play. We use that word like it's a label for a kid that's having a meltdown. Oh, they're just having a sensory moment, when really that means that you need to dive in and figure out what that sensory moment is, right? Yes, they're having a sensory experience, and have a hard time in transition. You may need to give them a sensory break, but knowing what goes into that, and why is evidence-based practice. Erin, I want you to explain sensory to SLPs.

[0:28:51] EF: As always, if I butcher any part of it, this is why I have you here. But the framework I also use for why speech therapists needs to better understand sensory is, if our goal Ð we understand that receptive language has to come before expressive language because you have to understand something before you can talk about it. But if your body doesn't have the means to experience the world in a certain way, then it's not going to have the experiences to understand and express.

Oftentimes, I get patients, especially Bertha three, that come and see me, and aren't talking likely because their sensory system makes them anxious and fearful, or have motor differences when experiencing the world. Or they seek out so many experiences so quickly because they want so much input that they don't take the time to stop and actually process what's happening with their body.

I need to understand where that's coming from. When we look at the sensory systems, there are three that you'll hear the most, because they form the basis for motor development. Also, we really need the senses to be fully intact to form that enteroception understanding of our body. We'll start with the tactile system, which is essentially how things feel. Your skin is such a big receptor of information. So touch, is it light? How heavy is something? Temperature, how do think this feel on my body? I'm very light touch tactically, it can be very alerting.

Also, if you think about it, it gives us information on what objects are, and how they feel. A lot of kids need to feel certain things before they will put them in their mouths because they're getting a lot of information from their hands. I was explaining to my aunt the other day about like, think about when you go into your purse, and you can't see everything, but that tactile discrimination, how can I tell what something is when I'm not looking at it? How many of our kids like have such a hard time finding things when we ask for it, or like if they're in a sensory bin, they can't distinguish one thing from the other because they haven't had those sensory systems with their hands and how many kids are very sensitive to that.

Especially, you're going to find kids that are sensitive tactilely that have been in the hospital for long periods of time, because things are always on their skin. They have leads on them, they've been poked and prodded.

[0:31:31] KM: Well, I was just going to say, remember that the primary system, all of these senses, primarily, your brain is always looking for threats. Especially, there are a few systems that I refer to as your guardian systems. I don't know if anybody else uses that. But your skin, your eyes, and your ears are your threat alert alarm bells. So when you start talking about your skin, there are two ways to get your attention. Either it needs to fire a fast-twitch, a fast pathway, like pain or light touch because those from an evolutionary perspective have like provided information about threats. Whether there's a spider crawling on your leg or something hurting you. 

The other way to get your attention from a tactile perspective is magnitude, the number of sensors that go off at one time. To Erin's point about children in the hospital, a lot of times you'll find children who have had medically complex backgrounds. They become very tactilely defensive because their tactile system was overloaded at the same time that they were actually physically in pain. And their brain learned early on that touch equaled pain, even touch that shouldn't have been painful. So it's protective. If you view it from that lens then a child who pulls away from you when you try to touch them, it can be very easy to feel like that kid doesn't like to be cuddled, or touched, or it can't receive affection. All of that may be true, they may not enjoy tactile touch. But that doesn't mean that they don't want connection.

[0:33:07] EF: Also, this is why you have to be very careful, and this is why I don't love hand over hand because it can cause a child to get defensive, especially your hands in a lot of ways can be your Ð like your eyes, for children that are blind, like you know their hands become their eyes. So taking away that control, I'm very, very cautious of that. It also just doesn't create the same pathways in the brain of learning when you make a child do something.

The next sense that you will hear a lot, especially from OTs, when they're working on motor development is proprioception. And that's really your tendons in your joints, understanding of where those are, which gives you information about where your body is in space. So that can impact your balance, that can impact your motor control, and also your arousal, which tactile has a lot of impact in arousal as well. We have to think about it in a way that if a child doesn't understand where their body is in space, it's going to be harder for them to develop language about what's happening. So often you'll Ð 

Karen and I would watch children develop and we'll talk more about this. But you know, as they learn more about what's going on with their body, their language develops in a similar way. That's why proprioception is an important sense to work on because feeling where your joints are, and that deep pressure can give them a lot of information. If they don't have that, you'll see, kids oftentimes like just running around the room, and you wonder why they're just running. Or they're running to walls because they're just trying to find some sort of boundary for their body. Oftentimes, if you can provide some of that proprioceptive input to just help them feel, that can help them feel more grounded, and also decrease their arousal. Sometimes if they're really high up here, because they're just seeking some sort of input.

