EPISODE 254

[INTRODUCTION]

[0:00:13] MD: Hi, folks, and welcome to First Bite: Fed, Fun and Functional. A speech therapy podcast sponsored by SpeechTherapyPD.com. I am your host on this nerd venture, Michelle Dawson, MS, CCC-SLP, CLC, the All-Things PFDs SLP. I am a colleague in the trenches of home health, early intervention right there with you. I run my own private practice, Heartwood Speech Therapy here in Columbia, South Carolina. I guest lecture nationwide on best practices for early intervention for the medically complex graduates. First BiteÕs 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.

[0:01:04] MD: In this podcast, we cover everything from AAC to breastfeeding.

[0:01:09] EF: Ethics on how to run a private practice.

[0:01:11] MD: Pediatric dysphagia to clinical supervision.

[0:01:15] EF: 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.

[0:01:23] 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, ÒTo build the bridge.Ó

[0:01:33] 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.

[0:01:44] 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 Hearts Girls and enjoy this geeky gig brought to you by speechtherapypd.com.

[DISCLAIMER]

[0:02:20] EF: 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]

[0:02:28] EF: Well, hello, everyone. Happy Thursday. This is our last little installment, first by Karen and Erin's takeover, joy, and finding the just right challenge, is that what we call it? 

[0:02:44] KM: That is what we call it. 

[0:02:44] EF: Let us know, especially if you've been on the past four episodes, if there are, like what other questions you have, because we have some ideas for some other things you want to do. So, feel free to put them in the chat or the Q&A today or email us, because there's so much. We're realizing as we go through every episode that we have so much more to say, but we want it to be functional and helpful for you guys. We're open to a lot of suggestions. 

Again, even though if you've been here for the past four episodes, you've heard it. My financial disclosures. I have a salary at Cincinnati ChildrenÕs Hospital. I receive royalties at SpeechTherapyPD for First Bite and other lectures. Non-financial, I volunteer for Feeding Matters, and I'm on some other organizations, sometimes. 

[0:03:35] KM: It's all volunteer, right? When you have time to volunteer. My financial disclosures are that I am a faculty member at Georgia State University, so I get paid through them. Then I also received an honorarium for being on this podcast. I'm a consulting therapist for ATS kids in Greenville, South Carolina. I receive payment from them for those services when rendered. Non-financial. I volunteer when I have time with a couple of local nonprofits. 

[0:04:08] EF: Oh, we do, yes, we do have handouts from the episodes that we will email to Yumi, so she can upload them to SpeechTherapyPD, so that you can have them. As much as we do similar lectures, but genuinely and honestly, a lot of the conversations that we have today are conversations that Karen and I have regularly. It's not as formal as it may seem. We will provide a lot of resources and handouts that we've talked about today, but a lot of this is very conversational and which is why we love when you guys are asking those questions. 

Today, we really wanted to pull what we've been talking about the past two weeks together to hone in on what the true ideal outcome of our sessions are and that's helping children find joy and journey, because I always have to remind myself too, that the kids that we work with, some of them are receiving hours and hours of therapy a week when other kids their age are going to soccer practice and going to art class and playing a musical instrument. When their occupation of childhood is to play, we should be thinking about that and trying to find that joy.

Karen and I after looking at into play more and understanding sensory systems more and understanding our therapeutic relationship have found so much joy ourselves in what we do, like truly when I am laughing with a child, like I'm fully 95% in the moment. I'm still thinking about the next thing I'm going to do, but mostly in the moment finding joy myself, because I'm able to understand and relate to them in a way that I wouldn't have before, but that takes a lot of skill to do, because you have to understand really what you're asking a child to do. 

In order to have joy, we have to also help them be successful in whatever way that is. Being successful doesn't mean that they complete a task perfectly. It may mean that they problem solved through something or they had a new idea. In order to do that, we have to talk about how we're analyzing the tasks that we're asking of the children we're working with and finding that just right fit for the opportunities and the experiences that we facilitate in our sessions. 

As we mentioned last week, something that OTs do really well, because they're trained in it really well in grad school, is analyzing a task. Whether or not we realized or not when we set up therapy activities and we set up experiences, that's a task that a child is having to do. We thought it would be really important to take time to understand what task analysis is, so that we can better understand. I see so many speech therapists that will set up like an obstacle course as a break for a kid working on a speech task, but if that obstacle course is also challenging for them, then it may be doing the exact opposite of what you want it to do. 

[0:07:29] KM: Before we dive into activity analysis, I had like a, this is why I love teaching too, because it gives you the opportunity to see the world through other people's eyes. I had a student this week just come into class and explain how the student felt when they went into a clinic and saw for the first time children who had lifelong conditions when this person had not seen developmental disabilities before. 

In this case, they saw a family who had three children, all of which had the same form of muscular dystrophy. They were at three different ages and you know if you worked with that diagnosis, the older you get, the more you lose motor function. So, this student was just really struck with like the reality of their life and how different their experience must be compared to what our experiences are, because everyone's experience is unique, right? But when you have a lifelong disability, it can really impact that. 

It's really important for all of us, like Erin was saying to help them find the joy in their life, because that really is the key to maximizing every opportunity of interaction regardless of disability status or gender, age, whatever. All of that is that joy is that connection juice that makes life worth living. Then at the same time, play really accelerates learning as well. It's important to find it, because there are some studies that point to the fact that if you're trying to learn something really, you would have to practice that task 300 to 400 times to really get it down. 

