Episode 296: Childhood Apraxia of Speech and Orofacial Myofunctional Disorders with Erin Gaul

Hi and welcome to episode 296 of the Untethered Podcast. Today we have Erin Gaul joining us. Erin is the owner and the speech language pathologist of your Speech Path llc. She's prompt certified only one of two clinicians in Pennsylvania to have that distinction and she's also proficient in American Sign Language. Erin's clinical interests lie primarily in her the passionate treatment for childhood apraxia of speech and other speech sound disorders. Erin has sought extensive professional ongoing training in childhood apraxia of speech and and she utilizes dynamic temporal and tactile cueing DTTC in motor speech sessions. Prompt is also used for tactile cueing within the DTTC hierarchy. Erin is also listed on the Apraxia Kids SLP Directory for experienced expert treatment of CAS Apraxia Kids SLP Directory. Erin also specializes in orofacial myofunctional disorders and was trained through the International association of Orofacial Myology. Experts within the specific scope of speech language pathology are rare and Erin has discovered a high level of need for OMT in the Philadelphia area. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Holly Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. Aaron, welcome to the podcast.

Thank you for having me. I'm excited.

I'm excited too. So I want to jump right on in because I think you have a really unique graduate school experience to share with us. I went to University of Maryland, so I wasn't too far away from where you went.

Oh, super close.

Yeah.

Yeah.

But you went to Gallaudet and you know, I know you have this background in deaf and hard of hearing, you know, and so, and you even started, I think in your first private practice experience working with that population. So I would love to, or maybe it was maybe your internship. But I would love for you, either way, to share with us your background, your experience. And I think that's really unique for a lot of our listeners.

Sure. So I initially thought I would end up at a big children's hospital in a cochlear implant program. So my goal was always to go to Gallaudet University. And for those who don't know, it's a university primarily for deaf and hard hearing students. The speech language pathology program is one of two programs not taught in American Sign Language. So a fun fact of going to Gallaudet was, I mean, we are on their island, the deaf and hard of hearing. So you had to use sign language in public spaces. It was a culture. You had to respect it. Many of my clients on campus, like in the clinic, were codas, children of deaf adults. I had an adult hard of hearing, but he wanted to speak his wedding vows to his wife who was a speech pathologist. So it was just immersion in deaf and hard of hearing culture. And that's where I thought I was going. But then, as the speech world generally does, it kind of opens your eyes to other populations and other areas you want to explore.

So I told you sign. Did you sign before grad school or did you like get fully immersed and have to learn it there?

My undergrad is in deaf studies.

Okay.

Originally I thought I wanted to be sign language interpreter, maybe an audiologist. But a professor sent me to an audiology clinic in undergrad and they're like, go observe, go observe. And I went. And I was like, oh, this isn't quite what I had in mind.

She's like.

And when I was talking to the audiologist there, she was like, oh, you might want to look into speech pathology. And I said, I had no family history of speech. I didn't even know what it was. I didn't know it was thing. So I said speech pathology. So I looked it up and the rest is history.

I love that. I love that. So you then did an internship in a private practice in grad school. And so that was still focused on working with deaf and hard of hearing.

Not as much. We had some, but it was a pretty large private practice in the D.C. metro area. But it started to get me. It had me exposed to apraxia of speech, aac. What I love about private practice is that depending on where you are, it's a little bit of everything. So there were some kids that were deaf and hard of Hearing, but it ran the gamut as far as populations. And I just remember really enjoying it and liking the freedom that we had. I had an awesome. I hesitate to call her a teacher, but she was a mentor. She was my supervisor. Call out to Jane Bomba at Skill Builders in Virginia. She was amazing. And I just remember thinking, I think this is where I want to be.

Oh, that's awesome. And so is that the point when you found your love for cas, for apraxia?

It started there. And then I went. We moved. My husband and I moved back to the Philadelphia area where we're from. Ish, like the suburbs. And my clinical fellowship. I still stuck with the deaf and hard of hearing because that's what I knew and that's what I loved, and I still love it. But after the clinical fellowship was over, I was like, you know, what, three to five in a special needs preschool, county run, essentially early intervention. Not for me. Met amazing people, co workers and all, but it was just, it was not for me. So I applied to a private practice. I went back to private practice. And that's where I will never forget this little boy. He grunted at me for four to five months. And I sent this kid for a hearing test. Everything, everything came back typical. And I was like, this might be that apraxia that we were talking about in grad school. So I did a ton of research, sought out a ton of trainings, and it became my love, my love of speech pathology. And it still is.

