EPISODE 253

[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 PEDs SLP. I am a colleague in the trenches of home health, 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, and watch out for all hearth's growth, and enjoy this geeky gig brought to you by SpeechTherapyPD.com.

[DISCLAIMER]

[0:02:21] 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]

[0:02:30] EF: Hello. Happy Tuesday. ItÕs only Tuesday. Welcome to The Importance of Motor and Language Learning for Effective Therapy with my OT partner in crime, Karen McWaters. For those of you that have been with us for the Ð this will be our third installment of this little first bite series. To get the boring stuff out of the way, my financial disclosures are that I receive a salary from Cincinnati Children's Hospital and receive royalties from SpeechTherapyPD for First Bite and other presentations. Non-financial disclosures, I volunteer for Feeding Matters. I'm sometimes Dysphagia Outreach Project. I'm a contributor to Michelle Dawson's book, Chasing the Swallow.

[0:03:26] KM: My name is Karen McWaters. I've been on the other two episodes if you want to know where I am and what I do, we introduced ourselves two times. So I think we don't need to do it the third. But I get paid through my job at Georgia State University as well as my consultant job with ATS Kids in Greenville, South Carolina, as well as through my guest appearances on this podcast. I think that's it.

[0:03:54] EF: For those of you that are tuning in, either listening to the podcast or just tuning in and haven't listened to the other two episodes, we encourage you to do that as well. Because it leaves a lot of the groundwork for things we're going to be talking about today because it all kind of layers on top of each other. This is something that the parallels between language development and motor development are something that Karen and I have a lot of conversations about. Because it's something that we have noticed in parallel with a lot of the patients that we worked with and then started to put together these ideas and dive into the research as to why we were seeing these things align very similarly in regards to the children that we were working with and their development.

A lot of what we'll talk about today involves learning about praxis, as well as language. We'll go into what praxis is and the stages of praxis or the development of practice. Because we play a much there or role as speech pathologists in that development than we might realize. So I will let Karen start with the stages of praxis because she explains it so much better than I do. But yes, that's kind of where we want to start because it's important. We learn about apraxia in regards to speech development, but similar but different in regards to the broad Ð apraxia is much more specific than when we're looking at praxis in general.

[0:05:34] KM: Yes, and there's a lot of words that get thrown around in pediatric therapy generally, that have that kind of praxis part of it thrown into the word. So like, you'll hear OTs talk about dyspraxia. We all talk about apraxia of speech, but then also apraxia in adults with brain injuries and stuff like that. We throw these words around a lot, and it's worth kind of diving into what we mean by what is praxis, and then understanding that the word dys means a dysfunction in the way it's developed. So that little front part of that word carries a lot of meaning. Then it's worth understanding what praxis is.

But in relation to speech language pathology and speech therapy, please know that when we talk about this, I'm going to present to you the research that OTs have done on body-based praxis. What Erin and I have researched and found to be clinically true as well, is that language is just really a symbolic representation of what happens with your body. So we're going to go through the concrete, motor version of praxis first. Then we're going to talk about how that parallels in language development, and how motor development, and language development is really intrinsically linked. And just how clear some of the research is about how you learn first with your body, and then you learn to play around with those ideas symbolically in language and in cognitive development.

Let me explain a little bit about what praxis is. Praxis is a uniquely human ability that allows our bodies to conceive of, organize, and carry out a sequence of unfamiliar actions. So that means that in order for a task or activity to have to require praxis it must be novel. The good thing is, is that we really, truly never do the same thing twice. Even our daily routines, there's a little nuances in it. So we're pulling on this ability of adaptation frequently to just get through our daily lives. So when we start talking about development of that adaptability, you will hear from a sensory language perspective, people talk about that ability to organize and carry out unfamiliar actions as an adaptive response. An adaptive response and praxis oftentimes are used interchangeably, but praxis is the process of creating those responses that are adaptive.

What we know is that, if there's an issue in the process of developing a response, that's what makes the response not adaptive to the scenario. Whether there's a difference in sensory processing, or there's not enough experience in order to modify a plan to make it adaptive to the situation. The process of creating a response that fits and is functional is praxis. 

With that being said, I will also highlight the researchers who do a lot of this work. Their names are Teresa May-Benson, and then she's the Big Four runner in the OT praxis world. She publishes a lot on praxis. She also provides a fantastic continuing ed course that I would recommend any discipline take about the neurology of your brain and how this process of forming responses to our dynamic and changing environment rarely happens. But she identifies four major stages in praxis, and then there's other stages within that.

The four major ones are ideation, planning, execution, and feedback. It creates a cycle that goes back into the first stage. So I'll go through those four areas, and kind of define them really quickly. Then, we'll put it into like a case-based example to kind of explain how all of those stages work. Ideation is conceptualizing the goal of the activity, or plan, and coming up with a rough plan. That includes the initiation phase of any sort of movement or activity. It means, you've got a goal in mind, and you've got a basic outline of how to get there. But then the planning phase that comes next is really filling in the details of our brain, our body, and what to do with our body in order to reach that destination.

[0:10:20]

When we talk about body-based praxis and motor planning, we really talk about that planning and sequencing phase as being motor planning. You'll hear OTs throw that word around a lot, and sometimes they refer to that as the planning phase, and the execution phase as well. Because the execution phase means that you're putting that plan into action. So if the plan has flaws, that's when you really going to see them pop up. Then, there's the feedback portion. So you have the idea, you come up with the plan, you execute it, and then you have the feedback portion, which is like, did that work? That's your brains process of like Ð did I accomplish my goal. Some people refer to this stage as the adaptive response generator. If it didn't work, your brain develops a hypothesis about what to do differently.

