Episode 301: Bridging Cultures, Families, and Child-Centered Care with Bibiana Fuzer da Silva

Hi and welcome to episode 301 of the Untethered Podcast. I am your host Hallie Balkan and today we have Viviana Fouzer da Silva joining us. Viviana is a speech language pathologist and pediatric feeding therapist passionate about helping children and families navigate feeding challenges. She's also the co founder of Anima elementary educational platform in Brazil dedicated to professionals seeking training in pediatric feeding difficulties. She considers herself a curious mind and a food enthusiast, constantly exploring ways to connect the science of feeding with the art of mealtime. Over the years, she's completed numerous national and international courses and certifications, including Feed the Peds, which she attended two years ago. She has graduated from the Federal University of Rio Grande Soul with a exchange at neurobrandenberg University of Applied Sciences in Germany, and she holds a Master's Degree in Genetic Pathology from the Federal University of Health Sciences of Porto Alegre. For the cpft, our Certified Pediatric Feeding Therapist curriculum, she's created a comprehensive course on the evaluation and treatment of pediatric feeding disorders featuring 12 hours of in depth lessons. As a bonus, she's also created a two hour module focused on autism highlighting key points and important insights about this population and their unique feeding challenges. Some of her key trainings include Feed the Peas aeiou, the SOS Approach to Feeding, Responsive Feeding Therapy get permission Approach to Pediatric Mealtime Challenges Food is sensory and transitions to chewing 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 of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host Hallie 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, Tethered Oral 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. Viviana, welcome to the podcast.

Thank you. I'm super happy to be here.

I'm excited to have you join us because as many people will come to learn if they haven't already. You are one of our amazing course creators for our certified pediatric feeding therapist certification courses which are now also a lot of them are available to the general pediatric feeding population to enroll in. But so before we dive into that, I would love for you to share with our listeners how you got into pediatric feeding. Like what what is your story that's.

Interesting and I love talk about it. So as you can hear, I am not an American. So I am a Brazilian pediatric feeding therapist who already is living in the United States. But I start my journey through this pediatric feeding area about 10 years ago. So I had an experience in Germany where I had a exchange program during my graduation in Brazil. And then I had my first contact with patients with feeding challenges. And that was the first time I had contact with something different than just dysphagia because dysphagia was something we were used to see or understand about the treatment study read. But then we I faced patients with food refusal and dysphagia. And then over there I had a mentor and she started to talk about the feeding challenges more than just dysphagia. So I came back to Brazil, I finished my graduation, I went to my master's and I start to make specific courses. And during this time I have done so many different courses certifications. Three years ago I finished I'm training a feed p training now and I have created my own courses in Brazil. And I think my goal during this journey is always try to bring science more close to the practice because I'm studying and I have the feeling that every time we talk with other feeding therapists they ask us about how to do things so they know in theory what they should do. But when comes into practice I have the feeling that sometimes is so far away from the reality or that seems to be I'm not sure if I can do that. I don't know if I have the exactly tool. I don't know. And then I'm telling this because my journey through and during this process as feeding therapies has a really big part on this other in the on during this talking with other therapists telling me I'm not sure if I'm doing right. I'm not sure if I can do this. Oh sometimes it's super difficult. I'm not sure if I I'm going to be able to do that. So now the last five years I'm working more closely to feeding therapies, working as mentor, working giving courses and studying. I'm giving like we call supervisions. We talk about the patients, we have a study group. So I'm working really on the teaching side and on the teaching area. And my goal is bring, okay, what we are seeing on the articles we are seeing, what are the new perspectives of feeding challenges and how can we bring that close to our practice? So that's kind of how my journey is going the last, especially the last five years.