Oh, I love that.

Yeah.

Yeah, well, and now you've even gone a step further, right? And you kind of fell into the OMD world, the Maya world. So, I mean, I know you started your own private practice too, in like 2017, so we can back up and, and start there. When you started your own private practice, were you focused mostly in one area? Did you have. Were you kind of, you know, dipping your toes in whatever patients came your way? What did that look like?

Yeah, definitely emphasizing my specialties. But as many brand new practitioners in private practice know, you basically say yes to whoever comes in as long as it was like, ethical. Like if I had a kid, severe autism and they needed aac, that is not my thing. Refer them elsewhere. But overall, I was mobile. I was driving everywhere and taking basically everybody that fit under my personal treatment umbrella. And I loved it, but very quickly learned, wow, I'm losing a lot of time in the car. I'm not able to take more patients. And so that led me to my first office. And I was there for like, I want to Say, a year and a half. And then I moved to this clinic just before COVID Hit. Awesome timing. And I've been here since December of 2019, and it's grown. And now it's not just a solo practice anymore. I have four other SLPs on staff. One of them is a CMT.

Very nice. Yes, yes. Proud of her.

She's very motivating. So it's. It's evolving and it is just super exciting. I am where I'm meant to be.

I love that. I love that. So I. My big question for you, because I know so many people are so curious about this, right. How do you differentiate between CAS and an omd? I mean, that's like a big rabbit hole. You don't have to give us like, the entire. You know, but, like, when you see somebody come in, like, I'm sure you have a patient in mind where you're like, well, they have both. Like, because they can have both. An omg.

Oh, they can. It is an incredibly complicated and nuanced population. When you see both, I'm looking at. I mean, immediately I'm looking at the patients through a motor lens, language orofacial. And what I often find is because these patients with CAS have such little awareness and control over the articulators, that ends up resulting in that low tongue. Sometimes we're mouth breathing some. Now what happens to that palate? High and vaulted. I see it all the time. And then I look at how much speech do we have, what age? And I mean, I could go on and on and stay tuned because more info is coming, but it's complicated, and a lot of my treatment decisions are based on stimulability. Parents come in and they have priorities. I tend to find in my clinical experience, the OMDs tend to improve with improved speech production. We work on the speech, and then the awareness gets built up, the neurons are firing accurately, and then all of a sudden, we have more awareness of our tongue. Oh. When we work on certain movements in speech. Oh, we need our tongue up. We're able to start working on that. And all of a sudden I see the tongue elevating more often the movements of bilabials. Oh, we're bringing those lips together during these movements, and all of a sudden, mouth breathing is decreasing. So overall, I would say it's very difficult to target those OMDs without adequate speech because the awareness is just not there.

It's fascinating. I mean, I can think of certain cases that I worked with where I knew both were present. Right. I just. I kind of knew Just from my own experience and having worked with children with apraxia in the past, before my OMD days. And, and I'm no, I'm no apraxia specialist. Like, I, honestly, I, in some of those cases, I will even say, like, there was someone who was addressing some of the apraxia and they had, they were working with a child maybe three days a week doing more intensive types of, you know, like shorter sessions. And I was working on feeding or I was working on something else. And we were collaborating together to kind of almost separate some of our approaches, but then also collaboratively work together because the parent wanted to address multiple things. And we were like, but you got to understand that there's some, there's a reason, you know, they have this open mouth posture, they are struggling to chew their food. They're, they're a mess. Like, there's food all over their face, right? Kind of spills in to every other area.

And like you mentioned the speech itself. Based on the research and whatnot, I'm seeing kids three to five times a week for speech. When do we incorporate, when do we have the time to incorporate that? Myofunctional work, it's very tough and logistics come into play. Scheduling, insurance, private pay, you know, like, what can we do? But I've seen some notable improvements that happen organically once the speech is improving. But still, there's some, there's some work we still have to do with the myofunctional component. Very tricky. I don't lie to parents. I say, you're, you know, I hope you like me because we're going to be together for a while, you know.