But I will also point out that that feedback section really heavily depends on sensory processing. So if you don't have reliable use of your sensory systems, it's really challenging to know if it worked or didn't work, did you accomplish your goal, and also to understand what to do differently next time. So go back to the first episode about sensory processing, to understand a little bit about that framework, because all four of those stages really heavily depend on sensory processing. But particularly that feedback stage is really where you can observe differences in sensory processing and integration.

I will also say that our motor responses, what we understand theoretically about motor development, is that there's this experimentation phase where our ideation becomes dependent on our understanding of feedback and of observation of feedback through interaction with our caregiver. So early, early on before you can truly have well-formed ideation, that feedback phase really starts first. Erin, I think that you should probably talk a little bit about like communication as relates to that, because that's where we see it happen a lot really early on, is with differentiated baby cries, right? So that feedback from mom, I want you to talk about that a little bit.

[0:12:41] EF: That's how like so early on, a lot of people Ð I used to explain it too. I worked in early dementia a lot, and you see an OT and PT come in. So often, you feel like OT and PT, it looks like they're doing the same thing, but they're working Ð their end goals, and what they're focusing on are different, but the groundwork is the same. Early on in that development of attachment and communicating what Ð that first bases of communication are involuntary behaviors.
So how you develop the understanding of what those behaviors and those motor plans mean, is by the response of your caregiver. Like Karen said, do a certain cry. My caregiver knows I'm hungry, and they feed me, and I feel better. So I understand that that cry is going to get that response. I focus on this a lot with feeding with a lot of the infants that I see. Their hands splayed, their eyes get wide, this communicates, "I'm stressed, take the bottle away from me, this is too much." Then that's how I build understanding that my motor movements have meaning. 

So, what Karen and I talk so much about is how as speech pathologists, we play such a large role in this development of praxis. We might not even understand when we undermine it, because that ideation piece is both cognitive and development of communication. Because so many of the children we work with, might not have all of the skills to have an idea, execute it, and then plan it, execute it, and then build on it. So they need to use communication, and they need to problem solve with somebody else in a social situation to be able to grow these ideas, and to be able to learn from them.

How often do we in sessions have an idea for them? They do something that's different and we stop them right there. So right away, they have an idea and we're stopping this loop of building praxis. Like Karen said, it is very rare that we do something that's exactly the same every time. So unless we're going to put a kid in a room that looks exactly like ours with the exact same voice, and the exact same stimuli, and the exact same positioning, we're setting them up for failure if we don't allow them to use their own ideas as well. 

In communication, every sentence I'm spewing out, unless I'm reading from a script is slightly different than what I've said before. So to develop these new ideas with language, they have to have their own ideas of how they want to say it. If we're so strict about exactly how we want a kid to imitate something, and exactly how they need to say it, we're not making them adaptable for the world that they're living in, and they're not building this loop. To the point about their sensory system, we have to also understand that to know what feedback we're giving them. Because if we're giving them feedback that they're not processing because of the way their sensory system works, then that's not helpful. So I do need to understand their sensory system, like Karen said, from episode one, to give them the right feedback, to go through that loop again, and build off of it as well. But there's communication in every part of that.
[0:16:10] KM: I would also say too, if you cut the loop short, it's really hard to actually gather data on what they're able to do. Because it's not until they get to that feedback stage that you can actually see if they understood what they did or not. That's really what matters for creating change. You don't get to walk with them everywhere to cue them. They have to understand the differences and the nuances in their performance, whether that's a communication ability or a motor ability, and how that lines up with the environment around them. It's all about supporting their independent use of Ð

Here's a situation. The situation is I need to put my shoes on. The idea is, the shoes need to go on my feet, the kid knows the shoes need to end up on their feet. The question is, do they have a rough plan of how to put the shoes on their feet? They may have a rough plan, like put my foot in the shoe. Well, how often do we have kids and this happens all the time in the clinic. Where like, they put their foot in the shoe, and then they just start walking off and their foot is still halfway out of the shoe. What did that just tell me? They had an idea that the shoe goes on my foot. I put my foot in the shoe. To them, and their feedback, they've planned, pick up my foot, put it in the shoe. They executed, pick up my foot, put it in the shoe, and then they start walking off as though the task is completed, and the feedback of like, "Oh, the shoe is not on my foot, it's only halfway on my foot" did not process with them. 

That is more valuable to me clinically, than how much assistance did they need to put that shoe on. If I jump in and help too early, then I don't actually know what they can and can't register as complete a task, or as effective, or if their brain gets overloaded by other stimuli. So then they tune out that their foot is halfway in their shoes. These are the kids too that, they're always on the move, and they trip over their own feet. They try and get them out to their car, and they've fallen on the pavement and skinned their knee because they didn't realize their foot was halfway in their shoes. So you end up in this much more dysfunctional situation because there was a piece of feedback that was missing for them. But if you cut that short, or if you provide too many cues, it doesn't create a generalizable response.

On the other hand, we also have to talk about scaffolding and cueing, and making sure that you provide, like Erin said, the right cues for their sensory system for them to learn that independent praxis, that independent problem-solving. It's a real balancing act between gas and brake. When do I step in to provide support, and when do I back out to watch what they can do? Mindfulness of how much gas you're giving into the situation, how many cues is really I think the key in that.

[0:19:27] EF: Yes, and being comfortable with spending Ð when I learned about this too, it helps you realize the importance of [as floortime would say 0:19:36], wait, watch, wonder because you need to first understand what their brain is doing before you jump in. Because if I'm already giving all of these cues and all of the support, it's harder for me to figure out where to back down and harder to Ð sometimes you can scaffold backwards. I think speech Ð nothing against speech therapist. I think we often will jump very quickly to giving all of this support, as opposed to taking time to let them figure it out first.