If it's done in the context of play, that number drops down to 30 to 40 repetitions. It just tells you how powerful play can truly be. That secret sauce of play is joy. To figure out how to incorporate more joy, that's where it really matters about activity analysis, like what are you actually asking the kid to do, because they may not be experiencing joy and play, because it's too much, right, or it's too little. It's either overstimulating or not stimulating enough to create that magic that we all feel when we are truly in the moment with a child in an activity. That was all I wanted to say before we dive into what activity analysis really is. Anything else, Erin, before I explain what activity or task analysis is? 

[0:10:12] EF: I don't think so. I think when thinking about this, just I always will go into really diving into what your goals are, because that plays a large role. Sometimes the activity and the goals might be different, but you have to, again, understand what you're facilitating. We'll talk more about goals afterward. 

[0:10:35] KM: Activity analysis, OTs use it to analyze how an activity is being used in a context with client-specific factors. There are actually supports that you can find through AOTA forms and information about how people look at the activity and break it down. Generally speaking, it's analyzing what is the activity? What is the context for that activity? Then who is performing that activity? 

In the OT world, we call that the PEO model of therapy, the person environment occupation model of therapy, or depending on how much you emphasize the context, you may also use a more ecological model, because you're emphasizing the ecology of where this is coming from, this occupation or activities coming from, but if you think about those three factors, the person, the environment, and the activity, or the occupation, you can take those and put them into steps, strengths, and weaknesses. 

Then part of the environment is the social environment. You are a part of the environment whenever you are analyzing a therapeutic activity. You're in that as well. When you look at an activity itself, you can look at what it requires a person to complete it and then analyze the person specifically that you are working with. If I were to analyze the activity of putting your shoes on, most children, when they put their shoes on, do so seated on the ground or in a chair, which means you have to have sitting balance, you have to have coordination of your upper extremities and your lower extremities to not fall over when you reach for your feet and you have to be able to manipulate the shoe, you have to be able to extend and flex your legs and your arms to be able to put your foot into that shoe and pull that shoe onto your foot. 

You have to be able to put all of those steps in the right order. So, some cognitive sequencing in that. You have to be able to follow directions to be able to learn that and put it on in the foot. That's just a very quick activity analysis of just putting on your shoe. If you take that as the activity and then you put it into the environment, right? I'm part of that environment, if I'm the one giving directions. The clinic, or the school, or the home is part of that environment. The sensory components of that environment play a big role into the activity and how it's performed. 

Then after you finish pulling those factors out, then you've got the person too, right? So, you've got the thing that needs to be done, the environment is done in, and then the person who has to do it. Again, that child sensory systems come into play, their strengths and their weaknesses, their cognitive skills and stuff like that. That's where an understanding of how to analyze a person from the top down and bottom up at the same time really matters. Thinking broadly in terms of your developmental theories, like what stage of a POJ are they showing you, right? 

What about how putting on their own shoe may impact their own self-image, like independence? So that's going back to an Erickson route, because most kids learn to put their shoes on when they're toddlers and they do not want help from other people. That's because they're dealing with this, like internal self-image, identity crisis, right? Anyway, so thinking top down and then also bottom up about that child's sensory systems and how those may be impacting the occupation or the activity itself. Doing all of that at the same time really helps you get an ingredient list together. What am I asking this kid to do? What is it that I'm asking and then how does it interact with them? 

[0:14:50] EF: No offense to all of you, wonderful speech therapists, but I feel like this is something that we have a lot to learn from because we're taught to focus so much on the outcomes as opposed to how we're getting there. It's so important how a child gets to a certain outcome because that teaches them so many things. So often, we're looking at where their deficits are, which is a very ableist model instead of sitting Ð and this is where it's encouraged me to sit and talk with a parent and say, ÒWhat are your big goals for your child?Ó Ñ ÒI want them to be happy, or I want them to make friends, or I want them to be able to communicate that they care about me.Ó Sometimes it then makes me look at the context of where they're communicating and why they're communicating. 

If we start to then also look at what that child's values are too, then if we can break down a task for really what we're asking, it gives us a little more freedom in what experiences we can facilitate that in, because if we're so focused on the end goal, sometimes it limits us. We feel like we have to control more of the situation, but if I'm breaking down, say I have a goal for a child to expand their MLU to two-word phrases. They're stuck on single words, and I'm really wanting to expand two words. If that's my goal, and I'm understanding their motor system, so I'm understanding how they're working with toys, pulling from our other lectures, I'm understanding their sensory system, so I'm understanding what supports them best. I can better facilitate opportunities where they're actually working on those two words, as supposed to putting them in a scenario where that might be more difficult for them. 

Now, if it's more difficult for them, they're more stressed, they're creating more cortisol, and they're not learning as well. It can also help us when we do make activities, like speech therapists love Ñ we do a puzzle, or we do an obstacle course. Well, what are their motor differences? Am I putting more cognitive load? So, like a big part of task analysis is how much Ñ if I'm driving somewhere new, it's pulling more cognitive load on my brain to get there than if I'm driving somewhere that I know. So, I have to turn down the music, because my auditory system is too much, because there's more load cognitively. 

If we're asking a child to do a motor task that is very difficult for them, while also asking them to imitate words and focus on their articulation, that might be just too much cognitive load. Sometimes giving them a task that we know they're going to be successful and while we're expanding the communication component can also be helpful, but if we don't understand, like Karen said, all of their differences and their development in general, we're not going to understand how to facilitate that also. 