I love that. I mean, first of all, congratulations to you because I think it's really challenging to figure it out for yourself, right? You take all these courses, you have to piecemeal everything together. And that's kind of like one of the things I say in Feed the Peas. Like, feed the peas is not meant to replace anything else out there. But it's like you said, people have a hard time kind of pulling all the tools together and trying to make sense of them, to actually apply them in clinical practice. And so I think that, you know, like, yeah, we get a lot of people saying, okay, like, you know, I was hearing people say the same things. I understand, like the idea behind it. I understand what I'm kind of, kind of like what we're working towards. I know the goal, but like, how do I get there? How do I work with the patient on a day to day basis? What do I do when this patient refuses solids? Or what do I do when they're, you know, struggling to imitate what I'm modeling for them? Or what do I, you know, and so it's like you get all these questions about the actual practice of implementing therapy in the day to day. And that's where I started to like scratch my head. And I was like, oh, okay. I feel like people like, like you said, they get it, theoretically they get it, you know, but they don't understand the application clinically. And so I think that's really cool that you've focused on that because we need so much of that, of just making sense of what is out there and so that we can basically help our patients. And so I love that that's been a big, big focus, focus of yours. I remember when we had kind of like put out like an email to like ask for some of our graduates to help create some of these courses, more intermediate to advanced level courses for the certification. And your name came through and I was like, oh, okay. And you know, and I remember seeing like what you, some of what you were doing and I was like, taylor, we gotta talk to Bibiana. Like, this is fantastic because now you've created, you know, three courses for us. So we have like the sample evaluations and pediatric feeding disorders, which is obviously very like, it's like a more hands on approach to teaching. Right. It kind of talks about like what we want to see in the evaluations and what those look like and more that I'm not, I'm not doing it justice. But. And then from there, you know, after the evaluation, creating a treatment plan. I know you created a whole course just on that for pee feeding disorders. And I know we have a bonus one on, you know, on autism as well and pediatric feeding. But these were the kinds of things where we were like, okay, it's so interesting because a lot of these therapists are out there treating already and they're still confused, they still want to see examples. They still want to see, well, how do you write your report or what are you putting in your report or what does an evaluation look like, right. And then how do you take that information and bring it over here and create a treatment plan and then how do you take that and put it into practice on a day to day basis? So, so anyways, we'll talk about the different courses, but I know that, you know, a big part of your approach was very, very much aligned with mine in that you kind of, you put the person first, right? The child first, ahead of anything else. And I feel like one of the big things I've talked to in the past is, you know, we can have a whole big checklist of things we're looking for in an evaluation. For example, are you going to go through the whole thing in one eval appointment? Probably not. And if you do, I almost encourage you not to because that means you're not spending enough time like getting to know the patient and building rapport with the patient and their, maybe their caregiver. Right. Because we're talking about pediatrics here. And anyway, so I'll let you speak, but you know, I do think I'd love for you to talk more about your approach and your whole like child first approach with, you know, figuring out the challenges kind of like as we go and how to address them.

I'm going to start talking about something that remembers me. So, so it's so strong on my mind. When I took, I first took the feta pits, Romeo was giving a class where she talked about culture. So when you are doing an evaluation, you have to think about the future of this family. Is table appropriate for this family or it's not? And at that point that came so strong for me because I'm a foreign people. I am a stranger here in The United States. And that came and I. But I have done so many courses here and when I go back to Brazil, when I talk with colleagues in Brazil, I always bring, okay, we have an amazing theory here, but we have to bring that to our reality. What we have here and feeding is so complex. We have so many things that can affect directly or indirectly. And I think that's why it's so confused sometimes. I know the theory, but my reality, it's another, it's different. It's because we don't have one fits all approach. We don't have a cake recipe ready. And I think during the process to create the courses I was really thinking about, I don't want to give you a ready recipe. I want you to learn how to think about the case. Because you can get any patient with any problem and you can know how to do. You know how to do because you know where you are going to look and start looking for the child. So look to this child, where this child is, what she's doing. Because everybody does something good, everybody knows to do something. And another point that I have talked so many, many times during the course is this child belongs to a family and this family belongs to a system. So we can't evaluate, we cannot treat a patient without looking to this child and this family. So when we look to the child and the family, we are going to understand the context of the problem. We are going to try to find the best solution, but not because someone told us to do that, because we understand what they need. And I think as therapists, we don't learn how to talk with parents. We don't learn how to do approach exactly what you have seen saying about checklists. We know what we have to look for, we know what we have to mark, what we have to observe. And another thing about, during the certification, I had a chance to see the flexible framework that was present. And that's the thing, when we are doing an evaluation, we don't need to touch the mouth at the first time. We don't need to offer food. We are going to get so many informations about connection, how this family is feeling. Because sometimes when they come to us, they have passed to many other professionals. They have, they are like, okay, here I am again. So this child's not eating and I don't know what to do. So can you fix it? Yeah. No, I can't. That's not something that I'm gonna fix.

It, but I'm gonna wave your magic wand, right? It's like bibbidi Bobbidi, boop, boop, boom.

And doesn't it how that works? So I think this process of creating the evaluation and the treatment course make me realize how we can connect and how we have to connect. Because working with the other, other feeding therapists, they always ask me, okay, how I'm gonna do it.

They are focused on what exercises, what exercises should I be doing and how many reps do I need to be doing. And I'm going pump the brakes like we will about that. But that's such a small piece of what you're doing, actually.