Well, and it almost sounds kind of opposite of like a traditional myo case who also has some speech sound, you know, things going on. Because sometimes you get those kids where you're like, they come in for some speech reasons. You look at them and you're like, well, it's not apraxia, right? They just, they have speech sound disorder. But it's not extreme. It's not like, you know, more involved. And some of these kids have been in therapy forever. So not to downplay that, but you get these kids, you start to go, oh, well, if we address some of these myofunctional, you know, concerns, it'll be a lot easier to work on the speech sounds. But yes, again, are not children who are presenting with childhood apraxia of speech. So I think it's really important to like, differentiate between those because I think we get people who will come to us and Say, I've done all the things in mayo. I am trying to work on the speech. We're working on expanding food, diet. We're doing all the things, but the child is like, groping. The child is struggling. Like, we can't seem like I'm trying everything and we're not making progress. And that kind of, to me, is like a hard stop. If you're trying all the things and you've seen it work with other children, we got to stop and go, why?

Yeah.

Like, what maybe is the root behind this child's, you know, individual case here that they're not making that same kind of progress? Because. And I had a kid, remember, early on, who really struggled to move the tongue at all. Just, we could not connect the movement, the brain. And. And this was a child who really didn't have, you know, traditional childhood apraxia of speech. Their speech was phenomenal.

Yeah.

But there was still some kind. There was definitely a disconnect. And there, you know, in my opinion, was a muscular apraxia still where there was something more going on. This child could not control their tongue, you know, to the point where you would say, like, okay, put the tongue over here, or we put something on, just on the corner of the lips to try and lick it off. And it wasn't. It wasn't even a groping motion. It was the entire body.

Yes. I'll see the groping. I'll see the whole head move.

You know, you see those conversations?

Yep, yep. So it's a lot of that differential diagnosing. Okay. Getting to the root of it is this motor, is this muscular, is this tone. And you've just never learned how to move the tongue. You know, there's. There's a lot that goes into it, for sure.

Yeah. So at this point, what would you say, like, the bulk of your caseload is?

I would say at this point, I only accept CIS and OMDs. So 80% CIS, 20% OMDs. But then there's that overlap, the inevitable, where I see both in the same patient. Yeah.

Yeah, Okay. I think it's very fascinating, um, because I think it's. Again, it's not a topic that's discussed enough. And I know we're going to be bringing this conversation, this topic to the MYO membership because it needs to be discussed more. I think people need to really understand, regardless of your profession, you could be an SLP who's doing myo, you could be an RDH who's doing myo. You could be an ot. You have to know when to refer onward.

And I find that's a huge challenge. I get kids coming in that I'm like, oh, I should have seen you two years ago. You know, because someone is just not identifying the motor aspect of apraxia. I've had kids come in and the referral was, oh, well, he has enlarged tonsils. Okay. But that doesn't explain why his speech is a mess, you know, and then I have to go in, differentially diagnosed and say, this is not OMD related, this is just pure praxia and vice versa. So it's, it's definitely challenging, but that's why I like it. I really enjoy both.

Do you have tips for an slp, an ot, an rdh, Someone who might, let's say they get a MYO kid, right? And the kid is just really struggling to make progress. Whether there's a speech concern or not. Are there certain factors that you. Or symptoms or whatever you want to call it that you would recommend somebody kind of screen for or if we're starting to notice certain things, that's kind of a good time to refer. Any suggestions there?

So, yeah, it's tough because I'm biased. Like, I have such extensive knowledge about apraxia and it's not realistic for all of these, you know, RDHs, OTs to be well versed in apraxia. But, but my thing is when you see structure improving and function, not like, okay, our tonsils are much smaller, the tongue is, you know, getting up, but it's not consistent up to the palate. Like when that function is not quite occurring and you see things that you're like, oh, well, that's not typically in an OMD course, like the groping, the extraneous awkward movements, the tongue, lip, jaw dissociation is not happening. That's when I tend to think, okay, we might be looking at something else. And again, it's very nuanced, it can be very subtle. And then the next problem is, where's the apraxia specialist that you can refer to? You know, someone well versed. It's very, it's very challenging. But some basics that I look for, that groping, definitely the awkward movements when I see lack of coordination consistently. Also listening to speech. Speech is a big indicator too. Like I'll have a four or five year old that's still distorting their vowels during therapy. And as they're conversing, I can hear it and I'm like, oh, that's a red flag. You know, so it's tough. We need like, like a Like a handout or something to hand out to all possible referrals. Like, when. When OMT is not working. Here's what to listen for. Here's what to watch for. I think that that could be a super helpful tool in getting these patients where they need to be. It's just a matter of these resources being available.