[0:18:13] KM: Yeah. I think activity analysis is key when going back to what we talked about on Tuesday about motor system parallels and language parallels, you really have to be able to analyze activities in order to figure out what those central characteristics are that may be underlying some skills. Also, I will tell you that, like if you can do a thorough activity analysis quickly, mentally, and then also jot down notes for yourself as you treat these clients, it will sometimes help explain some of the contextual inconsistencies that we see with behaviors. 

I was talking to someone the other day about a child with Down syndrome, who can sometimes go up and down stairs and sometimes has a challenge going up and down stairs. I immediately went to, I wonder Ð is it time of the day? Is it context dependent? Is it cognitive load dependent? I don't know, because I don't know this child and I haven't seen them in those settings, but as you work with children for longer and longer, why they may be able to, like not have toileting accidents at school, but then have toileting accidents all the time at home is one of those contextual inconsistencies that if you were to do an activity analysis, that one's really common actually in the world of OT. You see that a lot. 

What's the big difference between home and school, especially in elementary school? Kids are scheduled for regular bathroom breaks and everyone goes. So, you have a lot of peer modeling for that inter-reception that may be lacking, so that when you're in a more self-directed context, like at home, you don't know, you don't pay attention to signals to go to the bathroom, right? It's just one of those things that helps pair down, like what are you asking a kid to do. 

The other thing is going back to Erin's point about what are you asking them to do. Are you asking too much? You have to also analyze a child's social-emotional development because that's how they handle frustration. All of us know that the feeling of like being cognitively overwhelmed, or sensory overwhelmed, or just tired and exhausted level of overwhelmed and all of that it affects our emotional processing. I think that's one of those key things that you really have to do some analysis on. 

Then also don't be afraid to write goals that allow you to, well, in the floor time language, linger longer at lower levels, right? To develop a Vygotsky zone of proximal development, stay in that proximal zone, because if you don't really define what they have mastery over and what the next outward step is, you're going to stretch them too far for too long. Finding that the lowest hanging fruit, the next best step is the key to promoting that joy, because we don't really find joy doing something that we know how to do really, really, really well over and over and over again. 

It's pleasurable, but it's not the same level of excitement as when you master something that's novel, but attainable. That is where that satisfaction and joy, that novelty brings excitement and joy. It's important to introduce that novelty in the proper dosage, so that it can be experienced as joy and not stress, because that's a fine line, especially for children with sensory processing differences. 

[0:21:56] EF: I mean, I've had conversations with therapists that I work with, especially working with neurodivergent children, and how it felt so stressful for them for so long because you can feel the child stress and you feel like you're going around in circles because you're trying to meet this goal, but there's sitting them in a chair and forcing them to look at flashcards is not necessarily the most multi-sensory engaging functional task. 

I encourage Ñ from Karen's point too Ñ I encourage you to think about you set ups and you may be able to set up scenarios in the therapy room, where the child knows exactly what to expect and they're meeting these goals, but how many of us have heard, they only do this here, they will not do it anywhere else. Is that because the parents aren't doing what they're supposed to be doing, or the school isn't doing what they're supposed to be doing or is that because we're not building the depth of the learning and understanding, and it has to be so contextual for them to remember it because it's not as child-led or motivating for them. 

ItÕs, ÒI know this is what's going to be asked of me when I come in the therapy room, so I'm going to say these things to move on from the task.Ó I also, and I will have this conversation with families, specifically for feeding, like when Ð I have a lot of NICU grads right now. I will say they'll come to see me afterward. They're like, ÒWe didn't have time to work on this, or we didn't have time to work on this.Ó I said, ÒYou know what, you also get Ð there's value in just sitting in the joy of being home or sitting in the joy of meeting a milestone, or sitting in the joy of having a child accomplishing something that you wanted them to, and to not so quickly move on to the next thing, because if that child is coming to see you, there are so many things that they can be working on. 

Sometimes it's okay, like Karen said, to linger there for a little bit, so they continue to feel successful. That may mean like, I'm changing the context a little bit, or I'm adding. It may mean I'm not just doing the exact same thing over and over and over again, but it may mean that I'm allowing them to feel a little bit more successful, and just get in the rhythm of the next step that they mastered, because if I get there, and then so quickly, you're trying to jump to the next thing that can be really overwhelming. Then continue to feel you're not being successful, because there's always something that you have to do next. 

[0:24:49] KM: Yeah. I will also say that like, oh, I have been really guilty of this in the past too, to have expectations of children who have developmental differences, that it's easy to fall into an implicit expectation that this child can just always make progress and that their progress should be linear. I think that's from our framework within our medical system, and our educational system. We have to write goals, and they we have long-term goals, and the short-term goals stack up to the long-term goals. It feels like a very linear, focused progression of development. 

The issue is, is that natural development doesn't really go on a straight line. It really, like if you were to track it, it would be skill attainment, and then followed by a plateau. Then another skill attainment, and then followed by another plateau, because it's when you hit those plateau moments that really like integration and mastery over that skill is established. At least, Erin and I talk about this a lot with kids, where weÕre like, we'll get into a place where we were really in a groove. It feels like I lost the groove, but maybe the groove just needed a rest, right? 

That's why we all have weekends because you cannot be productive seven days a week, for weeks on end without feeling the strain of that. Rest is really important. We should also reflect active rest within our goals, but writing goals that are that specific really is challenging for busy clinicians. That's a real push and a real challenge to be able to write goals that give children breathing space to master a skill, but also demonstrate progress to their insurance company at the same time. 