[0:35:09] KM: This might be a good opportunity to talk about what we mean when we say threshold. Because when we talk about threshold and sensory, we're not talking about that peripheral threshold to see if your neuron fires or not, or that sensory receptor fires or not. We're talking about a central nervous level to where your brain shifts attention to that type of sensory input. A lot of that is governed going back to that diagram, a lot of that's governed by your thalamus, and also by your sensory interpretation areas. Things that are perceived as a threat get attention much faster. Then, information that's not perceived as a threat, or that your brain has a hard time interpreting, then oftentimes gets overlooked.

Proprioception is that classic thing that gets overlooked and why our kids struggle so much, because they don't feel the boundaries of their body without an external boundary, without the wall to crash into or the floor to hit or the crash mat to whack. They don't know where their body is in space, because their brain loses that awareness. In other words, the amount of input flies underneath the threshold needed to cross to shift their attention to it. So they're the ones that become problems in school very, very quickly and get flagged very quickly, as well.

[0:36:25] EF: Mm hmm. Oftentimes, when you're looking at proprioception, vestibular will get brought in as well, because it Ð vestibular is basically the primary organizer of your sensory system for engaging in these daily activities. We know about the impacts of fluid in our inner ear and the information that we get from them, which is where we're getting that vestibular input that impacts their posture. It helps them stabilize vision. It can be a really powerful tool in building communication. There's a lot of research that we're finding to support that as well. It sometimes looks like Ð I used to think in the past that OTs put kids on a swing, and that's how they regulate them. But the swing is a really amazing tool if you use it in the right way, and if you're using it with the right child.

But when you put those vestibular proprioceptive and tactile sensory systems together, it can be very powerful for a child to engage in their activities of daily living, as OTS, we'll look at. But also, unique communication to engage in all those activities. What information are we getting from their sensory system, and how they respond to different things, to how they engage with the world that can help us clue in to provide them with support in some of those sensory systems?

[0:37:50] KM: That's something that I really have learned from my SLP friends, Erin foremost among them, and that OTs are not really trained in early signs of communication. We're not. We are taught a few milestones of communication and language, and then told, "Don't worry. That's what SLP is for." Then, we move on in school. I mean, genuinely, I learned a few stages of swallowing, and then said, "Don't worry about it. SLP is there. That's what they're there for. If you want advanced training, great, go get it, but like don't worry about it. Same when it comes to communication." And the challenge is, is that for OTs, communication has to happen in order for you to participate in an occupation. 

To participate in school, you have to communicate with your teacher. To get yourself dressed, you have to communicate with your parent, both verbally and non-verbally, depending on your age stage or, or your preferred communication method. It's just one of those things that is woven into every occupation, but the OTs don't get trained in. So, please help an OT out, teach them how communication works.

[0:38:56] EF: We know as SLPs, know a lot about the auditory system. What I will say of the auditory system is kind of like what Karen said. If a child has experienced trauma or is in a fight or flight response, they're oftentimes listening for really high-pitched sounds or really low-pitched sounds, because those are the signs of things that can harm them. And language lives and the bubble between those two. So if a child is not processing information auditory-wise, my first thought is not that they're just not listening to me. My first thought is, are they processing this information? Are they regulated enough to process information? Is there something about the environment causing them to be in that kind of fight-flight state where they're not hearing what I'm giving them?

That's when understanding of sensory system can be very helpful too. That's when I will include touch, that's when I will give input in another sensory system. I will also say when I was taught how to write goals for communication, oftentimes you start with reducing cues. So, maybe they're using Ð and that makes sense on some levels. But we Ð I talk with my hands a lot, I use facial expressions a lot. Eighty percent of the information that we communicate is nonverbal. So I'm not a big proponent of taking away all these cues for a child, because why? When are they Ð I get if you're on the phone, you won't be able to see all these things. But I think it can be a little Ð we have to think about that, how much we're using all of our other sensory systems to communicate. It's not just auditory, and it's not just visual. A lot of these other systems play a huge role in communication.