And I like the idea about. So Suzanne Morray is our super mentor. She has this pyramid where she talks about meal times. And then we are going to build our skills. But first we are going to build our relationship, our connection. We are going to look to the skills. And that's something I try to bring to the evaluation as well. Because another thing that I'm seeing so much is like, okay, I have a child and this child has a problem. Can you fix it? Okay, okay, you have a problem. I understand you have a problem. And we need to listen. The family, we need to listen. If the family is saying they have a problem, this is something we need to address. We need to give them space to talk about the problem and not trying to run and fix the problem that we don't know if it's really a problem yet. And recently I had a personal health stuff with my daughter where I was talking all the time, it's a problem, it's a problem, it's a problem. And nobody was listening. So we ended up at the hospital a few months later because nobody listened what I was saying. So if we are working with families, the family is bringing us concerns about the child. We need to take time to listen them. And then instead of asking what's wrong with this child or with this family, could we ask what happened to them? Could we ask what having been them through during this process, how many professionals having them seen? Because evaluation is like a snapshot. It's like just a moment. And we can't have all answers at this time. Maybe it is a place where the child is not feeling comfortable. It's not feeling safe. So, Amy, I think it's Amy, that talk this week on the podcast, she had talk about feeling safe. And we talked during the evaluation and during the treatment course about feeling safe, how this is this child feeling safe. So if I'm doing an evaluation, I need to consider that. Because if I'm going to release a diagnostic at the end of the first evaluation. And this child doesn't look at me or touch anything that I'm showing. Is that real? The child? Or maybe it's just at this time. So we talk a lot about how can we see that, how can we do a complete evaluation? That takes time. And we can have this time. We can, because we are not just going to do an evaluation. Oh, I'm gonna finish my evaluation, and then after 10 weeks, I'm gonna give you something to do. No, we can give instructions. We can give parental guidance during our first assessment. We can do that. And then we are going to building this rapport, this relationship and this connection. Yeah.

No, I love all of this because it's so interesting. People would ask me all the time, well, Hallie, how is it that you get these kids to do these things for you? Or how is it that you are making so much progress. Progress in your sessions? And it took me a long time, this was before I ever created a course and was teaching to kind of go. Like, it's just second nature. Like, I don't really know how to teach what I do because it just comes so easily to me. But also, I wasn't using a checklist. I had little notes to jot things down. But I was asking the family, like you said, tell me about where you've been. What have you already tried? What is it that you. When you say that there's a problem, can you explain? Can you describe that to me? Can you tell me what's going on? Because what's a problem for one family is going to look totally different than the next family. And both of their kids may not be eating, but maybe it's that in one family, the child actually is not chewing and they're gagging a lot and vomiting. Maybe in another family, they just want their child to expand their diet. Right. But for both of them, it's a very, very stressful problem that they've now come to seek help for. Right. And we can't begin to imagine what that problem is unless they explain it to us. And so I love that you're. You're talking about really addressing, like, the family with the child. Like, the family is such an important and integral part of this process and the therapy team and that, you know, So I love that you. You speak to that. But I also think that you. You talk a lot about kind of meeting the child where they're at. And I think one of the things that I don't know that you really outright said it, but what I'm Hearing and I think is very much aligned with me is I don't always like to just look at what the problem is. I like to look at what the child can do, like what are the skills that they do have. Let's celebrate that and let's use the skills that they have to build on the thing, you know, use it to kind of address the issue at hand that the family's coming to us with. And I think one of the biggest lessons for me was also just kind of like getting off of my own like therapist soapbox and thinking that I know best for every family and that. And there's this approach that's going to work and I know it's not going to look the same from session to session or child to child, but like at the end of the day, a textbook case like this should. We should do A, B and C and cross our T's and dot our I's. And you know, at the end of the day I was like, no, that's not actually what my therapy looks like. And success to one family is completely different than another family, right? What they're looking for, what their goals are completely different. And so I do think it's, I always say it's like a dance between art and science because like, we have to know the science, look at the science, understand the science, but it really becomes an art form to apply, apply it and to individualize it and to work with these families in the way that best serves them. And that's where I remember. I even did like an airway. I did like a 1 hour, 2 hour course on like airway after I had like my nasal surgery. This was like maybe a year or two ago in December. I remember if it was one or two years ago. But either way I. Everyone's like, well, what is your secret? I was like, my secret is connecting with the patient and listening to the patient. If you're not listening to the patient and you're not getting down, like for a child, getting down on the floor with them in the first five minutes of them being in your office and playing with them away from food, away from a formal chair, away from, you know, obviously if they need support, that's a different story. But you know, if you're not engaging with them in an age appropriate manner for where they're currently functioning, they're never going to trust you. And so getting that trust from them is going to be huge because you get it from the kid. The parent is going to be like, holy cow. Like, this doesn't happen ever, anywhere. So, okay, you know, like, we're sold. What do we do? Right. And so I think it gets a lot of buy in that way. But it also allows you then to develop that relationship further with the family. Right? Because they see that you truly want what's best for their child and them and that you're not going to push your agenda on them. And then the other thing you said that I really, really love, too, is, like, that whole dynamic assessment. Like, we come in, we start assessing, but we assess enough to understand, like you said, like, why they're there, how we can start to help them based on their goals. Maybe there's some cultural differences and some things that we need to be asking about and be communicating with them about to make sure that we're not offending them or suggesting things based on our culture and our. Through our lens. It's really, you know, adapting to theirs and saying, if you don't know, asking them to explain to you, like, well, what does that look? Where do you eat? What times do you eat? Do you eat together or not together? You know, like, all. There's all these different questions you can ask. But I think it's starting to really get like, you're talking about getting to know that family unit, who's there in front of you. That's our job. And I don't think a lot of people do that. And then continuing the assessments. Right. I look at every therapy session as a combination of assessment and treatment, because who knows where that child is when they walk in today, right? Like, they could be in a completely different place. 10 steps backwards, 10 steps forward. We have no idea when they walk in that day until they start to engage with us. And then from there, it's that dance again of figuring out, like, okay, where are we at right now? And how do we help you move forward, if you even have the capacity to do that today? So I always look at sessions as, like, this dynamic assessment that is just ongoing. And we're, you know, like, yes, I get it. We have to write goals. Yes, I get. Especially in the US Insurance dictates a lot of the process and everything. Just get enough to write some goals and create an initial treatment plan. You can always adapt it, you can always edit it, and, like, nothing's written in stone. So, anywho, I'm rambling, but, you know, I think I just love your approach because I love how you really, truly talk about putting the child first and then kind of focusing on the challenges but not making that, like, the highlight of what we're doing and meeting that kid and that family like where they are right now and all these considerations that need to be made.