Well, this is a digression of where we thought we were going to go with this, but let's just follow it for a second, and then we'll go back to it, because I think that that's where we lose the joy in therapy, often is the pressure to hit these goals, right? So, if we can create for ourselves an environment that supports us following the joy, it's really important, because it also helps your mental health as a therapist to be doing the thing that feels right. Then also you can prove that it's doing the child some good through your notes, right? Because you can document on it. 

My favorite way of doing short-term goals, especially when I'm trying to establish Ñ and Erin, we can compare and contrast this. I don't know if we've ever actually had this conversation. Let's do a little spontaneous, like what's your mindset or your framework for working through goals? When I write goals, I write them as skill presence check first. So, like can a child demonstrate this skill, yes, or no? I'll often write it with like supports as needed, meaning I don't care what it takes for the kid to make Ð I'll use a really concrete example. That's not my favorite goal, but to make a vertical stroke, right? Because that's for OTs that's on the P body, we have to do this vertical stroke thing a lot with a writing utensil. 

I will often write like a child will demonstrate the ability to imitate or copy a vertical stroke with supports as needed. So, that's just like, can they do it yes or no? Once I start to see yeses there or however, I want to measure that. I'll throw in a measurement term there. Then, I start to change the parameters, right? Like are they doing it on a vertical surface or a horizontal surface? Are they doing it seated or standing? Are they doing it with verbal cues or with imitation? Are they doing it in play or as an isolated skill? Can they do it five times in a row? What about 20 times in a row? Can they do it Ð can they attend to that task for 10 seconds? Can they shift their attention from another task to that task with minimal supports? 

All of those goals can be written just about vertical strokes, but when I use them and how I use them gives me space to still stay on that one skill and show progress over time. Then once they've met one of those parameter-type goals, then I'll swap it out for another one, right, and level it up a little bit, but really I'm still just working on vertical strokes. I don't know. Erin, how do you write goals to create more specificity and give yourself some breathing space to linger longer at lower levels? 

[0:29:39] EF: Well, I write really long goals, because I want to, especially like you said when I'm starting, I have a lot of birth to three patients, a lot of kids that have a lot of medical differences and etiologies. So, oftentimes what I'm starting is just trying to get that back-and-forth communication in whatever way that is. So, I may write a goal like patient will engage in Ð and opening and closing circles are a goal that I use really, really early on. Babies can open and close circles of communication. I may start with Ð I will put in a with supports as needed. I'm not if they need verbal cues, some gestural cues that they need sensory supports to engage in this. 

I will say using multimodal communication. I used to say total communication, but that's technically a term used for deaf and hard of hearing population, but what I will do is, I will document the number of times they can open or close a circle of communication. For those of you who don't know, opening a circle of communication can be a glance, a smile, a touch, a vocalization, or anything to engage the other person. 

If they close it, there's a response to it. In floor time, building that is also what helps build that social problem-solving, because I know you're here with me, we're here together. I will start with a very broad goal. Then I will document what I'm seeing. Are they using a lot of vocalizations? Are they more-so using facial expressions? Do they use more facial or more vocalizations when I give them certain sensory supports? It gives me a way to document progress, but also start to get more specific. 

Then when they've reached a certain point, I may say, say they're getting to a point where they're being much more verbal. I may say we'll open five circles of communication verbally, so that I'm pulling to the more symbolic version of that circle of communication. But like Karen said, when you make it broader, you still have that goal that you're focusing on, but you are then able to learn more about that child as well because it's less of I'm picking what supports you need. I'm picking it and more of, ÒHere's my goal. Let's figure out how we're going to get there together.Ó Then I can start to get a little bit more specific. Then when I realize what supports are helpful for you, I can use those supports in other goals as well. 

And then also from a contextual standpoint, it gives me a lot of room to maybe we're working in the exact same gestalt of Mario, but we're building. Then I can say to Karen's point, okay, maybe we're great at opening and closing circles of communication if it's got the exact same context, but then are they able to do that in an unfamiliar context or with an unfamiliar communication partner, because that at the end of the day is my goal also for them to be able to communicate what they need with somebody else. 

I have a Gestalt language processor, I may write goals for them to mitigate familiar gestalt, ones that they've already used. Then I may have goals for them to start to mitigate less familiar gestalt to see if that mitigation piece is carrying over and is being utilized in other contexts as well, because at the end of the day, that task is my goal for them to mitigate or is my goal for them to say a long phrase. So, like, what Ð but because I know, itÕs not language.

[0:33:18] KM: Well, and that's what Ð so when I write goals and when I mentor new graduate therapists or therapists that are just hitting a wall with their care plans. I do two things. One, our insurance systems and our education systems want to see particular mile markers in children. So, you can't totally get away from writing goals related to those mile markers, because an insurance company will audit and you're going to have to show them that you're making measurable progress along language that they understand, because otherwise they don't pay for services, right? 

That's the unfortunate reality of the medical system. So, what I generally do is I write 75% of my goals are actually related to overall processes and skills. Regulation, sensory processing, engagement, play type goals. Then like the last 25% are like those hard skill checks or those milestone checks. Then I'm very cautious about how I write those very specific milestone goals, like I was just talking about, and go from the version that gives the child the most options of how to show that skill down into more and more narrowed options, like Erin was talking about with like opening and closing circles of communication. Then moving into a type of opening and closing, whether that's gestural or verbal or whatever the skill is that the child is showing you're going to continue to enhance that skill or strengthen the independence of that skill. 

