EPISODE 268

[INTRODUCTION]

[00:00:14] 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 Ped's SLP. I am a colleague in the trenches of home health and early intervention right there with you. I run my own private practice, Hartwood Speech Therapy, here in Cola Town, South Carolina. And I guest lecture nationwide on best practices for early intervention for the medically complex graduate child. First BiteÕs mission is short and sweet; to bring light, hope, knowledge and joy to the pediatric clinician, parent, or advocate.

[00:01:01] EF: By way of a nerdy conversation, so there's plenty of laughter, too.

[00:01:05] MD: In this podcast, we cover everything from AAC to breastfeeding.

[00:01:09] EF: Ethics on how to run a private practice.

[00:01:12] MD: Pediatric dysphagia to clinical supervision.

[00:01:16] EF: And all other topics in the role of pediatric speech pathology. Our goal is to bring evidence-based practice straight to you by interviewing subject matter experts.

[00:01:25] MD: To break down the communication barriers, so that we can access the knowledge of their fields.

[00:01:31] EF: Or, as a close friend says, ÒTo build the bridge.Ó

[00:01:34] 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.

[00:01:45] EF: Every fourth episode, I join. 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.

[00:02:06] MD: Sit back, relax, watch out for all heartÕs growth, and enjoy this geeky gig brought to you by SpeechTherapyPD.com.

Hey. This is Michelle Dawson. And I need to update my disclosure statements. My non-financial disclosures, I actively volunteer with Feeding Matters, National Foundation of Swallowing Disorders, NFOSD, Dysphagia 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, NBASLH. And 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. And I hope you make it out there.Ê

My financial disclosures include receiving compensation for First Bite podcast from SpeechTherapyPD.com as well as from additional webinars and for webinars associated with understanding dysphagia, which is also a podcast with SpeechTherapyPD.com.Ê

And I currently receive a salary from the University of South Carolina in my work as adjunct professor and student services coordinator. And I receive royalties from the sale of my bookÊChasing 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.Ê

[00:04:06] EF: Hi. This is Erin Forward and these are my disclosure statements. I receive a salary from Cincinnati Children's Hospital Medical Center. I receive royalties from SpeechTherapyPD for my work with First Bite podcast and other presentations. I also received payment for sales from the First Bite Boutique, which I have with Michelle Dawson.Ê

For non-financial disclosures, I am a member of ASHA and a member of Special Interest Group 13. I also am a volunteer for Feeding Matters. I am a contributor for the bookÊChasing the SwallowÊwith Michelle Dawson, which I received no financial gain. I also am a member of the South Carolina Coalition Committee with ICDL DIR/Floortime.Ê

The views and opinions expressed in today's podcast do not reflect the organizations associated with the speakers and are their views and opinions solely.

[EPISODE]

[00:04:54] MD: All right, folks. We have some pretty dynamite interprofessional practice colleagues joining us today. And I am tickled pink that we are starting 2024 off with an emphasis on IPP. And that's pretty humbling. Because a lot of times we labor under the misimpression when we go through graduate school, when we go through our clinical fellowship that we have to carry it all. That we have to identify, resolve and move forward whatever you're seeing with the little one that's landed on your caseload. And nothing could be further from the truth. You truly are only as strong as the team that you build around you to lift up that little one that you're serving.Ê

And, y'all, we got some badass women, if I may say so, that are pretty phenomenal and also humble pie. Without further ado, I have the lovely Jen and Beth. And Jen is the founder of Tots To Teens Therapy Services up in Nova, Northern Virginia if you're not from around these parts as my girl would say. And Beth is her clinic director and an OT guru. And they are here today to take us on a sensory detective walk.Ê

Ladies, thank you so much for joining me today.Ê

[00:06:23] JR: Thank you, Michelle. We're so happy to be here.

[00:06:26] BC: Thank you. We're so excited.

[00:06:28] MD: And, folks, you know we like a good backstory. This one goes back many, many, many moons ago, too. I'm pretty sure it was SHAV's 50th or 55th. I don't know. It was a while ago. It was the Speech Hearing Association of Virginia. And I met Jen sitting at one of the tables having cocktails of all things. That's a fabulous professional introduction. And then we ran into each other again when I saw her volunteering for Feeding Matters.Ê

And, actually, her and her business partner, Patti Minicucci, were the first people that actually turned me on to Feeding Matters a lifetime ago. I owe you a debt of gratitude. Because of that introduction, you have literally helped diagnose patients that weren't identified because I mentored another friend who got her child the scholarship to go to Cinci to get the diagnosis of EOE.Ê

See what you did all because we had red wine at SHAV?Ê

[00:07:35] AH: It does wonders.Ê

[00:07:37] MD: Good for the soul. Maybe not so much for the liver. That's debatable. Okay. I'd like to know the backstory and so does everybody else. Can y'all tell us how did you become clinicians and then get to know each other and take this very amazing journey?Ê

[00:07:54] JR: Well, do we have the whole hour? Because it's going to take ÐÊ

[00:07:58] MD: HowÕs the seven-minute synopsis?Ê

[00:08:02] JR: I'm Jen. And I started my journey with speech because I always loved working with kiddos. I knew from a very young age that that was going to be where my passions were. And so, I had an aunt who was a speech pathologist. And I knew being a school teacher probably was not my personality. Having 25 at one time was not really for me. And she was like, "Oh, I've got an idea." She started telling me about what she did and it really kind of was very interesting. And so, I kind of looked into it. And the school that I actually went to, Auburn University, actually had a communication disorders program. And so, that's how I kind of started my career.Ê

And then I ended up in the schools for about 15 years. And I got to a point where I felt like it was time for something a little bit different. And I asked my friend, Patti Minicucci, if she would be wild enough to leave the schools with me and let's start a new adventure. And she was.Ê

And so, we ended up starting Tots To Teens back in 2008. And it started with just the two of us. And we were in the homes and enjoyed working with early intervention and pretty much any age of kiddos that we knew needed services and it just kind of expanded from there until we ran into Beth Cooper. And I'll let Beth tell her adventure and how she started in OT and then how she found us.