Visual too, we use visual a lot in speech to cue children. They watch our faces, they watch our mouths. We use visual in ASL, AAC, like that's a big component. But do we understand fully their vision? Do we understand how they're processing it? Because that plays a huge role in what communication device I'm going to pick, in how I'm engaging with them from a facial perspective and what colors I'm using. That's something that really pulls your OT colleagues in there to understand. Because if I know a child has a cortical visual impairment, I'm probably going to pick toys that are red, black, and white initially, because my goal is going to be for the colors that I know that they're more likely to see at first. But after I do that, maybe because I haven't talked to my OT colleague, I'm going to say, "Hey, what's your perspective on their vision? So that I can best support them."

Then if we've developed all of those sensory systems, children can start to develop enteroception, which is the understanding of sensations of your own body. So like feelings, hunger, going to the bathroom. And we play a huge role in that because that's not something that you can necessarily see. ThatÕs something that a child is trying to communicate. But if we're working on that, if we're wanting a child to tell us when they're hungry or go to the bathroom, and they don't have all of these other sensory systems developed enough to put them together, then we're way too far in the realm of Ð that's a little advanced for them, and that's hard to expect that that's going to be there. Because I know even when I'm anxious, or I feel dysregulated, like I don't know when I'm hungry. I forget to eat, I don't know whether I'm anxious, or my stomach hurts because I ate Ð apparently now, I can't eat cooked onions I learned because it tears up my stomach. But I don't know the difference. So how can we expect the children that we work with to know the difference?

[0:42:52] KM: Does anybody have, before we keep going forward Ð does anybody have any questions about those sensory systems, how they connect, what they are? There are some great continuing ed courses out there about sensory and specifically. So, if you feel like, oh wow, I wish I knew more about that. For sure, let's go find you something that's more than an hour about sensory because there's so much to unpack.

[0:43:18] EF: What I've learned from Karen a lot too is the importance of helping integrate those sensory systems. Because we have a lot of children who rely heavily on specific sensory systems. And because of that, they need so much information from one. I had one patient I worked with who Ð he would try to get on like the tallest thing. Then, he would use his visual system to find his boundary. So, he used vestibular, and then I remember being in the ball pit, he'd use his eyes and he'd go to every corner so he could see them. He needed so much input because he wasn't putting his other sensory systems together.

So, if we help integrate by encouraging proprioceptive input maybe while we're seeking vestibular by quiet by jumping or climbing, then it may result in them needing less from each system to get the information that they need.

[0:44:18] KM: Yes, and this is what I was going to kind of hope that we would get to.

[0:44:22] EF: On the YouTube videos. That's a good question.

[0:44:24] KM: There's a couple out there. I can see if I can find one that's pretty succinct and good. Sometimes YouTube videos are hit-and-miss. I will say that there are three major Ð when you talk about sensory, there are three major sensory theories that come up a lot. The challenge in the sensory world is that OTs in particular get so comfortable with these theories, that we use words from all of them at the same time and you don't really understand what we're referring to. So let me see if I can kind of help disentangle that a little bit.

The first one that's kind of the easiest to understand is sensory processing theory, which is from Lucy Jane Miller. She's from the STAR Institute out in Colorado. They're an incredible organization that does a lot of research on sensory. Her original model kind of broke it down into this tree, understanding how the brain processes information. So, you can see that she talked about sensory discrimination disorders across Ð and these are just all of the names of your sensory systems Ð across all of the sensory systems. Then, she talked about difficulty with motor processing and modulation, which is a big word that gets used a lot in the sensory world.

Then she talked about sensory over-responsivity, under responsive, and then sensory craving. There's kind of a taxonomy that goes along with this that you probably have heard these words. I would highly encourage you if you're interested in learning more about that to go to the source, go to the STAR Institute, and take a couple of courses. They are really, really excellent at putting together information and applying it to clinical practice.

But the one that you probably are most familiar with, with these words, sensory over-responsive, under-responsive, that's actually from Winnie Dunn. She talks a lot about sensory behavioral responses. And so you hear like, "Oh, they're over-responsive, and they seek." We hear the word sensory seeker a lot. The way that she broke this down was according to two continuums. So there's a neurological threshold continuum, and we've already talked about what that threshold means. If you have a high threshold, meaning it takes a lot of input for your brain to shift attention to it, and you're an active self-regulator, then you're going to be a seeker. Meaning, you take charge of your world to find what you need to get your brain alert and ready for action.