Yeah, the child comes first and they're difficult. And then from there we are going to understand what's going. And one thing that you were talking about, if we think about the perspective about strength based approach. So I'm going to start working with works best for this child and this family. And another point that during the evaluation but most part during the treatment that I think it's very important when we are doing this buy in process with the family because the family has to buy in the therapy. They need to understand that and they are going to do that. I have two situations that I like to think if I give something to the family and say, okay, now you are going to do this, this, this and that's going to work. That's not what's going to work because we are giving, we are one more demand for this family, one more thing to them to do. So we are not with the family. And then when we have an approach like a sharing power approach, that's something that comes from trauma informed care. So when we have the sharing power where we can talk. Okay, I'm thinking so then I bring my expertise and I'm gonna. Okay, I see this maybe is what the child needs most now. Do you think you can do this like maybe one adjustment at the meal time? Can we maybe have one mealtime moment during the day or maybe during the week? Or maybe during the week? Do you think that's possible? And the family brings me. No, I don't think that's possible. Okay, what do you think it's possible now? I think I can bring a new cup to the table. Okay, if that works. Can you do that? So I'm going to share with the family the informations that we have that I'm seeing. I'm. I'm bringing to them what I'm seeing. But I'm also let them know and I also let them talk to me about what is possible to them. And then when we do, we have this, we are going to create, start to create this strong relationship with the family and then from there we are going to improve the treatment. And one thing that you talk, I think it's very important think about the therapeutic goals. So we need to know what we are doing. Because feeding therapy is not play with food, it's not expose food to the child and then they are going to eat. We are going to think about, okay, why I'm showing them but that's our job and we have to have our goals clear. Sometimes they are not. But we have to make questions, we have to ask, why should I add this food? Why should present this? What that's the, what's the relevance about it? So all those key points or essential points are going to help us build more effective treatment and not just looking to how many foods the child's going to eat, how many foods I'm going to present them, how many bites they are going to have. So it's fitting, it's complex and it's the only thing that we are going to do or we should do every day for our entire life. So we are therapists. We need to think about it and think the power of our intervention and how we want this intervention to continue through the life. So it's something for the life. So it's not just this time the child is coming, I'm gonna treat it and they are going to go. And it's all fine though. It's, it's different.