[00:09:51] BC: Yeah. I have probably a really wild story. About 32 years ago, I was 14. And my parents are both educators and ended up Ð my dad became an educational advocate and for a set of group homes for kiddos with special needs. And then it ended up that Ð we ended up getting Ð I got some siblings that came to live with us. And I have five foster brothers and sisters who have been with us for now 30 some years. Three of them are autistic and two have cognitive disabilities and big behaviors. We've got some big behaviors at my house at home.Ê

And they were Ð I still call them kids but they are adults now. They are much older. My parents still providing a lot of care. Those are my siblings. And I went to college thinking that I wanted to be a pediatrician. I started off pre-med and went in my sophomore year to one of my brother's OT visits. And they had him on the swing and I watched him start to engage. And I was like, "Nope. This is where it's at. This is my calling. This is what I want to be." The OT ended up coming into our home and allowed us to sleep for the first time. Got our sleep under control. And we were actually sleeping at home. And I just knew I wanted to make a difference in that way.Ê

I continued with biology and chemistry and finished that degree. Ended up getting married to my husband. And he went into the Air Force. So, I sat out of school and was a preschool teacher for a little bit and a substitute teacher. But then we ended up getting stationed in Chicago and I was able to go back to school at UIC and get my master's in OT, which had been a dream for a really long time. I was very, very excited.Ê

And then ended up through our journey through the military. We ended up adopting our four awesome kiddos. And I have two neurodivergent kiddos. One with ADHD and another son, my twin. I have twins. And one of my sons is autistic. And so, that has made me a 10 times better OT than even being a sibling.Ê

And so, then we got stationed in Northern Virginia about 10 years ago, I guess. And my twins were very little. And two, I believe. And I started working at a clinic. And my twins were IUGR. So, growth restricted. Preemie babies. Three pounders. And ended up my daughter needed a speech therapist and my son needed OT and speech.Ê

And the clinic I was working at did not have speech at the time. And so, I called up. And next thing I know, Patti Minicucci is in my home as my daughter's speech therapist. I was at work her first day that she had speech therapy. And when I came home, there was an iPad recording of the entire session and all of the things that I needed to do.Ê

And in that moment, I just knew that Tots To Teens what I needed to be a part of. Because I had always been really passionate about parent education and about home programming. And that therapy doesn't happen in a vacuum. Nothing magical happens within the four walls. What happens Ð true change happens when you educate everyone that's surrounding them with the tools they need to feel self-efficacy with the kiddos that they have.Ê

And so, Patti and I did a little dance where I'm really trying to become a part of Tots To Teens. And I ended up making the jump. And they can't get rid of me, Michelle. I've been with Tots To Teens for eight years. Like I said, I'm a military wife. I've moved to Texas and stayed with them doing teletherapy. Moved back prior to COVID. Moved back to Northern Virginia.Ê

I now live in Illinois. I've been here for four years. And I am just hanging on tight. It's something I'm really passionate about. Jen and I share the same passion in parent empowerment, and home education and parent coaching. And it's really, really fun because Tots has grown. We were four of us, I believe, when I started. And now we have over 20 of us. And we have some really young therapists, which Tots did not have for a long time. We've had some CFS and we've been promoting this educational program. And it's really fun to pour into the next crew.Ê

[00:14:26] MD: Yes. Yes. Yes. So much yes. God. Folks, we are clinicians and not magicians. And I said that comment. And bless it. Goose danger and his brilliant smart [inaudible 00:14:40], he goes, "But are you?" And I was like, "Okay. You're funny." But actually, maybe I am a magician. No. I'm just kidding. But I feel like that's going to be a new t-shirt design. I'm a clinician. Not a magician but with a bubble one. It's as close we come to it. Anyhow, [inaudible 00:15:02]. I feel safe. I can let my neurodiversity fly with you two.Ê

Folks, this is a trifecta of three women that love caregiver coaching and empowerment regardless of who the caregiver is. The caregiver might not be the one that the child resides with. When we really get to a caregiver, it could be their nurse. It could be their aunt or uncle who keeps them. It could be us going in and consulting and educating teachers and parapros. They are providing care to that child. When we use the term caregiver, please don't think we're just meeting the figures of mother/father, right? It's all-encompassing.Ê

[00:15:50] BC: Can be siblings as well, Michelle.

[00:15:53] MD: Yes.Ê

[00:15:53] BC: I mean, yeah. I don't know how many Ð right. And how many times we have included siblings in our session as well. And they can be the best teacher and the best advocate for those kiddos.Ê

[00:16:05] MD: Yes. My husband has an older brother who has microcephaly CBI, intellectual disability and CP. Sibling. Love it.

[00:16:17] BC: Yeah.Ê

[00:16:18] MD: Okay. But that brings us to the actual topic of the hour which is like our role in sensory and being a sensory detective. Because as we're talking about siblings Ð folks, you know I record in advance. Christmas is coming, right? And we're about a little less than a week away. And it's the first time that my brother-in-law is coming to spend Christmas day with us. And that's a big deal. But the anxiety that builds up in him around the day events, he gets, at 45, so stressed about unwrapping gifts. His whole hands, both of them shake and he'll pick them raw. And not having his set pattern of his rocking chair adjacent to his TV at the distance from which he can see it, we have to move and accommodate, which we gladly do. Although my husband does pout at the end of the day. Because it's my husband's rocking chair. Not that this runs in our family. But those little traits.Ê

But I Ð knowing that the time is coming closer and closer to Maddie coming to live with us, I'm having to see his traits, and characteristics and needs in a different light, which is very, very eye-opening to transition to the role of a caregiver of an adult with needs.Ê

When we talk about this, why is it important? Not that this is about me. And I'm really excited. Because it's not about me. But, also, it is a little bit about me help me be a better sister-in-law. But why is it important for SLPs to need to know this?Ê

[00:17:58] JR: Well, I think as an SLP, we were not given training and anything related to sensory. Now I will say that I graduated a long time ago as compared to the therapists that are coming out now. However, I'm seeing ÐÊ

[00:18:18] MD: Yeah. But you look really good.