Sometimes the most passive way that I will cue, whether they're consciously listening or not in that situation where the child put their feet in the shoes and walked off. As they're walking, I'll be like, "Oh, my shoes aren't all the way on my feet." Like giving them in a joking, playful way some language to describe what's happening. Because whether they recognize it or not, their shoes are not fully on their feet. You're just stating something that's happening in their voice that maybe will make its way to Ð or even in a much less sequential example if I have a child that I have a lot of children on my caseload that are very medically complex, that are working on tastes of food. Maybe they can't self-feed, maybe they Ð I have a lot of children with cardiac conditions right now, and we're just trying to support that motor movement. 

One of the things I will say is always use the exact same cue as much as you can at the beginning so that they're understanding what's going on. So whether it's eat, or bite, or whatever the family wants to say. So you're giving them something to support that development of what's happening with their body.

[0:21:28] KM: Yes, yes. The other thing that I will say, sometimes I'll give a cue that doesn't have Ð it's an emotional, cognitive cue without language, also known as a sound effect. Because sound effects really do allow you to bring attention and pair some sensory sensations together, without overloading the cognitive part of the brain with processing the language. For example, the example of the kid in the shoe. If they didn't put their foot all the way in, sometimes I'll be like, "Oh, my foot." Which is a lot more of like a multi-sensory way of expressing the tactile feeling of their foot trying to cram into the shoe.
At the same time, giving that meaning through a sound effect, rather than Ð that's a lot more like from the emotional centers of your brain and less from like the cognitive language centers of your brain. So it just pulls a different cognitive load along with it, which can sometimes be helpful. When we talk, though about motor, and language development, and when we talk about language, specifically, we're really talking about language being a symbolic form of those stages. Like, first, I have an idea of what I want to communicate, then I plan how to communicate that, then I execute it, and then I get feedback. Did I explain that okay? The message, the mode of communication, the delivery of that, and then feedback from the other party of like, would that work? Don't know. Especially for Ð and this is where we're going to talk about this too. We're going to go through typical development, and how typical development motor movements lead to language milestones.

But we're also going to talk about our Gestalt learners because they learn language that way. But clinically, I've also seen them learn play skills and motor skills that way. Sometimes, their language is a window into their learning style that you wouldn't otherwise be able to harness. The other thing I will say quickly is that, when children have a limited range of how to play or how to use their body, you often find that they have a limited vocabulary and how to communicate meaning and needs as well. That's why speech and OT end up working together.

[0:24:19] EF: This is also why it's not very helpful to use flashcards of actions because also, in a picture, they're not actually moving. So if you read like Ð if you really think about it, sometimes you'll show a kid a picture of like jumping, but they're not Ð you have to understand that very symbolically. That multi-sensory if we're trying to Ð neurons that wire together fire together for trying to really build that depth of understanding and memory. That emotional Ð like Karen said, connection can increase their memory of it. And that motor movement can also increase their memory because you're pulling those things together.

This is why we need to understand motor development because if you're seeing a child that has difficulties with playing with a toy in different ways, they're probably going to have difficulties with the understanding that different words can mean the same thing. Or that a word can mean different things because it is so connected. I'm also going to use these strategies in my sessions, to think about the language that I'm trying to work on, and then think about what we can do with our body to also Ð to build that understanding because that's the most effective way for them to learn it.

[0:25:48] KM: Yes. I love the way that you think about how your language impacts what activities they participate in, so that you can use more of your language to help them understand what their body is doing and feeling. OTs think a lot about how can we expose them to different activities, and novelty, and see how they adapt. We think about that, but we don't think about our half of the deal, which is, you're there with them the entire time and using your interpretation through language to help guide them. I don't think that OTs always think about narrating for them like what you just explained.

When we talk about motor development, though, let's go back and remember that we're talking about Ð when we go through this, we're going to explain some milestone behaviors that you see at different ages and stages. What the research has started to point out is that the motor milestone will happen first. And then subsequently, there is a communication milestone that mirrors very closely what they did with their body. When you look at a list of motor milestones, I encourage you to think deeper than just the surface level checkbox behavior. To think about what may be required by that body or that brain to be able to achieve that behavior, because those are the observable checkboxes. But the soft skills that underlie them is what leads to those Ð that development. 

Next week, we're going to talk a little bit about activity analysis, and what that is, because that's a Ð

[0:27:47] EF: Thursday.

[0:27:48] KM: Sorry, Thursday. Thursday, not next week. Next episode, we're going to talk about, yes, activity analysis, which is an OT thing that we do to break down what an activity or a task is, and what goes into it to understand some of the softer Ð tease it apart, understand what kind of components underlie it. When we talk about these milestones, please be thinking deeper than walk at one, talk at two. We're going to be talking about, why is it that they parallel communication because there's a central characteristic of that milestone. Something that that brain learns from that body-based milestone, that then they apply into communication and use symbolically to communicate. So they take it out of context and use the meaning that they learned.

Generally speaking, though, as the complexity of motor skills increases, the complexity of prelinguistic skills increase. That's why you walk at one, and you talk at two. Your motor skills get more complex, and then language skills come a little bit later. But the communication milestones that go along with that pre-verbal language in typical development are really closely following behind all these motor milestones. That's not something that I was taught in OT school, was not Ð I didn't learn the parallels between those two, and I know OT schools and speech schools, they only have two years with you. They don't have forever, but it's so helpful.

[0:29:32] EF: That's also why I will say from Ð and this is just a quick side note, is that because that walk at one, and talk at two, a lot of that is building that sense of agency that my body can do something for me, and then my communication can do something for me. So if you have a child that you're working with that has communication differences, I also would encourage you to be cautious about taking away any of that body autonomy and agency that they have just to work on language. Because that can be very traumatic for a child when they don't feel as competent in their communication skills and you can develop both at the same time.