But if you have a low threshold, and you're a passive self-regulation person, then you become very sensitive. You startle easily, you respond to the environment, but you don't seek to change your environment, or change your circumstances. These two models get thrown around a lot. This one is more to explain the behavior responses. This one's more to understand how the brain processes. So Miller really did a lot of work talking about the brain processing side of things. Winnie Dunn did a lot of work explaining how the behavior worked. 

Then, good old Jean Ayres talks about how sensory systems are combined to kind of make meaning and promote skill acquisition. So, you can see here, she has multiple sensory systems combining to integrate, which is what Erin was just talking about. When you can use proprioceptive and tactile together, then you get more meaning out of that integrated experience than the individual sensory systems alone. They may not need as much input because they're getting a multi-sensory source of that input. She had this theory that's really broken down to explain where some of our skills that we recognize at the top of the tree, like academic learning and self-confidence, those are things we're quick to point out in evaluations.

But then, when there are issues with self-confidence, self-control, self-esteem, organization concentration, or academic learning, what do you do about that? You've got to go back to the root side of things. Those are the three major theories that kind of get thrown around in the sensory world. We use a lot of words from all of them all the time, which can make it confusing. They all have a significant role to play, and none of them are 100% correct by themselves.

[0:48:58] EF: I think like for me, one of the hardest things, you say that OTs don't learn a ton about communication and early communication. But something that I've learned from you guys is the very subtle signs of regulation and things that you can pick up on to give you some of those cues. Because I think it can be scary or nerve-wracking at first when you're trying to aid in that regulation, and providing some of those sensory strategies. But you're like, ÒI don't necessarily know when they're giving me that cue.Ó Because so often, you'll work with a child and you'd be like, "Well, they seem totally fine and they have this huge meltdown. When in reality, there were all of these very subtle signs that, if you understand what they are, you can start to pick up on them a little bit more. 

Something that like Ð we know with babies, I work with infants all the time now in the hospital, and like when their breath rate increases, that can be a sign that they are dysregulated. You see that increased work of breathing that carries over a lot of times to older children that we work with. You can even feel like Ð I'll stop kids sometimes and be like, "Whoa! Do you feel your heart racing or do you feel your breath?Ó Because sometimes pointing out that change in their body can be very helpful for them to start to understand that like, "Oh, wow." Because sometimes, it isn't just, "'m feeling overwhelmed." Sometimes kids need to know. "Wait, my heart is racing. This must mean that I kind of need to slow down.Ó Karen's talking a lot about like, can you talk a lot about like the eyes in regards to regulation, and like some of those Ð

[0:50:48] KM: Yes. That's a great segue into, how can we play a role in regulation? Your biggest role for you or for me as a clinician is to be the detective and to be that sidecar that helps a child interpret their own experiences. You do that through really careful observation, and like I said earlier, hypothesis. Like, "I wonder if this is true," and like being very mindful of yourself, and that child's experiences at the same time. But the key to data collection is observation because you can't Ð they may not be able to communicate how they feel, or what they're feeling. So the best way around that is to get really, really good at paying attention to subtle shifts. Like Erin mentioned, a baby holding their breath. That's a great example of a sympathetic state. We've got a sympathetic state and a parasympathetic state.

What a lot of people think regulation is, is being 100% parasympathetic. Well, I really don't know the last time in my personal life I was 100% parasympathetic. I don't do the rest and digest very well. My anxiety doesn't really let me do that. But that doesn't mean I'm not regulated. Like Erin said, regulation is appropriate arousal and preparedness for the task at hand. If I was just chillin' right now, we wouldn't have a very coherent conversation. So it's really important to pay attention to some of those behavioral markers. There's some really interesting research in the world of microexpression that could help lend you some lenses on how to observe regulation in a child. My favorites are heart rate, posture, eyes, facial grimacing, and the cadence, and their flow of speech, or their movements, because it's kind of the same thing.