[00:18:20] JR: Thank you. But I do see the same thing even with our younger therapists that are coming out of school. They're really not getting a lot of information related to sensory. And what is going on with the sensory system gravely impacts the communication. And that's what we're trying to improve upon. But we cannot do that without addressing first the sensory needs of that child. It's just like you were saying, when somebody's agitated and they're picking at their hands, their attention is not in what words you're saying or what they should be communicating. It's what's going on with them with their nervous system and in their hands itself. That's where the attention is.Ê

We can't address those higher-level skills like speech and language without addressing what we call the lower brain things going on that are the sensory and the nervous system and all of those things. We need to address those first in order to get to those higher skills that we need to address.

[00:19:31] BC: I think it's been Ð well, also, from an OT perspective, I would say we don't come out as sensory experts either. We get a basic knowledge of the theory and we get Ð depending on our fieldwork placements, we get some experience. But it really is one of those similar to feeding I think with speech. One of those things that you continually learn and it's something that you're constantly developing with continuing education and experience.Ê

I think that our newer OTs need just as much education in this area, too. But I feel like it's also a little bit freeing for our speech therapists when they learn. They've got the hardest job. Though those communication skills and working on that, everything else has to be lined up. And the stars have to be aligned in order to get to those skills.Ê

I think that just knowing that they've got a really difficult job in getting that. We can do an entire OT session without saying a word. And in order for that self-regulation to happen, for them to process sensory information adequately for the muscles of their mouth to move or for them not to be dysregulated. Because the first thing when you're dysregulated, the first part of the brain to shut down is your speech center of your brain.Ê

And so, with a dysregulated kid, or a tired kid, or a hungry kid, you're just not going to be in the just right learning state for them to be able to participate in your sessions. And I think that's been helpful for our speech therapists to know, "Okay. This might not look like a speech session. But we really are getting somewhere by addressing these needs."Ê

[00:21:15] MD: That's something that I will never forget Crystal Vermillion. Woman, you made me better. One time, her and I were co-treating. She was an OT. And she goes, "You need to shut up." I was like Ð and she said it with all the love in her heart. And I was like, "What?" She was like, "If you repeat that, "I am swinging. I am swinging," one more time," she was like, "you and I are going to have a conversation." She was like, "He knows he's swinging. But he can't concentrate on regulating because you keep parallel-talking to him."Ê

Okay. She didn't say parallel-talking. But like that was what I was doing. Because I was taught you have to parallel-talk. Because if I'm not talking or modeling, then I'm not doing my job, which was how I was trained on misinformation. Evidence has shifted and evidence has moved, right? And that's huge.Ê

And she was like, "Watch. Watch him get regulated and focus on Ð" the little guy that we were working with had spastic CP and complications from neonatal abstinence syndrome. He was really contracted and tight. And he was just trying to concentrate holding onto the swing. And once she had his core and his body aligned, then he spontaneously lifted his head and looked at me. He was in the moment. And he did not have an autism diagnosis. But he was in the moment.Ê

And then he started like humming what I had been saying. Well, singing. But it was this aha. Also, this, "Oh, my God. I'm doing it all wrong," moment." But that's how we learn. And then I had her Ð she was is my safe place, her and Paul. They both work in South Carolina. To teach me about what dysregulation means.Ê

Could y'all explain what that looks like? Because that Ð I mean, when we first think of dysregulation, I think of a meltdown. But it's a crescendo that builds up. Can y'all describe that for us?Ê

[00:23:30] BC: Yeah. I mean, dysregulation can look like a lot of different things. Because a kiddo can be dysregulated. And that means they're just not at the right level for learning. Their body is not ready to learn. We can have a dysregulated kid that is lower tone and just not engaged. And they're just not at the right level for learning.Ê

Oftentimes, we don't get called in for those kiddos. Those are not the ones that people are panicking about. But that's just as much as a low level of regulation that they are not ready to learn. They don't have that alertness. That aha, "I'm ready. I'm engaged with you learning."Ê

Dysregulation can look like a meltdown. Most definitely, I think that's the way that people most often describe it. Dysregulation can be excited. Excited feels the same way as nervous. Excited can feel the same way as scared. A kiddo can be very excited and be dysregulated. A kiddo can be very tired or hungry and be dysregulated. Dysregulation just means not at that just right level for learning.

[00:24:36] MD: And that's hard as an SL Ð okay. One. Now I have to just like interject. Can you guys come out to JMU and do an in-service with my students? Because this would be like ÐÊ

[00:24:45] BC: Absolutely. Okay.Ê

[00:24:48] MD: Okay. I'm going to go ahead and tentatively tie y'all down for a Friday morning in June. Folks, you heard it here. Because we're going to be the source of solutions at First Bite. But to get y'all to come out and talk to all of our students as we enter into the summer program, that'd be huge.Ê

Okay. I got excited. Back to what we're actually here to talk about. But we're going to make the world a better place. When we go in and we're doing our evaluations as an SLP, sometimes the SLP is the first one that's called out because we're speech delayed. And not everybody knows the roles, and responsibilities, and scope of practice of an OT. But what do we need to know? And what are some tips to develop that transdisciplinary team for ped's?Ê

[00:25:34] JR: Well, I think that all good diagnosticians ask a lot of WH questions. And that's how we start figuring things out. Because it's what we learn. We can be great at our specialty for speech, OT, PT, whatever it might be. But we are not the professional in that child. That caregiver is a professional in that child.Ê