So taking away motor doesn't mean you're going to build that communication, when they start to understand that I can have more affect, and emotion, and connection with the way I talk, they're going to choose that. But that's just something I'm very passionate about is still allowing them to use gestures, and movement and whatever they need to do to communicate and not take it away in hopes that they're going to talk instead. 

[0:30:40] KM: Right. Frankly, if you see a child with language or communication delays, I would argue that the majority of the time Ð I'm not going to say 100% of the time, but I'll go out on a limb, and say, 95 at least percent of the time. They're going to have individual differences in the way that they learn with their body. That may not have red flag someone early enough until they get to the symbolic level of communication. But often, if you break it down, you're going to find issues deeper than just Ð that they can't write a paragraph.

Let's go to typical development, and kind of outline how these things are connected. At seven months, a child will go through this exploratory phase where they shake and rattle things a lot. So they've learned to reach and grasp things. Now, they're learning that when their hand moves, and they shake a rattle, that a sound is made. Literature says that two to three weeks later after this explosive exploration with cause, and effect, and timing of muscle groups, and sounds differentiating the temporal nature of sounds. Literally two to three weeks later after this hand play with a rattle, they start to do a reduplicated babble. It's the same action, just moved to vocal cords rather than their hands, like that alternating timing of muscles, that cause and effect is the same thing just moved from their hand to their communication system. 

So it's really cool to know that there's such tight parallels, and that's not the only one either, at a little over one or a little over two. A child will like be able to place a bead into a container or pull objects apart. Then at two years old, they start to be able to string beads. While they're learning those things with their body, they start to learn to pair objects, understand what objects allows them to do with them, which is a knowledge of affordances, and then make specific meeting with those objects. Then, right around that age two, Erin, what happens, communication-wise?

[0:33:11] EF: Puts words together.

[0:33:13] KM: All of a sudden, they make like specific meaning to sound. They have specific meaning with objects. Then, bam, all those sounds have specific meanings as well. It's a really cool exploratory phase. That's why toddlers are my favorite, personally.

[0:33:34] EF: Think about for those of you that work in early intervention, especially like Karen said, a lot of kids will get flagged because they're not communicating or they're not talking. And then you watch them, and you're like, they only know how to do one thing with this object. So much of their play is like running around in circles and they're not truly engaged. So you watch, and you're like Ð and then you work with them and if you have this knowledge, you can start to put that in place, but you're like, "They really need to see OT too. Like they really need some help with their overall motor development." 

So often, I think when Ð if kids are walking, and like once they get to that stage parents don't Ð it's not as noticeable about what else might be going on with their motor planning until they maybe get to school. So we with this knowledge not only can help with our sessions, and help the children we work with learn language and communication, but it can also help children get other supports they need with OT. Because, unfortunately, sometimes OTs do so much that then people don't know what they do. I just feel like it's Ð

[0:34:55] KM: No one knows what we do, and we've just accepted it.

[0:34:59] EF: But Ð

[0:35:00] KM: I had a family member recently asked me what I did with children. "Why are you an occupational therapist with children? They don't have a job." I was like, "Yes, about that." I mean, really, nobody knows what we do, and that's okay. But yes, there are things that you guys as speech therapists could help flag and pull in some supports for their overall learning, not just their language and communication learning. For us, oftentimes, those children then have social-emotional challenges because they're frustrated with the learning process overall. They're the ones who have meltdowns, or are sensory seekers, or having classroom behavior challenges. They get a speech referral because they have trouble with pronouns, but they're also the ones falling out of their chair during handwriting, right? Or melting to the floor with losing a game.

It's because that learning process, those praxis stages have some Ð it's just something gumming up the gears, and finding what that is, and working together to clean it up, and oil that machine is our goal.

[0:36:17] EF: Michelle asked about some other specific motor tasks to think about if we're in early intervention, and I'll answer my perspective on that, and then let Karen answer. I think what Karen and I's Ð what we want to get across a lot is that these things that are developing in parallel are indicative of a more Ð a broader learning. For example, being able to put those two objects together to do something that demonstrates maybe the ability of being able to put two words together, or thinking about how I can do different things with or I can do the same action with different objects.

Karen and I shared a patient that we worked on the idea of pull up a slide. Karen, specifically. I just use the language and then I followed along. I learned from the scenario. But with a rope, and a hula hoop, and a pool noodle. What we were trying to get there was not, do I know I can pull with a pool noodle? But Karen was trying to get with working on that was to understand that objects and their affordances what we can use them for. And then to problem solve, so that he has the adaptability to understand. Sometimes in that scenario, that took a very long time. We worked on that for weeks. 

But what we taught him was that he can problem solve to use different things to create a similar solution. So it wasn't necessarily pull and it wasn't necessarily the exact objects we were working on. It was that overarching motor pat Ð or that cognitive pattern in his brain to understand how to problem solve that. That was a big part. If you're working with a child, and they're having trouble coming up with new ideas, like say, you're working with Ð and this is a plaything. We talk about play all the time. This is when play is such a great tool. But if you're playing with a kid, and you feel like you're always Ð they're doing the same activity over, and over again, and they have a hard time if you bring something new in.

Like Sam pushing a trainer on the circle, but then, oh, no, something's in the way of the train. We call that a playful obstruction. Can they work through a playful obstruction? Can they add another sequence? Can the train go in a circle, and then maybe I add a bridge to it, and it can go up and down the bridge as opposed to going around in a circle. In that instance, if they can't do more than one sequence, they're probably going to have a hard time saying more than one word.

[0:39:04] KM: I will Ð

[0:39:06] EF: Go ahead.