Yeah. No, I mean that mutual respect that you're talking about between like therapist and family. Right. And even the child, I think that is not talked about enough. I think we're talking about it more and more these days, but especially with like trauma informed therapy approaches. But you know, like as you were speaking to, but I think for a long time people kind of look to therapists like they look at doctors. It's sort of like, oh, you're the white coat. Like you're the person who has, you're the superior knowledge, you've gone to school. And I never ever approached a family like that. I'm like, yeah, okay, I got some extra years of schooling. But truly a lot of what I've learned has been hands on working with the families and the kids. Like, I mean, yes, I had to go to grad school. I'm not going to downplay that. Yes, I learned stuff in grad school, but really it's that hands on real life experience that has made me the therapist that I am today. And it was like that connecting, right? Connecting with the family and realizing who's sitting in front of you that you know, and what their goals are. Right. And you know, and I also love that you spoke to, you know, from the trauma informed therapy perspective of, you know, what is it that you know? Okay, here's what I'm thinking. Like, what do you think? Right. And really putting that power back into their hands. So you have that shared power like you were talking about. Because I think that's where that mutual respect really comes. And then from there, you know, I also like to make suggestions based on things that, like, kids have had success with. Like that day in therapy, it's like the parent just saw them have success doing it. Because a lot of times, like, what do we hear from families? Right? They'll go home and be like, well, they did this for you in the session, but they won't do this for me at home. Well, let's bridge that gap, right? Let's work on that generalization. And so, you know, a lot of times, I think parents feel very empowered if they see it in therapy. But then I also, like when I have a parent present, because we honestly don't always have parents present in our sessions. But if they are present and the child has success, I like the parent to do it in, like, in front of me, with me, so that they can experience that success as well. And then their confidence goes up, right? They go home. It's easier to carry over. They understand what they're supposed to be doing. And I think they. They feel really good about it because now they're actually helping their child as well. Right? And it's not just, oh, the therapist can do it, but I can't, because I think there's that big dynamic that really speaks again to that whole power. You know, the power dynamic that, you know, is. Is not something that people. I've had a lot of therapists tell me, like, oh, it's kind of strange. It's kind of weird to, like, have the parent try to, like, play therapist in the session. And I'm like, you need to get over that. You need to figure out why that feels weird for you. And if it feels weird for you, and that's a stretch for you, you. Here's your goal. You work on that. Like, that is your IEP goal. Because right now that you got to get over that in order to help this kid in this family, like, you are there to help educate and empower and help the family overcome certain hurdles. And if this is what they're asking for and it's in your scope, like, this is. This is what we're here for, right? And so I really love that you speak to those points, because I think that, you know, this is what helps us feel successful and have more success and move forward.

And another point that recently I came from the national conference in Brazil where we talk a lot about the feeding. So now we have a specific area where we just talk about pediatric feeding disorders. And one thing that we are I spoke at and I talk about that many, many times. So parental guidance, parental orientation, it's not something that you do at the last five minutes of your session. So that needs to be considered during your treatment program. So that's so important. And sometimes the family feels so frustrated because they can't do and they can't do because they don't know how to read the child's cues. For example, they don't know how to read the stress signs and they think, oh, I'm not applying any pressure to it. But then the child, it's super stressful. But for them it's how the child is at table. So teach the parents to read the child signs. Having a time with the parents without the child. So you can have, you can now you can have like online sessions if the parents cannot come to your appointment, but you can have online sessions. You can record this online sessions if they allow it. So you can talk with them, you can show them how the child is doing and then give them tips. Okay, what are you seeing here? Oh, that's okay. Can you see that face? Can you see this movement? Can you see that the child turns the face away. So this child is communicating something. And then recently a family, a mother told to me I was seeing a boy, he was two years, two and a, two and a half I think two and a half. And then the mom told me, I never heard him saying that he loves me. And now he tell, he tell me all the time, mom, I love you. Because they were always in a battle about feeding. So feeding is not just about food. And then we, when we can bring this to the therapy, when we can bring this to how we are going to talk, how we are going to, we are going to address specific food, we are going to make change, we are going to, but we are going to think about change in the environment, we are going to think about change in the food, in the presentation, in the exposure. But first of all we are going to look at how this relation, this dynamic, it's going to, it's being building.

I love that. I love that. I think it's so important to just keep having these conversations because another thing you mentioned early on was that like we don't, we don't get this training as therapists, right, like in counseling families typically. I actually I have to take that back because in my grad program I did have a phenomenal counseling course. It was like a one credit thing though. That should have been like way more than what we got. But I was so grateful for it, because I had the most phenomenal, phenomenal teacher in that course. And we role played a lot. And so she had us in the position of the family, in the position of the therapist, giving us different scenarios. And it was sort of like very impromptu, where she would give us a piece of paper, we'd have to go up in front of the class and actually try to implement some of what we were reading. And it was hard. It was really hard. But I think it made me such a good therapist. And that's something that we're trying to implement in the. The certified pediatric feeding therapists, you know, not necessarily the curriculum itself, but in some of the larger group calls that we have where we will present certain topics and we will, you know, kind of go over counseling and we can like, do some role playing and talk about how to discuss this with families. Because I think a lot more of those conversations need to be had because I don't, I don't think, think, you know, I have my own private practice too. I have therapists who come to me for advice sometimes who are like, this is what I got from this parent. How do I respond? Right? And, and look, there's an art to writing emails and being very delicate, right? But there's also an art to having conversations over certain topics. And we had a very interesting scenario recently where a child has had a lot of oral work, a lot of dental work. And the parent was very uncomfortable with us doing an oral exam. And the therapist is like, hallie, how do I do my job? Like the kid, you know, we're working on speech, we're working on mayo, or we've got some this going on and that going on and all these other things. And she's like, I don't ethically feel like I can do my job without an oral exam. Like, I need to see in that kid's mouth. And so I was like, well, maybe we can talk to mom. Like, let's let her get comfortable with us. It doesn't have to happen in the first couple sessions, but like, let's ask for dental records. Maybe they can send some dental records so we can kind of see what the teeth look like without actually looking in the mouth. We'll have an image, right? There's ways that we can sometimes work around it and get information need. And in other times, it's just a matter of kind of time, right? And so it. We ended up getting permission to do some of the oral exam a couple sessions in. And the therapist said, you know, look, I'm not Going to make it medical. I'm going to make it very fun. We're going to play in a mirror, we're going to play a game. We're just going to imitate each other and I'm going to see what the child can naturally do without, you know. You know, and I think that kind of put this parent at ease a bit and everything ended up being fine. But it was interesting to me because the therapist was kind of like, how do I even do my job? And I was like, you're not wrong. Like, at the end of the day, like, we do need to get in there and look at, like, the physical limitations that we may be working with so that we're not asking the child to do something they physically can't do. But, like, we have to massage this situation because this is this. We have to meet the needs of this family, you know, and also try to meet the needs of what our license and our ethics require at the same time.