The more WH questions we can ask about what their regular routine looks like, where are the breakdowns happening? If it's for speech, we're asking about communication breakdowns. If it's for OT, maybe it's transitions. Or it could be regular routines in their daily skills. Things like that.Ê

Trying to figure out where those areas are that impact that child on a daily basis is always a good start from a speech perspective. We'll start hearing things that are related to sleep, potty training, eating. All those daily living skills. We'll start hearing that, "Oh, when they get in the car they have difficulty and they start screaming at the stoplight," or whatever. Or they'll start crying over when something's not where it normally would be. Or we'll start hearing that there are things going on that are making that family's daily routines difficult. Because the child's having that transition of going from place to place. Or they don't like brushing their teeth. Or whatever it might be. And that's usually our first clue that we need more than just speech involved. That's usually where we go, "Okay, have you thought about OT? Have you talked to a Ð"

[00:27:36] BC: We rely heavily on speech to give us our referrals. Generally, people don't know what OT is or what we Ð they're like, "That kid doesn't have a job." "They don't need an occupational therapist." And so, we rely heavily on speech therapists for our referrals to really notice those things and to know where we could be helpful.Ê

I think, as a team, it's really important. One of the things I love about our company is that there aren't boundary lines. Or we want everybody to treat that child wholly. And so, there's never a time when a speech therapist will give a sensory recommendation that they're like, "Oh, why are they giving Ð" there's no ego involved. It's we are a team and we are brainstorming.Ê

I think the biggest thing that I've seen in having an effective team is everyone being curious. One of the quotes that I love the most is Ð and a video. If you get a chance to Google it, Dr. Ross Greene's Kids Will Do Well if They Can. And if you have that basic belief that a kiddo will do well when they can. And so, you're going to be curious. What are the skills that they're lagging? What are the situations they're in? If you're really being curious about that and your entire team is holistically being a detective at why they're not successful, I think that's what creates the awesome brainstorming.Ê

We had a kiddo that speech and OT was seeing this kiddo. They had just Ð military family that had just moved into our area. And they were just really perplexed at if this was even more of a mental health thing. Or if this is speech and OT. They just couldn't get to this kiddo. And they were seeing some really bizarre behaviors from this kiddo.Ê

And I got a call last night at 6pm. So excited from the OT that we ended up figuring out that this kiddo has a visual perceptual problem. That the kiddo cannot see and cannot focus. And it took really everyone involved. Speech, OT. Everyone involved. We ended up doing a vision assessment. Sending them to a developmental optometrist. Kiddo got prism glasses last week. Came in Ð it was a different kiddo. He was happy. He understood what was going on with his body.Ê

Sensory-wise, the visual information wasn't getting in. He hasn't been in trouble in school in a week when he was being restrained for really multiple times a day. And it's just amazing that this team came together. And it was not a one-off session where they sit down and we say, "Ah, check vision." It was this peeling apart of this onion of let's figure out Ð he doesn't feel great about itself. What is your con Ð I remember they were like, "Well, we try to talk to him about these Ð" I think it's kind of that socio-emotional pragmatic education that we have. Let's talk about what zone we're in. And they're like, "But the second that we talk about anything that resembles therapy," this was from the speech therapist, "he knows it and he shuts down."Ê

And I was like, "Well, what is your relationship with him?" "Well, we've only seen him a couple of times." Well, then how are you having these conversations with him if we don't have connection? If we don't have a relationship, then there's no reason to have this." I said, "Well, I don't know how to work on my goals. If these are the goals and I don't know how to document in my session the goals that I worked on." Well, it was like, "These goals don't mean anything if you don't have a relationship with him. If you don't have connection."Ê

And that's one of the things we talk about is that connection, and relationship and regulation prior to participation and communication. And if explaining to a parent, "This isn't going to look like OT. Or this isn't going to look like speech for weeks." And that's okay. We're going to develop a relationship. We're going to find out what he likes. He's going to learn to trust me. And that is way more important than getting some trials done, or working on articulation, or working on these socio-emotional skills where he doesn't have the trust, too. Those are the really fun wins when people are just curious and work together as a team. And more brains in on a kiddo, I think that's where we let the boundaries go, is the more brains we believe that we have thinking about a kiddo. The parent, the teachers, the social workers, the speech therapist, some random clinic director in Illinois that they call, the owner of the company.Ê

If we have more brains thinking about a kiddo, and being curious and truly believing that a kiddo will do well when they are set up with the right situation, and if we have found what skills are difficult for them, then they're going to thrive. And it's really fun to be the payoff. And the kiddo that they were so nervous about going in with and didn't know what to do, they're now making those calls just excited, and passionate and so happy for him to come in. And it's really, really a nice payoff.

[00:32:55] MD: Okay. So many thoughts. One, I hear Ð when you're talking all, I can hear is Erin saying connect first. That's all she does is focus on that connect first piece. Actually, one of her passion projects has been getting DIR Floortime into the hospital that she works at. She's at Cincinnati Children's Hospital. And they're coming sometime after the first of the year. Maybe early Ð late winter, early spring. And they're going to do an amazing in-service. Because that's a huge component of DIR Floortime is that Ð and she's also Ð Pervis. I just forgot the first name. [inaudible 00:33:29].Ê

Yes. I'm over here signing. As if everybody can see me signing the letter K. But that's on my bucket list for 2024, her class. But, yes. The connection piece. Second question, how old is that young that it took Ð I mean, that he was in his school?Ê

[00:33:46] BC: He's seven.

[00:33:46] MD: Bless his bones.