What do I mean when I say posture? If I see a child who has slumped rounded posture, and I'm about to ask them to do something active, I can tell that their body is not prepared for that. From a neurological perspective, your axial system, at the core of your body has to be prepared for action in order to coordinate your distal lens. So if they're slumped and rounded, and not prepared for action, they're not regulated for the task at hand. Vice versa, if I'm asking them to sit and pay attention to a worksheet at a desk, but they are also hyperextended, and their eyes are darting around, they are not regulated to focus on the task at hand. They're over-aroused. A

You can tell that because they're more in a sympathetic reaction. That sympathetic reaction is that fight, flight, freeze, faint, fawn reaction. A little dose of that is good. It keeps you moving forward, but too much of it shuts you down. So being aware of tension in the eyes and the mouth, tension in the neck and the shoulders, hyperextension through the spine, that's one of those things that you can really clearly see. Pupil dilation is huge. Your pupils get really large when you're scared. That's because your visual system says, ÒTake in as much information as possible so that threats can be detected.Ó

So if a kid has dilated pupils in a context where it looks kind of funky to you, it's probably because they're in a sympathetic state. Knowing that means they're probably shutting down and not able to attend to everything that I'm saying, or all the directions, or the demands of the task at hand. Breathing rate is really, really common. Older kids will also hold their breath when they're over-aroused. Then, the last one I mentioned was sort of cadence of your movements, or of your speech. OTs call that rhythmicity a lot. You'll see OTs will document like, able to complete tasks, but with decreased rhythmicity. That means that their motor synchrony was not fluid. When it's not fluid, it still tells me that you're having to think really hard to get this done. You're probably kicking into more brainpower than should be needed to complete this task.

If I continue to layer on more task demands, that child will not feel as though they've completed that task well. So it's just really important to pay attention and get to know those kids and get to know what their baseline is. My baseline is a little bit not coordinated, because I tend to not pay attention to proprioceptive information until I crash into the corner of the desk. So I'm not the person you want on your softball team. I will mess it up, and I know that about myself. So if someone asks me to join a competitive sport, I'm automatically going into a sympathetic reaction, because you've asked me something that I have felt failure tied to in the past based on my sensory system. So you can see how especially when you go back to that Ayres model, that self-esteem and self-efficacy get really tied into very specific learning experiences and sensory experiences.

Knowing my body doesn't pay attention to proprioceptive information means that I was a horse girl because you can hardly get more proprioceptive information than from a horse. There's just something else giving you more input, and your joints are compressing every time that horse takes a step. But I was not the person that played volleyball. You make me run across a flat surface, and I don't know where my feet are.

[0:56:44] EF: Mm-hmm. An important thing and what I focus on too is, okay, like we notice these small changes., I will comment on them or give words for that, or, "Oh, this is too much" or "Oh, I need a break" or, "Oh, let Ð" Like giving words and language for what's happening in the environment gives power a lot of times to the children that we work with, because it, like you said, makes more meaning. Sometimes you can build language in a time where a child may be a little dysregulated because language can also be regulating. That's really important. Sometimes just having the words to explain how I'm feeling and that I don't know what I'm feeling can be grounding.

So, don't be afraid of those moments, and to give words to those moments. And if you're wrong, and you label it wrong, that's okay, they will for sure tell you, and you can kind of repair that. But I know there's Ð I have so much to learn about sensory. You're always going to be learning about sensory. A thing that Karen and I encouraged and Floortime training encourages is to start to understand your own sensory system. Because then, you can understand why some children may take more out of you just energy-wise and some don't. That doesn't mean you can't work with those children. But if you can better prepare your own body for that session and that moment, because you know you're going to need a little bit more energy, then that can really make a big difference in a session.

I hope that this just encourages you all to dig deeper, and to realize that this is something that I hope speech pathologists realize that it can really, really improve your practice and connecting with your children, and develop Ð and helping them develop a true authentic sense of self. Like Karen said, that self-esteem. If we understand their sensory system, we can better understand them. If we better understand them, we're going to better help them communicate what they authentically want to communicate. I think that's really, really important. Because the less we understand, the more we're going to try to put them in this bubble of what we expect them to do, which is not very neurodiversity-affirming and not very trauma-informed. So we kind of have to start learning more about sensory to take that shift too.

[0:59:24] KM: Well, and psychology is starting to pay more and more attention to sensory as well. There are sensory integration programs that are starting to be done with adults with schizophrenia. It has a realm outside of just children. Every human is a sensory human because we all have a body that we have to interface with this world. So, we all have sensory experiences and it's worth understanding what goes into that to the best of our ability. And there's so much that we can learn. 

We will link the article that I talked about, the neural foundations of Ayres' SI. It's so helpful to just trace areas of the brain, what they do, and what sensory systems they're tied to. It's a great evidence base for some of your practice. Erin, I have a question for you, because I don't know if ever I've ever asked you this. I think I know the answer, but I don't think I've ever asked you. A lot of sensory people have their favorite sensory system. If you had to pick one sensory system, which one do you think is the most interesting and why?