Yeah. And it's, it's tricky because we are, we learn that we need to look at the mouth and we, and we really need, we really need. We really need. But what we are saying now that we can do that without necessarily at the first moment putting our hands inside the mouth. We can do that while they are playing. We can do that while they send us a video, a photo this family can show us on phone, maybe this child eating during the meal time. So those things are very interesting. And also I believe that's a change of perspective and it's a way that we are building feeding challenge, feeding therapies. We are building this process, we are building this journey, and we are always adapting. We are always learning new things and trying to put the puzzles together to see how it's going to work best. But if you keep our eyes on how this child's feeling, how this family is feeling, and we use what we know about our practice and we have this balance between them, if we can align the treatment, align our goals with the family, we are going to have a successful therapy. So I think that's a big point.

Yeah. So will you tell us a bit about, like, what do you do when you're treatment planning? Right. So you've got, you've done your evaluation, everything we've talked about. We know that it's kind of an ongoing thing, but we've got enough data to maybe set some initial goals. We know what the family's kind of looking for. Will you just like, share with us a little bit, like, some ideas, tips? Is, I Feel like I can hear people going, like, okay, guys, this is great. But like, what do I do if I feel like I don't have enough or I haven't completed my evaluation? Like, can I really make a treatment plan? Like, any thoughts on that?

Yeah, sure. I like to think about the idea of having general strategies and specific strategies. And then I'm gonna have information about what this child needs first. I always, always start looking at the routine, how this child is doing during the routine, how is this family working, how many meals per day this child is having, what kind of food this child is eating, what are the comfort foods. And then I'm going to start understanding the context. And I call this like Viviana, call this like general information and general strategy. Like, I'm going to think, can I change something in the environment? Can I change something? What change I can do? And I'm always going to start with the small change. And then I start with the small chaining routine to see how the family adapt to this change that I'm telling them to do. And then after that, I'm going to have a session with the parents to see how the first strategies were going. And then the parents told me, oh, Bibi. And I think that's going to be nice. This is not working. This is working. And then we are going to see, when they start doing, we are going to see what's going on. Do we have problems? Do you. Do we not? What's going on? And then I'm going to the specific strategies for this child. When I talk about the specific, every strategy is unique for each family, is specific for the family. But when I'm talking about specific, I'm thinking about a specific utensil, I'm thinking about a specific food exploration. I'm thinking about a more specific feeding thing than just the routine or. And it's just not just, it's like a big part of. It's not just. But I always start the treatment aligned as. Okay, I found this on the evaluation. What's my priority now? What I need to address first? And I'm going to address that, starting with the general strategy. And then we are going to the specific strategies and then we are going to see. And then in this specific strategy I'm going also include do I need to see this child once a week, twice a week, who is going to see this child? So that's going to be specific, but general strategy I can do at the first time with the parents. So I'm gonna. I want you to try this once a Day or depends on what I have and the evaluation what I found. But then starts with the general and then go to the specific with specific adjustments. And we talk a lot about responsive feeding therapy. That's something that's coming up very strong. And I like to highlight the difference between responsive feeding therapy. That's an approach and being responsive. We can be responsive without doing responsive feeding therapy. Because if I want to do a responsive feeding therapy, I need to follow the guideline of responsive feeding therapy, which are five values. And then we have the document, the white paper and that's going. We need to specific doing this. But we always can be responsive to the child. And that's the base of everything. Because being responsive. And we are going to do the dance that you mentioned before. We are doing those dance and then we are creating opportunities. So the child is going to show us what they can do or they can't. We our role as therapist, as parents, as adults. We are going to show them opportunities and they are going to decide if they want or they don't want. And that's a big thing. When we think about strategies that people ask us, okay, but what kind of play I do, what kind of food, what kind of utensil? And the answer is not what the most people wants to listen. It's like depends. Depends on the child, Depends on the needs. Yeah, depends. That's the. That's the answer. And then we are going to figure out the specific strategies.