[00:33:48] BC: He's seven. And he hasn't been able to see for this long. And that's what I talked with about the therapist last night is, for so long Ð he said he hates words. That was our first little piece. He hates words. And he was tearing up paper. And then I heard from them talking with the teachers. We're clinic-based but they've reached out to the teachers. I mean, this is full-on team mentality. That he was tearing up his classmates' papers. And all I could think of is if you've got Ð and there is research. I'm a big research nerd. There is a lot of research about prior to a diagnosis with ADHD. You need to rule out sleep apnea and you need to rule out vision issues that that presents as ADHD.Ê

And so, I got that in my back pocket. And I'm thinking Ð I'm sharing this research with them. And I'm like, "We just need to rule out tracking issues, convergence. The eyes working together." Because I'm just imagining I'm putting myself as a sensory detective. I'm putting myself in his situation. Why would he tear up a classmate's paper?Ê

Well, I know that he's very self-conscious. I know that he is very sensitive and doesn't want things to be pointed out that could be perceived as wrong with him. We got air quotes going on like people can see it. I know that he does demonstrate what would they would call behaviors when he feels self-conscious about something. And I'm asking about his reading. I'm asking about his writing. They're really not able to tell me anything about it because they can't get there.Ê

But I can't imagine being seven in first grade and looking over and all this work seems so much easier to everybody else and I can't see it. And that's all I could imagine was how that would feel for him that everybody else is reading and writing just fine but I'm seeing something? But your perception is your perception. You don't know that they're not seeing the same thing as you. And you're seeing and look seven different ways. Or whenever you're trying to track.Ê

What they found with him when he's trying to track, he can only concentrate on a section of the paper for a few seconds at a time and then his eyes jump out to somewhere else. He's constantly exhausted. When we did the tracking exercises, he started rubbing his eyes and they started watering. And just from basically looking at an object going from side to side, how hard must his life be?Ê

And then we add school to that. That's really difficult then to not be seeing the same things. And so, what do you start to do? There is a really great video that I had to watch in grad school called FAT City, frustration, anxiety, tolerance. It's very dated if you look at it. But it puts a bunch of educators together and it mimics them having learning disabilities.

And what you start to see happen with these adults is they start giggling. They start having behaviors. They start talking out. Not listening. Because when you start Ð when you're being asked of you does not match your skill set, that's when behaviors happen. When you don't have the skills to meet the demands, even adults that don't have learning disabilities, this is just mimicked for 20 minutes, start to have behaviors. And so, let's look and find what those skills are. Start digging in. Seeing how they're processing the sensory world. Seeing how they are processing even smells. Or what does that look like from where they are? How many kiddos we have that like Ð well, I am super sensitive. Jen, you're sensitive to smells, too.Ê

[00:37:37] JR: Very much so.Ê

[00:37:39] BC: Are you sensitive to smells, too?Ê

[00:37:40] MD: The very first week back for the semester when all the Freshman males showed up with their cologne, it's disrespectful to walk around with your shirt covering your face. But I had some of my lavender and sage essential oils and I was rubbing them on my nose tips because I couldn't handle it. I was like, "This is how you die. This is how it ends for me."Ê

And then my next horrifying thought was, "Oh, my Lanta, the boys are like on the cusp of this occurring in the house." Because right now, we're at the, "Okay, you've bathed two days ago. But you're right, honey. You got to go back in." And I know that like we hit 11. We're about to hit that 12-ish thing and it's going to start. But smells. Oh, yeah. No. There. Got it.Ê

[00:38:34] BC: My 15-year-old loves some cologne. And I just make myself. Because I think he bathes in it. But he was always a sensory seeker with smells. When the twins were little, he would smell their hair. He just loves a good smell. Okay?Ê

[00:38:51] MD: I'll smell a baby.Ê

[00:38:53] BC: [inaudible 00:38:53].Ê

[00:38:55] MD: I legit think I keep my CLC just so that I can smell other women's newborns. I mean, if I'm going to be honest. Because I have no uterus. This is closed for business. My nieces live too far away. And Erin hasn't given me a niece yet. Erin, I'm calling you out. I mean, I'll take a nephew. But like I really need a baby girl so I can play with her hair. And so, yeah. Somehow this devolved in catastrophic levels.Ê

Okay. All right. I'm gonna bring it back. My third question, also, kudos for me for holding the thought this long, was, Jen, wait. When you're doing the team evaluations to make all these referrals for this little guy, when we're in Virginia EI world, what is the domain test that we're using? Because back in South Carolina, I know they were trying to move towards BDI. The Battelle Developmental Inventory.Ê

But, folks, big picture. As a speech-language pathologist, as well as an occupational therapist, you are allowed to administer the five domain tests to qualify for early intervention. It tests cognition, gross motor, fine motor, self-help skills and social-emotional. Yes. Yes. Yes. Yes. The emotional component.Ê

And it is best done when administered with an IPP partner. Because you're getting a different set of eyes on it. Because I don't see the child through the lens of an OT. And this is where it gets tricksy. Insurance will stay in the back of that manual. And this is why we are taught to look at the manuals in class. You have to look at the back of the manual and it will tell you who can administer those standardized instruments. And some states, South Carolina, I'm calling you out, still allow non-licensed individuals to administer scores and report on these assessments, which is terrifying. Because they're not allowed to do that. And it says so in the back of the manual. But anyways, I digress. What is the go-to product here in Virginia? And how does that look?Ê

[00:41:09] JR: Well, I am under the impression from being a part of EI for many, many years in Virginia that it's really up to each county or each jurisdiction. However, in Prince William County, the one that is used, is the HELP or the Hawaiian Early Learning. And that one has been Ð ever since that, I've been Ð I want to say 2007, they've been using the HELP. And that one gives you a lot of great information. Non-standardized. And it has been quite helpful.Ê

We're even using it with our kiddos within our clinics as well for those kiddos that are not candidates for a standardized test that we need more caretaker information. And so, we found that very helpful within our clinics as well. But it varies from county or jurisdiction to jurisdiction with Virginia. But I think there are several of our jurisdictions that all use the help.Ê

But I know Battelle was one of the ones. My daughter is an early interventionist as well who just graduated in May. And I know that they've used Battelle when she was graduating. She was in a Virginia school. So, I know that that is another one that has been used as well.