[0:39:07] KM: Oh, no. I was about to say the same thing. If you see somebody repeat the same play sequence over, and over, and over, and over again, and there is no adaptability, or change in it, oftentimes, that's because they can't ideate a change in it. And a change in it may make them frustrated because they can't ideate how to solve that. So gently introducing playful obstructions is a great way to check on these stages of praxis, and just see what happens if I throw you a curveball. Can you problem-solve it, or does it disrupt you so much because you don't have a pattern of that?
My other giant red flag, and that's because there's some literature published on this too. Children who have poor ideational skills, like play ideational skills also have a difficult time with narrative explanation of events. So if a child specifically uses Ð can't tell you what happened, in what order, if they started telling you a story, and it's like, "Whoa, I don't understand what just happened." Which you speech therapists get that a lot. That's a red flag that they probably cannot order or organize a sequence of actions, to then be able to symbolically communicate that order and sequence through their words. It's not that they don't have the words, it's that they can't organize it temporally or spatially.

The other red flag I will say is that kids who only use the verbs put, go, and play those three verbs are really, really common. When you ask a kid what they want to do, they'll say, "Oh, I want to play." Then you say, "Play what?" and they can't tell you more. Or if you ask them what to do with something, they're like, "Oh, you put it over there." Or they get frustrated, and they say, "Just go." But they don't tell you to run, to jump, to swing. There's no descriptor and the verb that they use. Oftentimes, it's because they don't have more than one association with that word. So they assume you can read their mind about what you want them to do, but they don't have specific meaning and separate ideas of what that play looks like.

Going back to creating motor-based learning experiences, and then giving them language to create that specific meaning is what really makes a big difference. But if you hear kids, if you're taking a language sample, and you hear kids only use those three verbs, get your friendly OT to come check them out. Because that probably means they're having praxis challenges. At least, in my clinical experience is like 10 out of 10 times. There's something Ð like I said, kind of gumming up the works of that praxis system. Erin, that kind of Ð oh, I did want to kind of share this one quote from this article we read. It was by a researcher named Iverson, which Ð

[0:41:55] EF: We love her.

[0:41:56] KM: We love her. Erin found her and we love her.

[0:41:59] EF: And she is at University of Pittsburgh, so we love her. 

[0:42:02] KM: Okay. Well, we love her even more then. Erin went to Pitt if you didn't know. So she said, language involves a unique constellation of interrelated cognitive and symbolic capacities that come together at one point in time. So it means you have to understand it cognitively to be able to translate it symbolically, all in one point in time. So in order to understand Ð oh, what are the three verbs? Sorry, Terry. Usually put, play, and go. If those are the three that they use the majority of the time, pretty red flaggie. So you have to understand concepts cognitively, which means you have to be able to interpret them.

From a sensory perspective, that's often where you run into issues because children have a hard time interpreting what has happened to them. What stimuli happened in what order, when you have difficulties processing and integrating information, it's hard to know. Did you hear that sound, and then the lightning flash? Did thunder happen, and then the lightning, or did it all happen at the same time, or did your brain reverse it, and pay attention to the lightning, and then the thunder? Really hard to process a sequence of events when your sensory systems are unreliable.

Again, language involves a unique constellation of interrelated cognitive and symbolic capacities that come together at one point in time. I just thought it was so beautiful that she compared it to a constellation. I love thinking about how you can draw connections between things to develop a unique constellation of that child's language, their symbolic understandings, and their cognitive understanding. You can kind of map out the way that they Ð their language and how they communicate about their world, it's just a beautiful thing. But that means you have to get into their brain. You have to get on the floor with them, you have to feel what they feel to be able to understand.

[0:44:09] EF: The amount of times that Karen and I are like laying on the floor with a kid looking at something, or like doing whatever they're doing with their body just to see why that might look a certain way to them or feel a certain way to them. I've learned so much about just the world. I was thinking about it the other day, and a way of like Ð especially a lot of the autistic kids that we work with, the pictures you that people post on Facebook or like the ones that they used to use in like psychology testing where it's like, "What does this picture look like?" We were trained to look at a picture, and then once you see it, you can't unsee it. How lucky are we that we get to work with kids that see it differently and we get to see it in a way that we never have before. Because we were just told that this is what itÕs supposed to be, and that's the way our eyes always looked at it. So like, I just think that's cool.

[0:45:08] KM: Before we get into a little bit about gestalt learning, and motor learning in gestalt, I truly think it's so beautiful that when you engage in the system of like, "I wonder if." If you start approaching your sessions with, I wait, I watch, I wonder, you learn so much about the world. And you learn about why a child's play is purposeful, which is really important. Because even though it doesn't serve a purpose that you may observe if you join in it, you may find the purpose for that child. It's just such a beautiful opportunity to find their meaning so that you can help stretch and understand their meaning to the wider world, right? Because when you have unique sensory constellations, it means you make unique language constellations or communication constellations. I don't even really like saying language because it implies that then, it's all verbal, it's not.

You develop these unique ways of communicating about your world, and that means that sometimes if you join in what looks like a stim behavior, you may find out why it's happening. I mean, I can't tell you the number of visual stims I've joined in on, and then like, "Oh, pretty cool." Who knew that the light looked like that if you went upside down, and you put your fingers in a certain way? It actually made like, especially with fluorescent lights, there's a lot of play with the refractory spectrum that children Ð autistic children will do with their hands, and their eyes. And they're actually, if you join in, you may actually see a little bit of how they're seeing it as well, which is important, because we all can only operate from the base that we understand. You can't Ð

[0:47:13] EF: It gives you freedom, I think, within your sessions to feel like, when you work Ð when you're focused on these capacities and these bigger cognitive processes within the context of what's authentic to the child, it gives you a lot more freedom. Honestly, it feels better. Like it just feels more joyful and it feels like, "Okay, I don't have to force them to do something that doesn't align with how I feel or how they feel." When I started to understand this on a deeper level and understand that there's so much neurobiology behind it. Like a lot of this isn't just us saying it because the way that their brain is developing, and processing this information, you're getting so much more bang for your buck than by having a lesson plan where they do this exact activity in this exact way. Because it's just not creating the same pathways for them and that's why it can be so frustrating and you're like, "Why are they not making progress?" Because it's not connecting the same things in their brain that when they're creating their own ideas, it is.