Yeah, no, it's. I'm laughing because sometimes people ask questions and we go and like Ramiel will even say, oh, you guys are gonna. You guys are not gonna like my response. But it depends. So it kind of became like a running joke because it's like, well, what else is going on and how else are they presenting and what are the current needs? It's like so many questions. And obviously like when you have a kid in front of you who you know really well, like then we can start to get into the nitty gritty. But you know, it's like it's. It depends because there's so many factors.

So yes, and we can have like strategies. Like in the course of the treatment, we mentioned the strategies, specific strategies. We talk about how can we change the presentation of the food, how we can make like how can we show the child or the family what is the exposure. We can. We are going to have like signs off by stretch from Marshall Dunkley or we are going to mention those strategies as well. But for that first we're going to understand why I'M doing this for this child. And then you are going to find all those informations and then you can pick up what works for your child. But at that point, the most important thing that I truly believe that you are going at the end of the course and you are going to be able to think clinically. What do you want to do with your patient? And that gives you as therapist autonomy to decide. You are going to be responsive to your child because you know what you have to look for. And then you are going to design the treatment and align the treatment with the family.

Yeah, no, 100%. I love it. I love it all. And I know you also created the third course for us that we mentioned was the pediatric feeding disorders treatment and autism spectrum disorders in particular. Anything that stands out to you, like from that course that you created that you want to share with us, that you know is maybe different than your approach in other with other populations.

I think the most important we used, we still have the unique child with the unique characteristics, with their unique family. But what we know specific actually today, what we know about this population, it's how they learn. And we talk a lot about eating is a learning process. And we are not just talking about automotor learning progression, but when we talk about this population, how they learn about things and then we bring that into the therapy. So if a child is more visual, if the child needs more concrete support for learning things, and then I'm talking about learn at school, learning at home, how this child learn a new skill or how this child learn a new activity or maybe extracurricular activities, how is this child with the new things? And then we bring this into the therapy. I think that's very important part of the therapy, the treatment for autism population. Because sometimes we just think, oh, okay, those are the characteristics of autism. But that's in a spectrum. So if we look at the child, how this child is learning inside as a spectrum, into this spectrum. So we can create a treatment for them in the feeding area.

Yeah, no, I love that. And it is definitely something where we should totally be looking at it across all kids. Right. How do they learn and how can we better best reach them? But it makes me think back to some of my early days as a speech therapist because I was not doing feeding like immediately from the get go. Within the first year I started to. But initially I was just working. Not just working, but working with a lot of language and speech. And I was in the preschool population, in the schools and I was told, oh, we don't do Feeding here. And I was like, oh, okay. And then all of a sudden, like within the first year, therapists went on maternity leave and I inherited her caseload in one of the schools I was in at her, her preschool. Caselo was one of the classrooms with like 11 kiddos and they were all non mobile and most of them had feeding goals. And I was like, wait a second. I was told we don't do feeding here in the school system. Okay. And now I'm like, I've been thrown to the wolves. Like, these were children with cp, with other, you know, with other, other diagnoses where I'm. They have full time nurses with them at school. Like, they are very medically complex cases. And I'm going from like zero to that. Like, and I was like, like, ah, what do I do? And I'm watching like these nurses, like put the kid's head in extension and literally just like pour food down their throat off of a spoon, like, you know, like pureed foods. And I'm going, I don't know much, but I know that is not safe. And so that whole concept of safety like we talked about too, started to come up very early on for me because I was like, I need to learn quick to figure out, like, how best to serve these children in a safe way so that we can make sure that these individuals who are feeding them most of the day are feeding them in a way that's not going to compromise their health, number one. Right. And then I was like, number two, I also want the kids to build rapport with me where possible, like, and, you know, make sure that they feel safe because it's not just a matter of like, whether or not their body is physically safe to swallow this food, but also they need to feel safe, which is, I know a lot of what we've been talking about today and I know Amy talked about that. Amy Williams, in the episode we recorded. And that was a very big eye opening moment for me because that's where I think a lot of my therapy was rooted in, whether it was feeding or not feeding. That's where I started to get down on the floor with the kids, or I sat with them if they were in a wheelchair. And we started to engage in things completely unrelated to our goals and things that made them laugh or smile. Right. You know, if they didn't have language, just things that made them feel good and safe. And as soon as we were able to do that, I was able to kind of see more into their world and interact more with them and they were more willing to try new things or to let me in, right? And so I just think it's such a beautiful thing because I even remember like a language kiddo who was on the spectrum. We, I started working with him. This was like maybe three, four years into me being an slp. And he had a therapist who would sit down, she knew he liked trains. They'd sit down at the table and she would basically make him imitate sounds in order to get a crayon in order to color a piece of the train. And I was like, this is boring. If I'm bored, the kid's bored, right? So I walk in one day, the kid's on the floor spinning something. And I laid down next to him on the floor and I started spinning another one of the toys that he had sitting there that he wasn't playing with. And he looked over at me like, what are you doing? But also like, wow, this person's in my world now. And all of a sudden, like that we had a connection. And that was one of the first times I had met the kid. I had observed one other session where I sat back because we were transitioning therapists. And I just remember, and after that point, it was like he would do pretty much anything for me as long as he felt good that day. Like he sometimes would withhold bowel movements. There was a lot of like control stuff there. And so on those days, you know, we were not going to have a successful session because he didn't feel good and he was preoccupied with something else. But on the days where he was, you know, available, it was very fascinating to see how quickly we went from a child who barely said any sounds to a child who was speaking. And then we started to dive into his food stuff afterwards because that's where I started to get more into like if he trusts me here. Let's find out what mealtime looks like at home because I'm seeing some very bland foods that are hard to digest and the kids bowel movements are interfering with our sessions. So let's have this conversation if the parent is open to it. And they were, and it was a beautiful thing. But child's doing phenomenal now. He's like much more, much older and very successful kid. But it was very interesting and it's, it's ingrained in my brain that early experience because I was like, if it's as simple as just getting down on the child's level and engaging in what they're doing, we, we didn't even talk. Like, we just, I Just started moving a wheel in a circle like he was doing. All of a sudden, you've now entered that child's world and the child is like, okay, you're like me, we can do this. Yeah.