Yeah, amazing. Okay. And I think that's a big key. And it's, you know, it's interesting too. It's funny. I have my. My little feeding development chart sitting here because I was doing a feed the peds call on Thursday night, and I left it sitting here. So I got my, like, little milestone chart. Right in front of me is just the whole, you know, jaw, lip, tongue dissociation, which I know in my brain is supposed to, you know, really be mastered by 18 months of age in a child who is typical progress and development. Right now, we know that a lot of kids are behind that, but even so, we're get. We get a lot of these four or five, six year olds to mayo that have absolutely no jaw, lip, or tongue dissociation. And you brought that up, like, that's one of the key things, too, that maybe if they're really struggling with that. Because I think that for me, like, I can remember back to a number of cases where. Where we just could not achieve, like, the dissociation of the tongue from anything. It wasn't happening. From the cheeks, from the jaw, from the lips. I mean, they really, really struggled.

Yeah.

From the neck. I mean, I'm telling you, like, I was that one example before. It's like, I would show the child, like, put your tongue here, and the entire. Not just neck would turn, but the entire body at the waist. It's like the waist and the hips were moving. And I was like, oh, okay, yeah, that's different. Like, yeah.

And those factors for others to look at, like an ot, an rdh, who is not a speech pathologist, putting these. These markers in understandable terms, like, when you see the whole body moving, like, you know, I'm not. If I describe something as groping or an awkward movement, I need to give an example. I have a kiddo. Right now, I'm thinking of nine years old. If I say lift your tongue, like, the tongue is moving left, my head is moving right. It is just completely disorder, you know, and putting practical examples so anybody could hopefully recognize them. I think that's super important, too.

Yeah. So the other thing you mentioned, too, was that you typically will see these children multiple times per week if they have Apraxia. So for our listeners who are not familiar with, like, why that frequency would be needed or even the type of approach that you would take to work with a child who has a child, you know, childhood proxy of speech. Can you speak a little bit to what that looks like? Just because I think it is very different than your traditional, like, speech sound disorder, kiddo, where you might be seeing them once a week, and you send them home with some homework, and they come back a week later. And, yeah, sure, we could see them twice a week if it's more severe, but that's not necessarily the same approach, you know, feeding kiddos. We maybe see them once or twice a week. Mayo. We're typically seeing once a week for 30 minutes, you know, so, you know, unless there's more going on. But, you know, I'd love for you to just kind of give people a little bit of insight into what it looks like working with these patients and the support they require.

Yeah. So apraxia is a rare movement disorder. So as you and I are talking, like, our neurons are firing, firing, firing from our brain to our mouth. We're not even thinking about it. For kids with apraxia, that's not happening. Like, imagining the message leaving the brain. There's nothing wrong with the brain, but then it makes a little detour away from the mouth. So in motor speech therapy, to teach that brain and that mouth to connect, to plug in and talk to one another, repetition, repetition. And to get there, we need to train these kids. You need to watch my mouth.

Sometimes.

When I'm starting with a kid. I mean, we could be working for weeks on just watching my mouth, because these kids know it's difficult to talk and to sequence these sounds together. So in order to teach speech and to communicate between the brain and the mouth, we're looking for 100 trials per session. Sometimes I'm thrilled if I get 50, depending on the kid. But it is all about repetition. And I use the analogy to parents. Imagine me sitting you down at a piano and saying, okay, play C to A to G to F. And they'd be like, well, what? You know? And I'm not giving them any kind of cueing. Like, just sit down and do it. That's what we're expecting these kids to do with apraxia, without cueing, without watching the mouth. They need more intense practice, more intense cueing. And, of course, that fades, you know, as. As we get improved speech. But especially in the beginning, it is. It is intense, it is focused, it is repetitive. And ideally, once we get that improved speech, we start to wean off. I've seen kids from five times a week, then we go down to three times a week, then we godown to two, and eventually, you know, they're once a week and eventually discharge. But in the beginning, those pathways need to be created, and that takes time. Whereas a kid coming in with an interdental lisp, you know, and without motor planning difficulty, it might just be a matter of having that model. You know, their mode on their. Their neurons are firing, but they need to be taught that accurate movement up and it's much quicker, it's much more rapid, and we don't need to see them three to five times a week. The brain is communicating with the mouth. It's just they're learning a new way. I say I always use, like, I never use, like, oh, the bad sound or the wrong sound. I always say the old way, the old way. So those pathways need time and intensive therapy to be created. Hopefully that's a good, in a nutshell, explanation.