[0:48:34] KM: Yes. Beautiful thing about play from an OT perspective, it's the only occupation that the meaning is determined by the user. I mean, and a little bit all of the occupations are that way. But ultimately, like dressing yourself, there's certain societal norms that you have to put on pants before you go into the grocery store. It's not Ð that is determined a lot of the times by society, and then it's personally meaningful because we're finding our role in society. But play is the only thing where it can truly just be that child's understanding of the world, and how they find joy in it. I love using that as a method of intervening, which means that when children have individual differences in the way they learn, like gestalt learning, it's really important to understand what meaning they're getting out of it.

Erin, you want to review the gestalt stages, and then we can talk about how that applies to motor stuff. Because I feel like, since we're talking to speech therapists, let's jump off of what you guys know, and then we'll apply it into the motor world.

[0:49:48] EF: Technically, there's six stages. I think the most important are the four stages. I'm sure most of you are familiar with this, because it's been a very Ð I'm grateful for how much speech pathologists are starting to talk about gestalt language processing, and get [inaudible 0:50:03] education and understanding. But the main idea, and what we know is that they're processing language in these larger chunks. So instead of an analytic learner that's going, "Ball. Blue ball. Go blue ball." I don't know why that was the color, whatever. They're processing, not only in chunks but what the focus often is, we call them the intonation babies. Because they're processing the emotion, and the melody behind what you're saying, more so than the word specifically. 

A lot of times, we will call them scripts, the scripts that they're connecting to, and that they're imitating are scripts that mean something to them, and that they relate to for whatever reason that be, whether they felt the emotion. This is why parents come to me and they're like, "Yes, he said this four-letter word the other day." I'm like, "Yes, because when you said it, you meant it. Then when they felt that same emotion, they said, "This is the right word for this. I know it." That's why they repeat those words.
We're going to start with delayed echolalia. Some Ð it might happen Ð you'll see some kids that will imitate right away, but most of the time, you'll hear them say a longer script, some scripts, or one word, it depends. But it could be down the road. Karen and I shared a patient who would always tell on his ADA therapist unintentionally because he'd come in, he'd be like, "Say stamps. Say stamps." Usually, he would say it when it related to how he felt. So if we were doing something, and he felt unsuccessful, he may have scripted something from his ADA session where he also felt unsuccessful. So it wasn't Ð the script had more meaning behind how he was feeling.

Then, you're going to get to mitigation, so you mix and match scripts. That's really cool because you'll hear like Ð I'm trying to think of a really good example, but they'll take two scripts, and maybe they'll take a script, and add different words. So if they always say, let's go home when they're leaving somewhere, they might start to say, "Let's go car" or "Let's go Ð" they might start to put on a new word to start to build new meaning from that script that had. What we talked about with motor learning, it can be confusing if you don't understand that they're just all language processor. Because, say, they're doing one activity in one sequence. But all their scripts are one script. If, "Let's go home," is just "I'm leaving." But you hear, "Let's go home," if you don't understand their motor development, you might not understand that that is a chunk as well.

I have one kid who Ð everything that lights up his flashlight. That's his concept. That's what's so beautiful when we pair language and start to really just look at the language they're providing us, because it gives so much information. So what that tells me is that, what he's picking up on these objects, and these things are that light that's coming from them, not necessarily other affordances or parts of them. Then after mitigations, you might start to see those single words or two-word combinations. That's stage three. 

Then in stage four is where you start to hear original phrases. They often say you'll know they're getting into stage four when the grammar isn't correct. Because if they're scripting, usually the grammar is correct because it's this big chunk. So then, when you start to hear words, and the verb tenses inaccurate, or the pronoun isn't the one that was originally used. You're like, "Oh, they're putting those words together." It's so cool what I will often say about gestalt language processors, and I tell parents this. If they're immediately imitating you, it usually means that they trust you. Because it means that they have learned that you understand them, and what you're saying is probably related to what they're feeling. I would take that, and just be aware of that because I don't ever take that lightly.

If a patient is trusting me to that level, I'm very Ð I'm always very careful with what language I use because I know it can impact the way that they think about themselves, and about what's happening. But even more so when they're imitating me immediately because I'm like, "Oh, I earned your trust. I have to really think about what words I'm giving you because they mean a lot to you because of our experience."

[0:54:37] KM: Yes, and there's some really cool research about how word retrieval is really linked to sensory-motor nodes. So understanding what that word means is embedded into a sensory-motor experience. I had a kid Ð there's a kid that Erin and I both treated. The first time he communicated to me that he was bored or disliked what I was asking him to do, he didn't tell me that. He was almost in tears repeating five miles an hour. Lightning McQueen needs to go 15 miles an hour. I didn't understand what he was saying, and I mean, I'll admit to it, I pushed him for like 30 minutes because I just didn't understand what he was trying to communicate. I went home and watched cars because I knew he was interested in. I was like, "What is he trying to get to? I don't remember this part of the movie." Because usually, PS, if you have kids that are into certain movies, and they're pulling scripts from it, go watch the movie, it will tell you so much about it, about what they are intending to communicate. 

Turns out, that's what Lightning McQueen is grumbling under his breath, while he's repaving the road that he destroyed, and he's bored, and angry that he's being asked to do like a menial task that's boring to him. Turns out, that's what that kid was communicating when I asked him to do an obstacle course two more times before we went somewhere. He hated that idea and that's what he was trying to tell me and I just couldn't pick up on the meaning of it because I didn't understand the gestalt, the script that came along with that.