A common question though is, like do our opening and closing circles of communication the same as joint attention? I think that joint attention is a word, like praxis or play that gets thrown around a lot and is not well defined in the therapy world. Then it gets confusing because we're all conflating different definitions of that. When OTs talk about joint attention, they're typically talking about imitation and sharing attention in the same space. Those two things are actually, very different skill sets, so I tend to not use the word joint attention, because I think it gets confusing. 

[0:35:27] EF: We use it a lot, but we use it in that context of, like are we sharing attention towards the same thing or like in that same space. I would say similar, but not the same Ð circular communication and joint attention are similar not necessarily the same thing. I think you can have joint attention towards an object without really being engaged with each other and those circles are so important. Joint attention can look very, very different dependent on the child that you're working with, because I may have an autistic client patient who is Ð we're focusing on the same thing and they may know I'm also focusing on it, so I would call that joint attention, but they're not super engaged with me. If that makes any sense.

We're learning that a lot of autistic people engage in joint attention without looking at you without necessarily being engaged with you, but they know you guys are both doing the same thing. Do I need them to look at me to have circles of communication? No. But it does look a little bit different sometimes when you can tell that they're engaged with you versus you both know that you're looking at this spinny toy together thing. 

[0:36:45] KM: Yeah. I will also say that OTs will say joint attention and they literally mean the proprioceptive attention to your joints or they mean the attention of two parties being shared. The joint attention. My attention, your attention being joined over the same thing. So, that's why I don't tend to use it because I think those are two, like I said, two very different things, like attending to your body's joints and then joint attention with me over the same thing are very different skill sets. So, I tend to use the word shared attention for the understanding that we are like sharing attention over an object so that speech therapy version of joint attention. Then I tend to use like other words to describe the other version of that. 

[0:37:34] EF: I'm going to post this on the floor time website does a really great job of like thoroughly explaining their FEDCs. They do this link has a great explanation for what, and that's what they call their third capacity is opening closing circles of communication, so I'll put that in there. 

[0:37:52] KM: Which by the way joint attention what we've been talking about is joint attention and the floor time model is actually, what part of the first functional emotional developmental capacity, but then opening and closing circles of communication is the third. If that helps you understand how to write more sensitive goals, because specific goals, right, specific goals allow you to know exactly how to measure them, but sensitive goals allow you to measure progress and change. What we always aim for is both specific and sensitive goals, so that the data you collect has fidelity to it, that every time you measure that you're measuring the same thing or the same skill or the same cognitive process. 

You're measuring the same outcome, but you need it to be sensitive enough to change with the child. Oftentimes, in pediatric therapy we get into this place where this kid's been working on the school for three years and we're like, what is the point and we're working on the same goal for three years? ItÕs just one of those things that happens. I would argue that your goals are not specific or sensitive enough. One or the other or both.

[0:38:58] EF: I will sometimes even put in a goal, like while I'm measuring, like having a broader goal, or putting a goal. If a kid is at the single word level of like, will increase single words to 10 in this progress period, just to give a measure of like how Ð if they're an analytic learner. Like Karen said, you can keep a measure on if the goal is they want them to have 25 words by a certain period of time. Then we can also take note on that. I will document all of the words I've heard them say, so that I keep that in my plan of care.

[0:39:37] KM: Okay. Goal writing is big, because it helps you hold space for joy, but Erin let's talk about, like why hold space for it. Let's talk about the fun part, which is the joy part.

[0:39:48] EF: Well, and we put play into all of our Ð 

[0:39:52] KM: Yeah. We've been weaving it in.

[0:39:54] EF: Because it is just the core of what we do of child-led play-based therapy. I will say, for I'm sure if you guys are all here, you know this. But child-led does not mean you let the child do whatever they want. Child-led means, you honor their differences and their interests to find a window into their play and their world, so that you can help expand that. My metaphor is always you can't turn an apple tree into a cherry tree, but you may, when they're planted immediately you don't necessarily know what type of tree they are. So, our job is to help provide the right fertilizer, and water, and sunlight. Sometimes these trees and these kids aren't born into environments and scenarios that are the best for who they are to their core.

When you start to truly take the time to understand the children that you're working with, you both find so much more joy. Joy facilitates so much growth neurologically, as well, because it's such a strong emotion. When we, like I know occupational therapists that have trained me in floor time that say they write goals for shared joy in their sessions like that is a goal that they, like that you can get through insurance because children deserve to feel that joy.

[0:41:35] KM: Well, and itÕs worker that they're actually participating in the occupation of play, and because play is an occupation, like by definition play has to be purposeless fun and all-consuming. If you really want to read more about play and like what it is, because I think defining these things helps you also understand how to measure them and use them in therapy. IÕm posting right now a link in the chat to an Amazon book. We just call it the playbook, because it's the word on the front says Play, but it's by Stuart Brown. It's a great easy read. I mean it's what probably 150 pages, but just a quick read, but so thorough about what play is and how it shapes your brain.

When we talk about play, yes, I have written that goal that like I have written that's actually a goal that I go too often that a child will demonstrate like a positive affective response in a play activity five times during the session. In other words, I want to make a goal that I hit the sweet spot with this kid five times in a session, because then that keeps me accountable to tailoring the activities to something that works for them, right? Then if they don't hit that five times in a session or one time or whatever the case may be, it means I haven't figured it out yet, so I got to keep digging, but it gives me space to keep digging.