Yeah, yeah. No, I think that really helps to help drive home the intensity that's needed in the beginning, because, you know, sure, we could see speech patients five days a week and, you know, but at the end of the day, we're hoping to. To not have to do something like that, to be able to send them home with some homework and maybe have them practice 5, 10 minutes a day and, you know, see them once a week. Right. So or twice a week, depending. But I. Thank you. I think that's very helpful.

One thing to also emphasize with apraxia treatment is I get a lot of parents and, like, they're so well intended. They're like, well, what if I put them in classes and preschool and they just hear other kids talking? Isn't that enough? And I was like, well, for a language delay, possibly, you know, hearing those language models, those simple language models could motivate a kid. But a child with apraxia can't just hear it and imitate it. They need that intense cueing system, models, simultaneous productions. I use dynamic temporal and tactile cueing as my primary mode of treatment. And then I'm also prom certified. I incorporate that for tactile cueing. It's just far more complex than hear it say it. I wish it was that easy for these kids.

Well, I mean, and it's fantastic that they have somebody like you, because it's. Not everybody understands apraxia. Not everybody can work with children who have apraxia and truly help them. Yeah. And so I'M curious to know too, what your experience has been collaborating with other professionals and especially even within our own field. You know, have you found that to be easy, challenging? You have a look on your face. Share with us. Well, loaded question.

Yeah, Let me dissect it a bit. I find if I'm looking at apraxia, I find a lot of SLPs are very eager to learn about it. I talk with a lot of SLPs who are in the early intervention system who are very limited and the type of treatment they can provide. So a lot of times I'm kind of driving the goals, I'm driving the therapy, and they're, they're following along with my plan as much as they can. You know, they're in county programs, state programs, and they're limited when it comes to OMDs. I have found it a bit challenging to be completely transparent. I will say I've established a very local team in my area of ENTs, sleep physicians, dentists, orthodontists, OTs. Now I have a nutritionist for my OMD patients. I have an amazing team that is super eager to collaborate, but I found within the speech field, there's a lot of. I don't want to say cutthroat, but I kind of do. I've left Facebook groups because you ask a question and I feel like you are belittled. And if you're asking this, you wouldn't be treating the patient. And it's like these poor SLPs who are in rural areas, you know, out in Kansas or somewhere, and they're the only resource for these patients. And you're made to feel badly because you're asking a question. So I stopped asking questions and eventually I left. A lot of the groups feed the peds the MYO method. Honestly, it was the first time I have felt comfortable asking questions about OMDs. And I feel like you filled a void that we needed in the speech pathology field, where you can come and you can ask questions, you can collaborate safely without feeling judged. Like, I will not go back to these other orofacial myofunctional Facebook groups because I just found them incredibly judgmental, not helpful. We're all supposed to be working together, and I just, I did not find that there. So all that to say, I have the MYO method, which is incredibly helpful. I have my personal SLP friends will text and just kind of talk anonymously like, hey, what would you do with this? Or am I looking at this in the right lens? Those trusted speech pathology, speech pathologists who get it and they want to be collaborative, too. Yeah. I've been very disappointed, to be honest, in fellow SLPs, even SLP versus RDH at times. I feel like, you know, we should all be working together. And I know that there's been a whole thing with the iaom, who I was initially trained with, Christy Gado and Amanda Chastain. I cannot recommend their class enough. But since everything that happened with the iom, I'm not affiliated with them anymore. And since kind of transitioning to MYO method and all, I finally have that safe place to collaborate with fellow SLPs.

Yeah. Well, thank you for sharing that. I think that one of the reasons why I created that, what I did, the way I did, was because, one, I had my own experiences in some of those Facebook groups, you know, by some big names in the industry. I was my own child's case. It wasn't even another patient. And I was like, hey, my kid has been in an ALF appliance for three months, and their tonsils went from almost touching to barely being visible. Has anybody else seen this happen? It was more of like a. I have evidence, and I'm asking if anybody else has witnessed this. And I got torn a new one. And it was like, I got a private message that it was so nasty from the moderator that was like, take that down. Right now. There is absolutely no evidence that skeletal growth can lead to, you know, a decrease in. In soft tissue. And I was just like, do you hear yourself? And now, by the way, there is research to prove that what I witnessed actually is happening in many cases.

So isn't that the point of what we do with OMDs palatal expansion? We're not doing it often. Orthos tongue goes up, we're protecting the airway. Tonsils maybe go down maybe.