[00:42:37] MD: I remember LAPD and DIAL being used back in '05. Down in Gloucester. In RIS program. Rural Infant Service program. Y'all, the way Virginia early intervention is set up, there's different regions or different sections across the commonwealth. We're a commonwealth. Not a state, which makes things even more muddied.Ê

There are different regions. And then they kind of steer it. The licensed OT, PT, SLP might be an employee directly of that region or they could be a contract and the private practice or entity contracts to that region. It's very different. In South Carolina, there's one state agency with different regions. But everybody is a contract. Nobody's a direct service provider unless they're like a non-licensed early interventionist that has no teacher certification, or any certification, or endorsement. Okay. I'm going to behave now and put Michelle back in the corner. Okay. So ÐÊ

[00:43:45] BC: That's been something that's been helpful with creating our teams is that, coming from Virginia, which was very different. Because I've done early intervention in Illinois, too. And so, in Illinois, we would have the social worker over. But then you may have a visit a week of OT, PT and speech. Somebody may have all of the disciplines.

And in Virginia, they use a primary service provider model. And so, we may be in a home and they're only going to allow OT, or speech, or PT to treat a child that has many domains. And so, that is one way that we've transitioned into our clinic is that, as an OT, I had to know all of the speech information. Because that kid will probably has some speech goals. And they're not going to get a speech therapist in. They're choosing one discipline. Or the speech therapist might be in and be the provider. And you'll get some OT consult. But you're not going to have an OT in there. That speech therapist has to know all of that information as well. And so, I think that's how that team developed. That team mentality developed, too.

[00:44:51] MD: Which part of me loves. Because that allows us the opportunity to engage in interprofessional education. And there is Ð as y'all stated earlier, there's a beautiful overlap between SLP and OT, and OT and PT. But even, and I'll argue it, SLP and PT, especially from a feeding and an access to an AAC device and those kind of things.Ê

But I do have a worry when we're not all allowed to have equal foot in the door. That is, in my heart, a significant disservice. If I can dream big, I would love for there to be national standards uniform across the continent. So, that if a child transfers Ð because we have a lot of military and we have a lot of families that just move because they're called to be somewhere else. I think we need to have a uniform national EI system. I'm not willing to claim that for 2024. Maybe we'll put that on the 2025 bucket list. But 2024 has other things to fry.Ê

Okay. Jen, when you're going in and you're doing your team building, how does an SLP take the information from this five-domain test? Do you then go in and do your speech-specific assessment and then collab? What happens?Ê

[00:46:12] JR: In our clinics, that is basically what we do. We go in. We start the assessment. We've got lots of those open-ended questions that we're asking the family or the caretaker. And then from there, we end up using Ð if we need to use a standardized measure, if we're able to do that, then we use our standardized speech. PLS or whatever we're using. Or we use Ð like I said sometimes, we use the HELP. Sometimes we'll use the Rosetti. It depends. Now these are all those early intervention little ones that I'm speaking of specifically.Ê

But we'll end up doing those non-standardized measures for those kiddos that we need to. And then from there, we start that conversation with the family about what OT is and some of the things that we're seeing. If it's a concern for PT, we'll even bring up you know things that we're seeing with PT. And asking questions about the pediatrician mentioned anything about this to you at your last visit? Things like that. Starting to lay that groundwork for where we have suspicions that we might need some additional services.Ê

Once we have therapy started and they're coming in, a lot of times we bring in whichever expert that we need, the OT or the PT, to come in and do an observation and sit in there. And we kind of work together and talk to the family about different ideas or more WH questions. We have lots of open-ended questions that are always being asked in our sessions. Because that's where we get the majority of our information from the family.Ê

That's sort of how we start that process. It's not going to be in our clinic a one-and-done type situation. It is an ongoing conversation that is happening with that caregiver constantly. Because sometimes it doesn't make a lot of sense initially to a caregiver about what we're talking about with sensory. Sometimes it's like we have to try different things first so that they can see what we're talking about. And then from there, move to that next step.Ê

Sometimes it's bringing that OT in and that OT starts telling them things that are resonating with them. And then they're like, "Oh, yeah. Yeah, we do do that." Or, "Yeah, I can try that." And then that starts that conversation. Because like Beth said, sometimes OT does not make a lot of sense for families. And they're like, "Well, what do you mean occupational therapy? I don't know what that is." And you say fine motor. And they're like, "Well they don't have any fine motor concerns." Well, really, we weren't looking at fine motor anyway. We were really looking at sensory.Ê

It's trying to kind of give them something that they can understand and then talking about ways that OT could be a benefit to whatever service that they're currently receiving. And for speech, like we mentioned at the very beginning, we've got to get the regulation first before we can do anything with speech. Because that's what comes first.Ê

And in order to get the regulation, we have to have the trust. Well, they're not going to have trust in you the very first time that they come and see you. It's a building block of things before we sometimes get to those next levels for getting OT as a part of our team. But they're still a part of our team because we're collaborating all the time behind the scenes to build on what we can try or how we talk to the parent about a certain thing or talk to the caregiver about a certain thing.Ê

It's just an ongoing process. But trust and regulation are our very first keys that we've got to get to before we can then build up to our speech goals. And I think that's where a lot of times we get frustrated. Like Beth was talking about with the other little guy, we're starting at speech and trying to work our way down to trust. And that's not going to work that way. It's just not.