[0:43:06] EF: Well, when I'm around, I don't have any kids. Yeah, I'm not any time soon, but when I'm around my friendsÕ kids, like just think about how kids play, like just within their world, like there's so much joy in these new ideas. New things that they experiment with like Bear who Ð those who would be listening to podcasts have heard about Bear, like Bear just gets so excited at like, there was a fly that was wet on his bag the other day. He thought it was so interesting, and so exciting that the fly was wet. I mean, he can explain Ð

[0:43:45] KM: That's not where my brain would go, but so cool that he is Ð

[0:43:47] EF: Like he just kept staring at the fly, because he thought it was so cool, but the cool part about it is that he could explain it to all of us and like he could make up a whole scenario out of it. So, how do we help like Karen said, the children we work with to find that sweet spot of like true. I don't even, like I wish there was a bigger word for joy, because like, when you really hit that sweet spot, like if you listen to the story that Karen and I talked about in the first podcast we did like months ago. Like when you have a child that like has an idea and has worked so hard and finally like is able to experience something that they were imagining in their brain. Like there's nothing beats that. It's because like, there's so much to it, that connection, that relationship, that problem solving, that excitement. It all comes together and you just feel it.

[0:44:52] KM: Yeah. That's the thing too, is anybody Ð anytime we start talking about this I can't help but think of Inside Out, because it just did such a good job explaining like emotions in your brain. A lot of what they talk about in that movie too is like, just straight up neuroscience, like it's just so well done. But every time I think of these moments with these kids, that soundtrack literally plays in my head. That like tinkling, nostalgic, that echo of joy, because anytime we experience someone else's joy it also triggers our own, right?

Even if we don't find joy in the wet fly on our backpacks, we want to be around somebody who does, right? It's infectious. As service providers what better service could we provide, right, than an avenue for these kids to find and explore their world, because if anybody out there watched The Magic School Bus, growing up, then we all know that we need a little bit of Mrs. Frizzle in our lives to help us explore the world with joy. If we can be that avenue for that person, it's just unparalleled, like it's just Ð 

[0:46:13] EF: I think the other thing that is important to think about is like we don't know what's going to bring joy to other people. There are things that art would surprise you about what gets someone excited, and what they find beautiful in the world, like I talked about yesterday of like when you're looking at those splattered black Ð what do they called the ink, black ink Ð yeah. Thank you. You should know thatÕs someone's going to like pick up on those things. When you have those moments of joy and I have one patient I can think about who like, he flaps when he gets so excited and mom calls them as happy hands. When you see that it also gives you information to see the way that they're connecting things, because then you can find more connections in what has brought them joy before.

I think about my patient who, the one who call everything a flashlight. He loves to take the flashlight and make shadow puppets. He calls it x-ray, because he thinks it's so cool to see something that like isn't there and then it is. I think that's the connection he makes by calling that an x-ray. He gets his hand the other day and he does, ÒThe flashlight goes giant.  I said to mom I was like Ð I love this child so much. It's like what I love about this is like, yes, is that really giant to us, no, but to him it is and that word he used is totally appropriate for how he felt, like how big that was, because in his mind he like grew it himself. 

It's in those moments that you can see where they're finding that joy from and then find other ways to build those connections as well, whether it be like I found a toy that looks an x-ray or we were able to find a different colored light that he could make puppets with. Just things that like I would never have thought about and I would never have chained from his experience, but it's like, okay we're finding joy in this thing, how can I expand the play, expand the communication, expand what we're working on still in the context of something that you really enjoy and love, because like Karen said, you find even more joy when it's something that is a little bit challenging, but attainable.

If we can create that still in the same realm of something that brings them so much joy, like that's when things blow up, because it's like, you have this idea and sometimes it feels like you're making magic, even though you're not, because I feel so grateful that we have the opportunity to help children who otherwise have difficulties with whatever challenges they're facing. Take their ideas and turn them into something, because they have so many ideas, but sometimes it's so hard for whatever reason in that praxis cycle or their sensory system or their communication, it makes it difficult for those to come to fruition, but we have the joy of taking a step back and understanding them, so that they can. Because really, like that's the most important thing.

[0:49:32] KM: Well, and to be honest. Anytime we start talking about this too, there's just so many things you can pull in from common wisdom to evidence-based practice to research in neuroscience and the frontiers of our understanding, but I always think of Horton Hears a Who. A who a person is a person no matter how small and it took the elephant to hear the smallest person to care for them. Sometimes we have to widen our eyes and our observations, so that we can hear, or see, or attend to what our littles are telling us, right? 

It may be that their communication voice is just really small or because of their sensory processing. It just doesn't translate well into something else that other people can understand. So, our job is to be the Horton in that situation, right, and to use our elephant ears of understanding sensory processing, and cognitive development, and motor development, and language development, and communication development, and social-emotional development, just widen our sensors, so that we can pick up on that, because everyone deserves joy. A person is a person, no matter how small, right? Everyone deserves joy. It's just such a beautiful thing to be on that front row.

[0:50:53] EF: Well, and I will say to parents, like because I know I get the question all this time of like how do you deal with parents when they say you're just playing with their kid or they don't necessarily know. Parents truly like 99.9% of parents just want their children to be happy and do love their children, but oftentimes they don't understand them. That's why they're coming to see you, because there's a mismatch and an atonement between the two of them. 