I don't know. You know, it could be a thing. Right? I mean, not like we researched it back at now or anything, but we do. Yeah. No, it was. It was fascinating to me to have that experience and then to see the exact same thing where people were asking questions, being belittled. Like, people will literally write, right. In a Facebook group, like, no shame. They're like, if you have. Like you said, if you have to ask that question, you shouldn't be working with this patient. And I'm thinking, like, so this patient should go without anybody, and we shouldn't, as SLPs, come together and ask our colleagues.

Right. Support.

I mean, isn't that how medicine should work?

Right?

I know we've gotten very far away from that country, but however you Know, I was like, that was part of my mission, was like, can we bring this collaborative nature back? And I'm like, if I'm almost at 300 episodes, if people are not tired of hearing me talk about collaboration and not bullying other professionals. And like, I mean, you obviously haven't been here for a while because it's enough, right? It's right. We are adult. We are serving our patients. If we cannot put our ego aside because none of us know everything, not even those experts who are belittling others, if we cannot put our egos aside to come forward and say, I don't know X, can you help me? Or can you direct me to where I can find more information on Y or, hey, I have a patient who is struggling with this. And we've worked, we've tried all these things, and I'm. I'm here because I need help. Like, if we can't create a safe space for that to happen, how are we supposed to help our patients?

Right?

You know, it just. I was. It was beyond me. I was like, I don't. I don't get it. I don't understand. And so I have so many colleagues coming to me and saying, I've taken all these great IOM courses, but I'm confused. Or I took a course and I left more confused than when I entered. Or I took a course and they promised me mentorship and then dropped me. Like, you know, like, I didn't even pay them anything after the course ended or, you know, or, Or.

Or right.

Think the stories continue. And I was like, what is happening? Like, I don't get it. And so that's ultimately why I initially created Feed the Peds to fill a big hole in the feeding arena. But then I created the my own membership next, which, you know, if anybody knows me, I'm very business minded. It made absolutely zero sense on a hierarchy of creating a business model online to go from a feeding course to a MYO membership. Like, there should have been a feeding course to a feeding membership to a feeding certification.

Right?

I was like, yeah, I was like, feeding course to my own membership. Like, then let's create the course because people are asking for it to. Then let's create them. You know, the cause people are asking for it to finally being like, okay, now it's time to create the feeding cert. Right? It was like, not a natural progression in the business mind, but it was what everybody needed and was asking. Exactly. It's just what I did.

And just in our patient care, what does that patient need not necessarily. Like, think about that EVP triangle. Sometimes everyone's research, research, research. And like, of course we. We have to have research, but also, what does my patient need in that session in their treatment plan? You know, and it's. It's important to also look at what do these SLPs need at this time? And we needed collaboration. We needed to feel like we're all on the same team here. And it has not felt like that arrogance, ego, it's taken over and. And it's really disheartening. I'm hoping we're on an upward trend, but it's, It's. It's tough to be positive at times, which is really disappointing.

Yeah, I mean, I think that there is enough. There's more awareness now, especially with social media, and there's less tolerance for wanting to spend time around educators or colleagues who are going to treat you poorly, who are not going to support you, or who are not going to actually provide you what they're telling you that they will. Right. And so I think that, you know, yes, it still goes on, but I like to believe in my own little, you know, perfect world that. That we are moving beyond that and that hopefully some of those individuals are also waking up to the fact that more people are not going to turn to you, because there are so many more people out there now who they can turn to instead, which was not always the case. Five, even five years ago, there was.

No one to turn to. There was. Well, I have this group. That's it. You know, I could pay for my.

This small set of courses, and basically that's the only way.

Yeah.

And I think that, you know, I don't want to say that I started, like a revolution or something, but I feel like once I kind of came out and started talking about this all of a sudden, and then I started with my own membership, and then my MILE course, I started seeing other courses pop up and other things pop up, and I was like, oh, okay. One, very entrepreneurial.

Right.

Two, they're tired of the old way of doing things. Yeah. There's a new, you know, there's a new way in order. And it's all about collaboration over competition. It's all about supporting each other, being kind to each other, really putting our patients at the forefront of this and keeping it simple.

Yeah. There's kindness. Like, there's none of that. And it's just. It's such a shame. So I feel like, you know, programs like the Mayo Method and having that space to go is setting an example for how the field should be how we should be treating one another. And hopefully people take note.