And then when we think, when we start to thinking or looking through this perspective, we are not trying to bring out outside.

Yes. We've entered their space.

Yeah. Because it's like we, I, I see you, I know what you are doing, and that's interesting for me because we always want. Oh, I want you to find interesting what I'm showing you and why you are not feel, feeling or interesting what I'm showing you. So I think this perspective, it's super important. And when we talk about the learning in the autism, I think that's the, the big thing. We look at this child, we know they have characteristics, but the same as I told earlier before autism, their child, what they like, what their strength, what they are good at, what the family, how the family see. And one thing that I didn't mention, but during the evaluation, we have specific protocols that we are going to use and they can help us a lot if it's a perspective from parents or if from caregivers or if it's more a feeding therapist perspective. And that's going to bring us more information that can help us to build a rapport, for example, but also to understand our goals with them. So it's a point that we, during the autism specifically, we have specific protocols that we are going to use and they were developed to this population so we can have this individualized career as well.

Well, I love this. I, I'm excited for everyone to hear your courses and hear you educate and I think, you know, we have a very similar approach. So I'm, I love it, love it, love it. I'm very excited. Is there anything that we, we didn't cover today or anything else that you want to share?

No, I think we cover a lot and yeah, of course, we have 14 hours, of course. So. But we cover a lot. And I'm super grateful for the opportunity to be here and to create the courses for you and to bring this perspective and bring this human thing to the therapy and during this process to being a therapy, feeding therapist. It's a journey. We are in constant movement. We are learning every day, and it's amazing. Thank you so much for the opportunity.

Well, and thank you for accepting and being a part of the team because, you know, we really wanted to pull in other perspectives and, you know, individuals, but also, as much as we could from our graduates, you know, who have taken Feed the Peas and who. We know you're out there teaching. You're out there, you know, you're. Everybody's educating parents to some degree. Right. As a therapist. But you're. You've taken it a step beyond that. We know, you know, you're teaching others. And so I'm really excited and grateful that you said yes. And we have these amazing courses to offer, so we will link them below the episode and everything. But. But if anybody wanted to learn from you or find you and learn about your other courses. Now, are your other courses in English or Portuguese?

No, they are in Portuguese.

Okay. So. Well, because I think that's great. So if anybody listens that also speaks Portuguese that would prefer to have courses in that language, where can they find you directly to access that?

So we are on Instagram @animaalimentari, which is an educational platform for professionals, and you can find us on Instagram and I will be more than happy to answer questions. The videos are in Portuguese, but if you have any questions, you can send us and it will be great.

Awesome. Well, and we will link your Instagram as well with the episode so everybody can very easily connect with you if they're, you know, wanting to ask questions or learn more about your courses. But thank you, Bibiana, so much for today. This was amazing.

Thank you.

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