When you can get them in there and show them the joy and show them the beauty of who their kid is, that will do so much for them, because in a lot of trauma training, they say like really what is the most important for a child is to have one person that unconditionally loves them. The more you can help a parent understand their child, the more that unconditional love can support that child to be who they are in whatever scenarios they're put in in environments. So, facilitating that connection, as well is Ð so many of these parents, like they're so focused on the goal development and the next thing that they're going to need to do, that they don't have time to stop and experience the joy either. So, when you give them that, it can change their lives too. 

I mean Karen and I we shared a patient who Ð and Karen started with them first and it took a while to buy into the floortime model and perspective both just per expectations and cultural differences, but like, man, that family, like years later was making speed bumps in the driveway and making Halloween costumes of a vacuum and like things that that child just loved. It was the most beautiful thing. 

They were so much happier too, because they could also just be like, ÒThis is my kid.Ó I feel confident in who they are and to advocate for them. They saw all this progress. It was just like, every time you're just like, ÒThis is the coolest job.Ó Like truly, when people talk to me sometimes, I'm like, ÒI really love my job.Ó I don't think, like they don't even get it. Then they're Ð I'm like, ÒNo, like I really love my job.Ó I don't even think Ñ I do my job for free all the time too, but that's because, like you just like when you see it, you see it.

[0:53:26] KM: Well, we're lucky that we get to work in a job OT speech PT. I mean we're just lucky that we get to work in a job that we get to love with our minds and our hearts at the same time. Like how lucky are we that we get to say like, ÒI'm doing evidence-based practice. I almost peed myself laughing so hard with a kid today.Ó But that's my job, right, or how lucky are we also to say, ÒI'm doing evidence-based practice and I cried with that parent for an hour in the parking lot.Ó It is so rewarding to use all of this. That's why we stack it this way. Sensory Processing, Therapeutic Use of Self, understanding the connection between your motor systems and your communication systems and now, Joy and the Just Right Challenge, because in order to understand the just right challenge, you have to have all of that in your mind at the same time.

When you hit it, man, you really hit it. It just like we all, I think have those moments that we can point to in our practice that we're like defining moments for us. For me the first time I experienced joy with a child who was not speaking, that is a moment that's burned into my mind and into my heart at the same time, because it was like a light bulb moment for me to understand the power of what we do. But how do you find the just right challenge? That's the question, right? Like we want the sweet spot, how do we get there? 

We've got a few practical takeaways we're going to talk through really quickly, like how do you're there when you're there. We're going to talk really quickly about keeping in mind that you are thinking about their problem-solving. They problem-solve one step, two steps, multiple steps. Can they use symbolic reasoning or is it all concrete? Going back to your developmental understanding of reasoning and executive functioning, that really matters, because that's probably the heaviest burden that people put generally, that we as therapists are guilty of putting on clients is a heavy cognitive burden. Then we expect them to be able to also handle it emotionally at the same time. 

For me that would be the equivalent of being given a calculus test and I haven't studied for calculus. Then somebody also told me that like that I have to be nice about it at the same time. I don't think I could do that. So, making sure you're not giving your kid an unintentional calculus test is really important, because you donÕt need to do that, but sometimes we're just not mindful enough about it. 

What about oh adaptation. Yeah. Looking for moments where kids are able to adapt. When you see adaptation, pause, don't push. When you see Ð that's my other big takeaway is when you see growth pause, don't push. I have to tell myself in the clinic all the time, pause, don't push. Pause, don't push, because my intuition says, ÒOh they're getting it, push a little harder. Get them a little bit farther.Ó Recognize and honor the skills that it took to get to that moment of adaptation and let them hang in it for a minute. Linger longer lower levels, pause, don't push. 

Sometimes with parents, I will even verbally tell them that, so they're not looking at me wondering why I'm hanging back. I will look at them and say, ÒAll right. Right now, I'm itching to push, because I can see that they're getting it.Ó But I also want to respect the effort it took them to get here. This is new for them to be this regulated while doing this activity. We're going to pause here and build this muscle right here before I ask them to go farther. Erin, you got any takeaways about how to know where the just right challenge is? 

[0:57:13] EF: I'm very so, because I'm very like feeling. I think sometimes I try to check in with myself too, because when I'm feeling common in the flow, they're often in the same flow like sometimes. I think sometimes the tricky part is if you take a breath and it feels easier, like when they're in that just right challenge and they're in the flow, like you almost feel like you're not doing anything because you've set up the opportunity, so well, that now they're taking over. 

I think that's to your point, like not pushing when it gets tricky, because you're like, ÒWait. Is this supposed to be this easy?Ó Like we're working together, like we're actually playing, like I have my therapy hat on, but like I'm able to release a little bit of that. I think check in with yourself more sometimes because that can give you a good indicator that like, wait. We set this up. We prepared for this, like this is where we're having this like fun magical moment and oftentimes like you've put in all that work to get there, but I often will feel it. 

[0:58:24] KM: Yeah. Well, Erin, you're a very intuitive person. I am a very observational person Ð 

[0:58:29] EF: Analytical.

[0:58:32] KM: Why Ð each other. Yeah, because we Yin Yang each other in that respect. 

[0:58:36] EF: I'll be like, ÒI felt this.Ó You're like, ÒOh, yeah. It's because this, this and this happened.Ó I'm like, ÒYou're right.Ó 

[0:58:43] KM: Ñ but my brain works so hard that I forget to check in with myself, so it's a really valuable reminder to like, if you feel it, feel it. Don't second guess the feeling, just feel it and live with that, but for those of you who are not feelers and need something like I do, what I often will do is grab a blank sheet of printer paper, write my kid's name in the middle of it and then draw just a thought bubble about every sensory system and like connect draw lines between sensory systems. If I feel like they are connecting things multiple ways or if there are weaknesses, I'll take a red marker and go like between visual-vestibular, like that connection is weak. That's what I need to target in my goals.