Yes, I hope so. I do hope so. It's always been my goal to create that safe collaborative space because I also through my own research and you know, at one point going back, I went from being entering into like business in college to then moving to early education to actually going into speech. And so I always joke, I'm like, I didn't study abroad, which I wanted to do but didn't do because it would have pushed my college years like longer than four because I switched my major three times and figured out what I actually wanted to do at the point where I was like, oh, well, we're out of time now. Right. But I figured it out. I figured it out. But I'm like, what was my whole point of sharing this, my train of thought lot? I'm like, I, I don't even. Oh no, it. When I was doing early education and learning about a lot of, you know, different ways that people learn. Right. Which hi, I'm, I'm neurodivergent. So that was a big learning experience for me in my own freshman year of my own journey. But then also learning that in order to actually learn and keep, you know, really commit information to your brain, you have to feel safe.

Yeah.

And if you do not feel safe, your brain is not going to remember the information. Your brain is going to focus more on the fight and flight that it experienced in that experience. And so I have a lot of people come to me and say, oh, I was taking this course and like I was like talked down to in the live training online or I was, you know, and the company that gave it actually, you know, apologized to us and I was like, oh, that's bad. Wow, that are happening. And that's, that was a couple years ago. I mean it's still going on. But that's why I always tell people, I'm like, research who you are taking courses with. If you're looking to spend your hard earned dollars, make sure it's with someone who's going to deliver on what they promise and who really has the patient and your best interest in mind. You know, because at the end of the day, that's what you're here for.

Yep. Completely and unfortunately you shouldn't feel like, yeah, you shouldn't feel like you're back in grad school, you know, where you're writing four page soap notes and they're all covered in red, you know, that fight or flight, you know, like we're all adults Here. Can we help one another?

Yeah. Yes, absolutely. Well, this has been amazing. Is there anything else that we haven't touched on that you want to talk about related to your work or your practice or anything like that?

Well, I wanted to say that there were times in the beginning of really getting deep into the MYO world that I was fighting that urge to say, wait a minute, we're not allowed to do anything in the mouth, those nsums, those non speech oral motor exercises. And I remember Amanda Chastain in my IAOM intro course said, we're not blowing bubbles to get the tongue up to the top of the mouth. You know, we are setting the stage for adequate swallowing, speech, resting posture, and setting the stage really clicked with me. And so I knew. I knew there was more because I. On a personal note, I was diagnosed with breast cancer a few years ago when I was 36. And I bring that up because when I was in PT after my double mastectomy, I had a reconstruction called a deep flap. And they take fat from the stomach and they reconstruct. But I was in PT and my ultimate goal was that I was very hunched. I was throwing my back out constantly. My ultimate goal was to stand up straight. Could I do that right away? No, I had to work up to it. So they were giving me strange exercises that I was like, when else would I do this? Like, have your hands crawl up the wall. Crawl up the wall real slow. And it made me think of these exercises we have our patients do and how there's so many people attacking these exercises. And I'm like, but for adequate function to reach that ultimate goal, we have to go step by step. I could not just jump from, you know, hunched over 98% of the day to standing up straight. I just physically couldn't do it. So there's a reason. There's a reason behind these exercises. And I always thought, you know, PTs, they work on muscles, you know, OTs, they're doing fine motor. And like I was taught in, in grad school, absolutely nothing about myo. I remember the extent was a professor took a poll about whose tongue sat on the top and whose sat on the bottom. And it was like there were like 16 of us. And I want to say like 13 were tongue up and three were tongue low, but that was the extent of it. And I always remember thinking, like, there's so many muscles in the mouth that affect oral function. Like, why wouldn't we address that? So for those that. Yeah, so for those that struggle with the idea of omt Think about it. In the grand scheme, pt, ot, when we work our muscles, how we work them, you know, whether we're in physical therapy or whatnot, you can't go from 0 to 100 in so many aspects of life. You know, we want to set that stage. And OMT is just such. It's just such a great practice and it's so needed.

Yeah. Well, and thank you for pointing that out because I think that's such a great comparison. Like no other professional who rehabs muscle in the body, it's attacked, I feel like in the same way we do. I mean, it's amazing that people want you to learn how to speak and eat, swallow, you know, don't touch without using your muscles. It just makes no sense.

Like, let me get my magic wand. Okay. You know.

Like, I'm gonna use that. It's.

It.