It's sort of like if somebody brought in a strange man to come and help you with your hair and you've never seen him before, and all he does is just come over and just start touching your hair, you're not going to feel super comfortable about that. Because ÐÊ

[00:51:11] BC: Probably a little dysregulated, Jen.Ê

[00:51:15] JR: I would be definitely dysregulated, for sure. But that's kind of what we do. We kind of bombard our kiddos like that by immediately starting to do things that really make them feel uneasy and dysregulated. They're coming already to a place that they're they're not super familiar with. And then they've got Ð I'm going to just say it for myself. I'm not saying this for all SLPs. But they've got a loud, excitable person coming at them. [inaudible 00:51:50]. And this is who's coming at them. That is so dysregulating for a sensory kid who's already uncomfortable coming into an unfamiliar environment.Ê

[00:52:02] MD: Wait. Okay. Honest to God. One time I worked at a rural county hospital many moons ago and our designated scrub color was electric lime green. I can't make this up. There are pictures of me 25 pounds ago in electric lime green scrubs. And it was a large shared gym where everything echoed. And it had fluorescent lights. And we're wearing lime freaking green. And one the students had the worst case of motherese, bless her pretty heart, that I have ever heard. And it was like everything ended as like, "Is it a question?" "I don't know." "Did she just ask a question or did she make a statement?" "I don't know." But it was like Ð and then Ð but it was like Ð it was like I wanted to stab myself in my eyeballs.Ê

If that was my response, then I can only fathom what it was like for the tiny humans and not-so-tiny humans that were coming through. And just electric lime green. Who picks that much less for a pediatric rehab unit? Also, who designed that in the first place? How many color schemes did that hospital have to go through to get there? Yeah.

[00:53:21] BC: That just is not flattering on very many skin tones.Ê

[00:53:28] MD: But you know what? I never got hit in the parking lot leaving when it was dark. Safety first.Ê

[00:53:35] BC: Safety first.

[00:53:37] MD: But I pulled them out. The Amazon delivered them and my husband was like, "Well, nobody's going to mistake you in the middle of the night." I was like, "Shut up."Ê

Okay. I'm looking at our clock and then all of the things that we still have to cover. this is for sure going to have to be a part two. But would you please back for a part two and then please come torture my students? Because that needs to happen. But, Beth, what do you wish that we knew? What do you wish the OTs knew when we were looking at it to say, "This red flag for me?" Also, the whole OTs are fine motor. I told the ladies before we started that I finally hung Goose Danger Dawson's artwork in my office. And it's the most beautiful watercolor sunflowers I've ever seen. And as I hung it, all I could giggle was think that's literally $4,000 that I just hung on the wall because of all of his OT co-payments.Ê

But he was my low-tone tiny human and then had a really, really gnarly concussion when he was in kindergarten and had divergence of his left eye. And we had to do convergence exercises. And he's a left-hand. Literally, four grand for my watercolor sunflowers. But also ÐÊ

[00:54:57] BC: Climbing some mountains.

[00:54:59] MD: He is. And I think Legos. Because we have done a lot of Legos to get those little skills. Also, he's created the perfect Lego jam mix on Amazon. If anybody needs it, just let me know. I'll happily share it.Ê

[00:55:15] BC: I have a very intense Lego lover. Yes. Send that my way. Yes.

[00:55:19] MD: Okay. There was a question buried in that story.Ê

[00:55:23] BC: I got it. Two things that I would love for anybody to know. One, I've already said that kids will do well when they can. It is our job to dig deeper. That, 100%. If you just have that basic belief that there is something getting in their way, you will dig deep and you will find what's going on. It's never just behavior. It's never because they want to, they want to not do well. That doesn't make any sense.Ê

Kids will do well when they can. Dr. Ross Greene. It drives a passion to figure out a kiddo. And I honestly believe in every brainstorming session, that is where I need everybody to start is to believe that, if this kid could do well, they would. And I think that opens everybody up for figuring things out.Ê

The second thing is knowing your own sensory profile. We all have sensory differences and sensory needs. And one of the things we talk about, I saw it online, was we meet our sensory needs. Do you go to the gym? Do you go to the spa? That's how we're meeting our sensory needs as adults. We are putting things in our mouth when we tell kids to take it out.Ê

Look at our bodies and how we regulate ourselves. And I think if you know yourself better, it makes it easier to understand where a kiddo is coming from. Those would be my two pieces that I would like the groundwork to be for everyone, every therapist, is to know themselves better. Know their sensory preferences. Know their sensory differences. And then, also, just to have that basic of that this kiddo would do well if they could. And it's our job to figure it out.

[00:57:11] MD: I now want to collaborate with the OT department and see if they can do a sensory profile on all my grad students. Because imagine having that going out the door for your heavy external clinical practicums.Ê

[00:57:24] BC: Huge. Mind-blowing. Just understanding yourself. I do it with parents. There's a simple sensory checklist I can share with you, too.Ê

[00:57:33] MD: Yes, please.Ê

[00:57:34] BC: Really simple about how you regulate. And, oftentimes, before I'm doing Ð because this sensory education isn't just for therapists. We educate our parents. People will say they'll know they're a Tots To Teens parent because they speak in all of the therapy jargon. We start off in parent-friendly language and then we elevate so that they can advocate for their kiddos. This information isn't limited to just therapists. But I will start them out with a sensory preferences list just so that they can understand their own bodies better. Because then they can have better understanding of their kiddos.Ê

My husband, even in his job in the Air Force with the airmen he uses, he uses sensory preferences. He uses, "They will do well when they can. So, we need to figure out what's getting in their ways Ð in their way with adults." Because it's true. And if you come at that from just people, it just makes you a more effective leader. It makes you a more effective friend. It makes you a more effective parent.