But I will also tell you that those stages, that delayed echolalia, or delayed repetition, the mitigation, the single words, and then the novel combinations, that same thing happens in your motor system. So you may have a delayed repetition of an entire action, or activity, which is why kids repeat activities over, and over, and over again because they're just trying to repeat it to understand it. Then mitigating when you see a kid have two activities that they do, try combining them because you're more likely to expand their understanding, and meaning by combining them before you add in new elements. Because you're just doing that mitigating thing with actions rather than words.

There was a kid that we both treated that loved to ride his bike. He also loves speed bumps, so I put speed bumps in the hallway, so he had to ride his bike over the speed bumps. Then eventually, that bike got called his red Jeep, even though the bike was green, and he understood that I was comparing the bike to his car that he liked to write the speed bumps in. You have to combine those two gestalt activities together, to expand meaning, and to really play around with symbolism because you've taken something familiar, and given it a new context, which means, you've enriched the meaning while working off of a sensory-motor note that they understand.

[0:57:46] EF: To use their Ð this is why also Ð I mean, Karen and I shared a patient where for months, we did Mario. And for months, we did cars. And then for months, we did Nightmare Before Christmas because those were the things that he was interested in. If you think about it, if you're understanding something in a chunk, then oftentimes, you can expand within there so that they can learn these cognitive processes within something that they're really interested in. The fact that we know that a lot of our autistic kids that we work with are gestalt language processors, we also know that they don't learn as well through repetition in the same way.

So instead of repeating the same task, it's a, "I'm going to learn this process within this chunk, and then I might be able to carry it over to the same chunk." As opposed to some other children we work with where it might be like, "Here is the Ð I'm working on sequencing, and I'm going to do sequencing with this activity. I'm going to do sequencing with this activity. I'm going to do sequencing with this activity." You're going to need to stay in the same activity and work on different things so that they can understand the depth of that activity. Because that's the other thing, our gestalt language processors are often very, very deep feelers, and deep thinkers. That's why they relate to these emotions. So you're going to have to put on your like Ð I'm going to pretend to be a crocodile hat, or I'm going to Ð it has to be authentic. They know when you're pretending to be having a good time.

They know when they're angry, and you're like, "Oh. Yes, that stinks." No, you need to bring the emotion, bring the intensity to a tune like we talked about with them. And that's when they're going to pick up on the gestaltÕs that you're modeling. Otherwise, it doesn't mean anything.

[0:59:54] KM: For example, Erin and I worked with a patient who loved anything that had to do Ð really, all I think about him Ð when I think about him, I think about the color red because anything that had to do with Angry Birds, or like emergency vehicles, or Ð he loved Rudolph for a period of time, and Spider-Man. Just everything he liked was like red, which related more to like his arousal, and then also like his social, like his emotional processing. 

But anyway, after months Ð years, actually, two years of playing around with the gestalt of fire trucks coming to the rescue because that's what he understood. I mean, we set different block buildings on fire, we use different vehicles as fire trucks, we would find ropes to be hoses, or we would find a straw that could be a hose, and we could blow the piece of paper off or the fire off of the building. Just playing around with all of these elements. I then started to introduce a different action that the same emergency vehicles did, which is save Ð rescue, I mean, stuck animals. Like the cat stuck up the tree, what are we going to do? We call the firefighters, right? 

Me and the firefighter would go rescue all these animals. Well, one day, the animal got stuck way up to high on the playground, and the firefighter couldn't reach the animal. I was like, "Oh, no. What are we going to do?" He looked at me, and then he mitigated in a new gestalt that I didn't know he had. He looked at me, and he said, "Cowboy." I sat there Ð now granted, I've worked with this child for a long time so I understood when he said cowboy, he was referring to the gestalt of cowboys and what they do. And looked at him and said, "You're right, we could lasso him, let's go get a rope and see if we could lasso him."

So he brought in an action that's not in that gestalt from a different one. He mitigated in a different one to replace it, and it was really cool to see him refer to it as like this term when really he meant the action. But again, he didn't have the term lasso, he just knew it was associated with cowboys so all he could say was Òcowboy.Ó So it really matters to understand how these children's brains connect, because then, I was able to tell him, "Oh, yeah, you're right, we need a lasso." The next time something got stuck like that, he said, "We need a rope." So still couldn't come up with the term lasso but more specific meaning and something that was more generalizable. So it was really cool to be able to see that.

[1:02:34] EF: I think the big point to, that like we've talked about today is like we have this job and this role to help our children feel understood, and the way that they problem solve and learn. So with them, we're able Ð from like my standpoint, if I'm able to understand how they learn, and then Karen gave him this language that he could then use because she was the only one that was going to understand that that's what he meant by cowboy. But then when she gave him the language of rope, somebody else could have figured that out the next time. So he could have problem solved with another person to help him expand his social circle, and expand his connection with other people.

So that's really, the biggest thing, is like understanding the children we work with on a deeper level, so that they can Ð they deserve to have these big ideas, and play, and enjoy. That's a really cool thing that we get to do.

[1:03:33] KM: Well, Erin is really good about watching a kid and see them start to initiate in action, the ideation phase, and she'll go, "I have an idea." Which even if the kid can't process all of those words, her tone is so curious and upbeat and it mirrors the way that they are excitedly initiating an action. I love watching her label that in kids because they oftentimes then start to script Erin like the ones that we have treated together, they'll come back from speech a couple weeks later, and they'll go, "Idea." And I'm like, "Aha, I found it." There's Erin's script, which is what she helps label that phase of problem-solving for them. 

I love watching that because that's so much more generalizable, and translatable, and helps create more connections for people who either don't have the time or the training to slow down and understand what that alert posture and initiation looks like. But when they say, I have an idea, everyone understands that. So it's really cool to be able to watch that and to help that grow. It's really Ð it's really an honor. When you see these kids start to do this, it will make you cry happy tears just thinking about it. Because it's just Ð 

[1:04:53] EF: Oh, it just meant a lot.