[1:00:31] MD: That's a good question.

[1:00:32] EF: I think my favorite is proprioceptive because I really need it.

[1:00:36] KM: That's what I was going to guess.

[1:00:38] EF: I find it so interesting how like it manifests in such different ways. I realized the other day that I was taught Ð I mean, I was telling Karen this, but like, I really love heavy sweatshirts. I mean, I have a weighted blanket on right now. I need that input, but the fact that it Ð I'm actually reading a book called The Wisdom of the Body right now. It's so interesting to think about how we learn about our body, and how we Ð I think also, speech pathology is a field of 97% women. 

Sometimes, we all have grown up with so many conversations, and a lack of understanding about our body. Even learning about sensory, and my sensory system, and like diving into yoga, and things like that has just helped me be more authentic in my own body, and then show up in a way with not just my patients, but like my friends and my family that just like, is more confident. So I think Ð wait, what's your favorite?

[1:01:49] KM: You want to guess? I want you to guess. What's my favorite sensory system?

[1:01:54] EF: I would say vestibular or visual. 

[1:01:56] KM: You're right. It's actually the combination. But if I had to pick one, because that's kind of cheating Ð

[1:02:00] EF: Wow. See, that was a trick question.

[1:02:03] KM: Kind of cheating. To pick two, I would pick vestibular. I think it's really interesting. Actually, I've fallen in love with the vestibular system as I've learned more about the language system. Because I learned a couple of years ago that the vestibular system is tied to such a strong sense of self and agency, that children who have vestibular experiences are more likely to communicate verbally while they have vestibular input. I thought that was so interesting. I was like, "Why?" If you put a child on a swing, all of a sudden, are they going to start talking more or communicating more?

Then, I read the research about the vestibular systems tied to agency. I was like, "Oh, that's why." Because our language is how we communicate, and change our environment, our social environment, and our built physical environment. But you have to feel as though your body has the power to make a change, it has to have that agency. Your vestibular system is that tie between what your body does, and what the environment does to your body. I just thought that was so interesting. I also am a kid who used to spend hours on a swing at a time. So you know, I also have really positive connotations, sensorimotor memories paired with that, that are also linked into my emotional centers. I really think it's interesting. But yes, and then it's also tied to the visual system, which is one of my favorites.

[1:03:34] EF: If anyone has any questions, I mean, we'll be here Thursday Ð Tuesday, and Thursday. So feel free to come back with them. Karen and I are both on Instagram. I think I'm @erinforward.slp, but I don't know. You can find me on First Bite, and I have tagged Karen. So if you guys have any of those questions, feel free. And yeah, we hope you guys come back because we'll just keep layering on top of it.

[1:04:00] KM: Yes. If anybody has any questions that they want to ask right now, go for it. We're happy to do that. You can either jump it in the chat or we can try and figure out how to make you talk. I don't know if we can do that or not.

[1:04:11] EF: Who knows? How nerdy are we that we have a favorite sensory system?

[1:04:15] KM: Pretty nerdy. When is the next course? The next course is on Thursday night, same time eight o'clock. So, that's what we're doing.

[1:04:23] EF: Well, thank you all so much. Yes, we'll see you on Thursday.

[OUTRO]

[1:04:29] MD: Feeding Matters guides system-wide changes by uniting caregivers, professionals, and community partners under the Pediatric Feeding Disorder Alliance. What is this alliance? The alliance is an open-access collaborative community focused on achieving strategic goals within three focus areas; education, advocacy, and research.

Who is the alliance? It's you. The alliance is open to any person passionate about improving care for children with a pediatric feeding disorder. Today, 187 professionals, caregivers, and partners have joined the alliance. You can join today by visiting the Feeding Matters website at www.feedingmatters.org. Click on the PFD Alliance tab and sign up today. Change is possible when we work together.

That's a wrap, folks. Once again, thank you for listening to First Bite: Fed, Fun, and Functional. I'm your humble but yet sassy host, Michelle Dawson, the All-Things PFDs SLP. This podcast is part of a course offered for continuing education through SpeechTherapyPD.com. Please, check out the website if you'd like to learn more about CEU opportunities for this episode, as well as the ones that are archived. As always, remember, feed your mind, feed your soul, be kind, and feed those babies.

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FBP 251		Transcript

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