[00:58:30] MD: I'm giggling because my husband's an engineer. Sometimes he makes things blow up. Now he's making things not blow up. And we're all better for it beyond that they don't really know what he does. But he came in and he was like, "Babe, they're talking about neurodiversity-affirming engineers. And I was like, "Yeah, my wife talks about this." And he goes, "And there's like a bunch of other engineers that are married to SLPs and OTs." And I'm like, "Yes. It's because we regulate you and you ground us. And like pick your partner. But there's something to be said for OTs and SLPs with like a math nerd brain balance." Right?

[00:59:12] BC: Yes. 100%.Ê

[00:59:15] MD: Yes.

[00:59:15] BC: I'm just telling you with my ADHD and without having him being super type A and organized. And I would say rigid. I'm going to put it out there. He's pretty rigid. Life would not be on track.

[00:59:31] MD: Mr. Dawson makes color-coded spreadsheets so that I pay attention to the family budget. And, plus, even on his day off, he still wears a button-up shirt. And I'm in like messy yoga pants and like all over the place. And he's still Ð you can't unmilitary that man. I mean, it is what it is. But he sure is pretty. Christian, I love you. You're very, very patient.Ê

Also, wait. This will be out after our 13-year wedding anniversary. Because we eloped on the first. Yay. Happy anniversary. Okay.

[01:00:07] BC: Happy anniversary.

[01:00:08] MD: I'm very excited. Wait. Jen, what do you wish newer clinicians knew when they're doing the diagnostics and to make the referrals? But, also, are season clinicians but they're taking on this new piece where we're starting more emphasis on IPP?Ê

[01:00:26] JR: I would love for them Ð and I'm going to just reiterate something that Beth already said. I would love for them to understand that the behavior is a way that they are communicating something's not going on right. There's something that they need help with. And if we look at it from that lens, then it's hard to look at it as a behavior, a bad behavior. It's not a bad behavior. There's something that they cannot negotiate with their body to make work in the way it needs to work.Ê

When doing an evaluation, use those people in your life that are going to give you the best amount of information you can get. And I said this earlier, I'm going to say it again, we might be a professional and no speech or we might know OT but we are not the expert in that child. Let's make sure that the expert in that child is the one being asked. Because a lot of times what I've seen, and I really have worked hard to try to steer this differently, is we ask the parents a lot of yes-no questions. And it doesn't really give us the information that we really need. And so, by opening it up and having them just explain what their day looks like or ÐÊ

[01:02:04] MD: A routines-based interview.

[01:02:07] JR: Exactly. Yes. I feel like there's so much that we can gain from the family that Ð and I think the reason why sometimes we don't do this as therapists is we feel like we're supposed to have out all the answers. And so, we're going to fill in all that blank air time. But, really, that's not what we need to be doing. We need to be listening.Ê

As your friend said to you, Michelle, we just need to shut up sometimes. A lot of times. And just listen. Because we'll get so much more information if we just listen to what that family is saying to us. And I'm a talker. I love to talk. But I have found that in, an evaluation process and in therapeutic process, the more we listen, the more we gain. And we're able to actually steer that team in a direction that's going to be more successful in the long run. Maybe in the short run we can do some real quick things that are going to look really great. But in the long run, what's best for that child in the long run? And it's going to be having that whole team approach and everybody collaborating for the best of that child.

[01:03:26] MD: Yes. Also, take a room for SLPs, and I dare say some OTs, and tell them to shush. That's comedic and in of itself. But, oh my God. Yes. Okay. Can y'all come back and we can do sensory detective case studies and take apart three cases?

[01:03:49] JR: Absolutely, we can. You tell us when, we'll be here.

[01:03:52] MD: Okay. Thank you both so much for lifting us up by sharing a heartfelt, honest conversation. And I love that you intersperse functional resources embedded within. Guys, check out Dr. Ross Greene's website. It was amazing, by the way. It's not visually overwhelming, which I appreciate.Ê

One of the ones they also talked about before we started was called the Neurodiversity Collective and then the FAT City video. And then, also, if you could please send that sensory preference list? Is that something that I can share with folks?Ê

[01:04:30] JR: Yes. Yes. It's sharable.Ê

[01:04:32] MD: Beautiful. Because that would be a great resource to add as well as to assign. And then, with all things, we like to pay it forward, right? Where can folks, if they have a little love money or mad money left over this month? I mean, let's be honest. The holidays just happened. We probably are all broke. Because I know Pack Dawon is. But my basement's painted mostly. Where could we send our residual monies or pennies?Ê

[01:05:02] JR: Well, we talked a lot about the trust-based intervention. And that was through Karyn Purvis. And she was out of TCU, Texas Christian University. They have a program that really works hard on educating families on trust-based interventions. You can go to child.tcu.edu. and it's Karyn Purvis Institute of Child Development. And that is definitely worth your time and effort to do training with them. Or if you just want to contribute to them, they do have a donate button there. But we highly recommend that. We see so many trauma-based. And neurodiversity is not exempt from trauma-based things. We have a lot of research that's been put behind trauma-based therapy and interventions. And we would highly recommend that as an effort. If you've got any money you want to donate, this is where we would say.

[01:06:09] MD: Awesome. Thank you. Ladies, thank you so much. Folks, check out Tops To Teens Therapy. You can find them on the land of Instagram as well as Facebook. Be sure to track us down on First Bite podcast on Instagram and Facebook, as well as we have t-shirt collective on Bonfire. I'm learning, Erin. I'm getting in there. And as always, you know we love it when you hit us up with a five-star review on Apple Podcasts and leave kind words. Thank you for being a part of the First Bite journey. And, ladies, thank you, thank you, thank you.Ê

[01:06:46] JR: Thank you.

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[01:07:27] MD: Feeding Matters. Guide system-wide changes by uniting caregivers, professionals and community partners under the Pediatric Feeding Disorder Alliance.ÊSo, 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. So, 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.ÊTo date, 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.Ê

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 PEDÕs 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. And as always, remember, feed your mind, feed your soul, be kind and feed those babies.

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FBP 268		Transcript

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