[1:04:54] KM: Such an enriching experience to be able to see them share their world for the first time with someone who truly gets it and then be able to tell someone else about it. Like it's just such a great job we have, you guys.

[1:05:15] EF: Do you guys have any questions? Oh, thank you. Don't make us cry.

[1:05:23] KM: Yes, if you have any questions, we're happy to answer them. Or you can also email both of us.

[1:05:32] EF: Yes, we answer. We'll talk Thursday about really how do we analyze a task to better understand what we're actually asking a child to do, so that they can be as successful as possible, and we can really find that joy. We'll give more like examples on Thursday too, because a lot of this is Ð it's hard when you can't see it exactly. We're also if you guys are at ASGA, Karen and I will be at ASHA. We'll be talking about embodied cognition, which is very in parallel with what we've talked about today. So yes, training on PD. What do you Ð PD, am I missing that?

[1:06:25] KM: We're doing this slide again on Thursday, and then they will be published later on the podcast.

[1:06:34] EF: Oh, don't forget Ð Yumi will be mad at me if I don't say this. Don't forget, if you want credit for this live presentation, make sure you log on to your SpeechTherapyPD account app before the end of the day today and complete the quiz. You can get live credit. Otherwise, I won't Ð I know we need a certain number of Ð some people need a certain number of live lectures. So the quiz will be on there. Just make sure you complete that and then you'll get credit for that. Thank you all for coming. We really appreciate it. I know everybody is very busy and it's the end of the day and Ð what colors Ð

[1:07:13] KM: Yes. Yes. The racing in towers, building tools, the marble runs stuff, that kind of thing is a fantastic way to use visual repetition and change with colors, swapping out things, testing to see if objects will fit on the track or not on the track. It's such that so much can be worked into that. Specific research articles or resources that you can specify for you. Yes, Iverson is a great researcher. If you can find anything written by her, that would be great. She put out an article in 2010, it's like a 35-page article. That really is huge, but it's such a Ð take it chunk by chunk. It's so rich with the parallels between motor and physical development. Let me find the title of the article really fast, because I don't have it written down. I have it saved somewhere.

[1:08:15] EF: Honestly, we're just grateful because it's nice to have like-minded. What is Iverson's first name? It's a great question

[1:08:24] KM: That's JM, JM. I can't remember. We just kept [inaudible 1:08:29] Iverson.

[1:08:30] EF: I want to say Joanne, but that's Joan Arbitson. I think I just Ð can we just call here Queen Iverson?

[1:08:38] KM: We should call her queen.

[1:08:40] EF: We just call her queen. But we're just grateful to have people taking Ð we know that everybody is so busy, and no one has time to do all these things. So we're just grateful to be able to have people that are taking the time to learn and develop their practice. Because these resources are so helpful when parents say like, "You're just playing with my kid" or "Why aren't you doing Ð" because there was this mindset, like we have to do work. We're here to do work, we need to work on this, and that's not even how kids are going to learn the best.

[1:09:19] KM: No, her name is Jana, not Molly. Jana Iverson. 

[1:09:23] EF: Oh, we're close.

[1:09:26] KM: Yes, you weren't too far. I just put the two article citations of two articles I would highly recommend. One of them is by Iverson about relationship between motor development language development. Erin and I have probably ripped that article to shreds at this point because we keep going back and forth to it. It's a really well-written synopsis of a bunch of literature from 2010. Then the other one is more recent, it's Teresa May-Benson, relationship between narrative language skills and ideational praxis in children. That's a really good quick little article about ideational praxis and how it reflects in their language skills. So those two are really excellent. If you want more references, you're welcome to email us. We have presented on some of this stuff at different conferences. So we kind of have a long list of references we can send you if you want more than those two.

[1:10:23] EF: Any other questions. Thanks for sticking with us. But yes, just email us if you have any questions, and hopefully, we'll see you guys on Thursday.

[1:10:35] KM: Oh, that's my old email address, Yumi. Don't use that one. I don't really use it anymore. I'll put my new one in here.

[1:10:42] EF: She's on it though. Oh, thanks, Yumi. Yes, just email us. If you come to ASHA, come stop by. I'll make Karen be at the SpeechTherapyPD booth.

[1:10:55] KM: I'll be there. I'll be there. I'd rather sit there and talk to you guys then wander around and try and awkwardly talk to a bunch of people.

[1:11:05] EF: Well, have a great Tuesday. I can't believe Ð yes, booth 721. I was like [inaudible 1:11:10] So we'll be there, and Michelle will be there. It's going to be great. I think our lectures are like 8am on Saturday, so Ð

[1:11:20] KM: Don't have too much fun on Friday. Come [inaudible 1:11:21] Saturday morning. Article citation is not in the chat. Let me see.

[1:11:29] EF: You sent it to Ð you didn't send it to everybody.

[1:11:34] KM: Oh, shoot. It went to the host, and the panelists instead of everyone.

[1:11:39] EF: We'll get it. Thank you for letting us know. Technology. Also, wait, fun fact. Fun fact. In Cincinnati, they have the biggest Oktoberfest in the nation. Comparative like the second biggest from the real Oktoberfest is happening this weekend. They also have the biggest chicken dance. They make everybody the chicken dance together. It's apparently like a world record. So I don't know where it moved, but that's what I learned today.

[1:12:09] KM: The only time I've ever done the chicken dance is with like a pair of rollerblades on.

[1:12:15] EF: Well, you guys have a great night, and we will see you all Thursday.

[OUTRO]

[1:12:20] MD: Feeding Matters guide 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 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 PEDs 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 253		Transcript

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