Then I'm reading over like what kinds of vestibular input do they enjoy? What kinds of visual input do they enjoy? What do they process? What don't they process, so that I can formulate an activity analysis or an analysis of my client across activities? So, it's a combination of things. That's my go-to thing. Then I keep those around, because after I've done that, I mean I probably do that at least once a year for every kid. I just mind-mapped out whatever is in my brain, because I'm an OT I have to make it visual. If you haven't learned anything about OTs is we have to make it a diagram or a visual or something. 

Anyway, and then I just keep that, because then the next time I need to refresh my care plan, I go back to it. I'm like, ÒOh, yeah.Ó Now they're doing that better, so what's the next step or do I need to switch my area of focus from one area to another, because there's that's getting stronger now the weakness over in this area is really what's holding them back, so I need to pivot. But yeah, that's my just right challenge and goal-writing strategy.

[1:00:35] EF: Yeah. We also have part of our ideas to add on. We would really love to do like at least one, maybe two of like case study stuff because I feel that could be really helpful to pull all this together. That's something that you guys are interested in, whether or not we're probably still didn't do it, but I hope you guys are interested in it. If you have any questions this has been fun, but there's so much to talk about too, and we know it can be helpful to like talk through a case or a couple of cases to be able to explain how we're taking all of this information and using it with a specific. 

[1:01:14] KM: I would also encourage you guys to go back to the first podcast episode that I was on, because that's what it was. It was a case-based explanation of this. We've referenced that kid a couple times.

[1:01:24] EF: And we both cry, I think in it. 

[1:01:26] KM: Yeah. We both cry. It gets ugly and cute. 

[1:01:28] EF: I love it so much.

[1:01:30] KM: I would encourage you to go back to that, after you've listened to these four, because you will hear strands of these four more detailed conversations reflected in that case study. Let me see if I can find out what episode number that was. 

[1:01:42] EF: I'm going to guess 167 or 169. If I'm right, nothing will happen, but I'll be proud of myself. Also, don't forget, if you want live credit for the course, make sure log on SpeechTheraphyPD, before the end of the day today and take your quiz for those of you. The earlier of course. Yeah, we're looking it up. It's a podcast that Karen and I did. We also, are going to be at ASHA. I think I can say it. Our course that we do at ASHA will be recorded, so we'll tell you how to find it too. Did it say what episode it was?

[1:02:14] KM: No. I couldn't find the number. I just found the episode, so I just linked to Ð 

[1:02:19] EF: 160. It's episode 160.

[1:02:21] KM: Okay. 

[1:02:23] EF: Yeah. That's a really good, putting all this together.

[1:02:25] KM: Yeah. It's where we started from, because I mean really truly that case example is how Erin and I got to know each other and got to be friends. The origin story of everything that we've talked about for the past four episodes as well, but it's also a really good example of Ð 

[1:02:44] EF: I know it was our first lecture together. Look where we've come.

[1:02:49] KM: Well, it's not over.

[1:02:51] EF: Not over. I said, I know. Oh, we just started. We're going to get those. We're going to send them to Yumi to put on the website, our resources, because we do have like a, just a handout of resources that we use for our lectures.

[1:03:09] KM: Yeah. We do. Then we also have, we used a couple of diagrams and stuff that we can include just all in one PDF, so you can refer back to it. But there are not handouts for that 160 episode. That was just us talking about a case. We didn't have handouts for that. 

[1:03:28] EF: Thanks, Marianne. Yeah, you know where to reach us. 

[1:03:34] KM: Yeah.

[1:03:34] EF: We'll put it in there.

[1:03:36] KM: Yeah. If anybody else has questions, now would be the time to ask, because this is the last one for a little bit or you can always email us. 

[1:03:48] EF: Thank you guys for listening to us for four hours, because man, we talk a lot. 

[1:03:53] KM: We do talk a lot. 

[1:03:56] EF: Well, we'll be back. We'll be back. Don't worry about it. If you miss us, don't miss us too much. We'll be back. Man, I'm tired. I got to go. I got to go.

[1:04:06] KM: Okay. You're starting singing again.

[1:04:09] EF: For the sake of all. Yeah. We'll see you all. Bye. 

[END OF EPISODE]

[1:04:13] ANNOUNCER: Feeding matters guides system-wide changes by uniting caregivers, professionals, and community partners under the Pediatric Feeding Disorder Alliance. What is this alliance? The alliance is an open-access collaborative community, focused on achieving strategic goals within three focus areas, education, advocacy, and research.

Who is the Alliance? It's you. The Alliance is open to any person passionate about improving care for children with a pediatric feeding disorder. To 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 the PFD Alliance tab and sign up today. Change is possible when we work together.

[01:04:38] MD: That's a wrap, folks. Once again, thank you for listening to First Bite: Fed, Fun, and Functional. I'm your humble, but yet, sassy host, Michelle Dawson, the All-Things PFDs SLP.

This podcast is part of a course offered for continuing education through SpeechTherapyPD.com. Please check out the website if you'd like to learn more about CEU opportunities for this episode, as well as the ones that are archived. As always, remember, feed your mind, feed your soul, be kind and feed those babies.

[END]
FBP 254		Transcript

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