Really? Yeah. I mean, look, I loved my grad school program at University of Maryland. I really value and love my professors, but I was taught about ensomes and I was taught that you don't do oral motor exercises. Like, but we were only shown one side of the conversation in research. We were only exposed to that. And so I honestly came out of grad school and I was like, I don't know how to treat articulation. And that's why I didn't like it. I was like, how do I work with these kids? Like, it's. It was literally just drill and kill and fun games. And if you. It's modeling and it's. I'm like, sure, that's one way to do things, but what about the kids that don't respond to that, which happens to be a lot of that. Them?

Yeah.

Because it's based on the muscle. Yes. Like you said, there's so many of them.

There's so many. We can't ignore them. There's anatomy, there's science behind this, you know, and to deny.

We took anatomy and physiology and grad school, you know, physiology.

Yeah, yeah.

Then we're told to basically ignore a lot of this. So it was very, very eye opening experience for me. And one that I think it took me a while to kind of come to on my own. But once I started to see, like, I always tell everyone, I'm like, I started working with children who were autistic in the beginning.

Really.

I actually started in the schools similar to. I was in a program in preschool education program in Montgomery county public schools. And that was because I refused to work with anybody older than five and they would not give me infants and toddlers. So they put me in two different schools, and I was the only full time SLP split between preschool programs in the county because most. Well, and I mean, and I love that age group, but that was like, impossible to work with them because now I was like, okay, I'm not the main SLP in the school who also has pep. I'm the PEP SLP between two sites where I'm very limited on working with them. And it was not for me. But anyways, long story short, again, I started working with some of these children, and then once I got into working for a private practice for a year and then working in my own practice, I just kept seeing patterns. And I was like, these children who are autistic, there's. There's something going on with the gut and the brain. And this. You know, I had one kid who was constantly constipated. His BCBA was with us during our speech sessions. And basically he wouldn't have a speech therapy. A speech language therapy session. We were working on speech and language. He wouldn't have a session because I was like, I can't work with him. He's uncomfortable. This is not ethical. Like, the child is withholding a bowel movement right now and bouncing up and down like, there's something greater going on here. And watching some of the children eat really opened my eyes. I started to go like, there's something more here. And that was my window into eating.

Yep.

Right. I fell into feeding, which then fell into mayo. And I just. And I was like, why? Why was I never taught anything about feeding and mayo and the muscles? I mean, I was taught about the muscles, but not in the way that I needed to understand them in order to work with them in therapy to help rehabilitate these children.

Yeah, we know that the muscles are there. We can label them. But then.

What'S the next step?

You know, how do we target them? Right, right. Go figure.

I'm like, I get the anatomy and physiology of it, but I don't get the actual application because I was basically told that didn't matter. And you just need to know. Like, you need to know they're there, but we don't actually do anything with that.

Right. Yeah. Right, Right.

Until. And I did, you know, I did take a dysphagia course with a graduate school professor, but it was all focused on adults.

Yes. Yeah.

And we know that adults and children are very different. Like, they're totally different when it comes to feeding therapy. And even the anatomy is different when they're younger. Until Every kind of, everything kind of shifts into its more adult like positioning and function. But yeah, it was just, it's still mind blowing to me. And I'm really, really very hopeful that more and more of these programs are introducing pediatric feeding and introducing orofacial myofunctional disorders, like during grad school, please.

Yeah. We can't be sending these graduates out with as little knowledge as we had because we've had to do the work, you know, we've had to do the trainings and figure it out on our own. So hopefully things change in the program soon.

Yeah. Yes. Well, this has been amazing. Tell us where can we find you? We will. We'll link everything, of course, in the show notes. But tell us where do we find you? Online on Instagram, Share all the things.

Okay, so you can, you can come to my website. It is your speechpathllc.com I'm on Instagram and Facebook. My business account is your Speech Path llc. And then my personal SLP page is Aaron G. The slp. And that is Instagram only, where I like to explore the, the dark humor side of speech pathology, the honest side.

Love it.

Love it.

Well, Aaron, right?

Love it.

So good. Well, thank you so much for joining me today and sharing your expertise and experiences. I love when we can bring that information forward because I do think Apraxia needs to be talked about more and it definitely this is not a podcast that does that too often. So I love highlighting that and really getting people thinking. Especially if you work with children who have, you know, orofacial myofunctional disorders, speech sound disorders. Like, could there be anything else going on if that child's not making progress?

Definitely this has been thought provoking. No, this has been awesome. Thank you so much.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, air weight and feeding related episodes, be sure to leave a review on any Apple podcasts and share this episode on your social media platforms. You can access free resources and all I offer@hallie balkan.com or pop over to Holly Balkan on Instagram to get all the latest updates.