Episode 32: My Processes from Referral to Graduation

Hi and welcome to episode 32 of the Untethered Podcast. Today it's me, your host, Hallie Balkan. I am a speech language pathologist, a certified orofacial myologist, and a feeding specialist. And I wanted to take time just to talk to you today about my process because I get a lot of questions about, you know, can you do myofunctional therapy with babies and what happens when you get a phone call for an infant compared to when you get a call for a teenager or an adult or a child who's 5, 6, 10 years old. And quite frankly, we have a very specific process in place in regards to onboarding our patients. But I can tell you what happens along that process and different scenarios of how we get from referral client in the door working with us to either referring them out and or treating them accordingly. Let's jump right on in and talk about that process. In my practice in particular, we have an electronic intake that everybody must fill out before scheduling an appointment. Or we might schedule the appointment, but we require that it be filled out within 48 hours prior to the appointment. And the reason we do that is because it goes over all the policies and procedures and all that, you know, junk, all that stuff. But the other half of it is a very detailed case history and intake, asking them various questions. It gives us a lot of insight into what might be going on, what's happened in the past. And yes, even when I'm talking to an adult, I would like to know what your feeding history was as a child, if you're, if you're aware of that information or if you're able to obtain, you know, some information, because that can be very telling. You know, if you could not nurse as a baby and if you had trouble taking a bottle or you would not drink cow's milk or couldn't stomach cow's milk or had issues with certain foods when you transitioned to solids, or you're very, you were a very picky eater growing up and maybe even into adulthood, you are still a pretty selective eater. This is all information that is just as important as the assessment that my team and I do. When we physically look at what is going on in the mouth and we watch you swallow and we watch you chew a bolus, chew up your food and form that bolus. So I share this with you because I think it's very important that we don't skip all of these pre steps that we really take a really great detailed case history, whether it's electronically ahead of time, and what we do is we take it electronically, but then we review it prior to the appointment, the day that they come in, and then we also ask them questions and we probe further based on what's been asked on that or what's been filled out on that case history. Because once, you know, once you have that information, it makes it much easier to dive a bit deeper down into what might be going on. Compared to seeing them for the first time, not having. Having fill any case history out, you know, having them in your office in front of you and just asking the questions, One, I feel that it takes much longer. And two, I feel like in that scenario, most people tell me they don't get a lot of good detail. They don't get the depth of the response that they were hoping for because it's the first time you're talking about it. So maybe it just hasn't really triggered all the things that might come up on a particular topic, whether it be someone's sinus history or somebody's food selection and intake and history and so on and so forth. Dental history. We look at all of these things. Speech, motor, we're looking at all of these things when we look at your history. So that is absolutely step one. Whether you're taking it electronically or by paper ahead of time, or you're doing it in person in your office. My preference, as I said, is electronics. We can just dive in and probe deeper once you're sitting in front of me and we're having that conversation. So that's step one of the process. Step two, or you could even back up and say, step one is the referral. Where did the referral come from? And then step two is the intake and sending them all the paperwork when you onboard them. The referral source is important because some of my referral sources are dentists. And they will say, this person has a tongue tie. So they come with the diagnosis of tethered oral tissues or tongue tie. And that gives me an idea of what we might be looking for. Or I have people who call and say, oh, I went to the ent, or oh, I went to the dentist. Oh, I saw the oral surgeon for something else. And they said I should get a tongue tie evaluation done. Oh, I've been, you know, my child's been in speech therapy for 12 years and this speech pathologists were new to working with her, but she said, we should come see you because, you know, you specialize in this. And we think there might be a tongue tie. So I'm getting a lot of those referrals. Into our practice at the get go, which definitely makes it a little bit easier because we know exactly why they're calling us. But then again, when we do intakes, you know, my team, my administrative assistant trained in how to ask questions and what to like listen for. That might be red flags or kind of certain words that she can go, you know, hey, Holly, do you think this, this child needs a myofunctional evaluation or a feeding evaluation or you think they're tongue, they have a tongue tie? Possibly. Because if the person calling doesn't come out and say that readily, then, you know, we are asking some other things just because we want to make sure that if you're coming in for an eval that we're doing a comprehensive eval, we're not going to miss anything. So in that process, you know, the referral source, that step one, referral source can be very important because it can kind of hone in on what we're going to potentially assess. And then step two is that electronic intake. Step three for me is actually getting them into the office. You know, I treat here in my home office and if you're watching this on YouTube, you can see behind me exactly where I treat. Maybe we'll do a little tour one day on YouTube and I can show you guys how I treat out of my home office and how basically I keep it. Everything is sterilized as you would in a traditional office. Because this is more medical based than some, you know, than just traditional articulation therapy might be. I have a whole closet dedicated to my materials and resources and things related to therapy and a whole other closet dedicated to all my assessments because we also do occupational therapy and speech therapy. And then I've got a whole closet full of toys because when you're working with little kids, you, they need to have a magical closet full of toys so that you can keep their attention. But I digress. So step three is getting them in here, doing the evaluation. And you know, in that evaluation we are assessing everything. We are essentially assessing the myo, you know, the orofacial myofunctional complex. I'm not going to go through that in this recording right now. That is a topic for another day. But you know, we are looking at everything from how they're using their cheeks, their lips, their tongue, their jaw, you know, what does the palate look like, what do their tonsils look like, you know, what does their posture look like, what foods do they. I look at their food intake, I watch them eat a snack. Sometimes I've Used snacks, different consistencies. You know, that's basically my mind. And I also will do an articulation eval or language sample, depending on. But either way, that's kind of a very gross summary of my orofacial myofunctional evaluation. And like I said, we can definitely record a podcast another day and talk about that, because I think I get a lot of questions about how that differs from a traditional oral motor exam. And I think there's a lot of overlap, to be completely honest. But again, we'll talk about that later. So in this process, right, step three, bringing them into the office, having the conversation, doing the assessment. And in my assessments, I. I use cameras. I take photos of everything, and I also take recordings. I take recordings of them doing various movements, oral motor movements, as well as a video of watch. I want to watch them eat. I want to see how they chew, how they swallow. I will ask them to do kind of some funny things when they're doing that, too, so that I can get a little window and insight into what's going on as far as their suction, you know, lingual palatal suction goes, and if they're able to form a bolus and what it looks like after they have a cleanup, swallow. And so I'm doing all these various things, and the videos are really great, as are the photos. But the videos are phenomenal to go back and watch after my patient leave so that I can see what it looks like in slow motion. And, you know, because in real time, when they're sitting in front of you and you're having conversation and you're asking them to do things and you're trying to take data down, you miss a lot. You miss a lot. So if there's one thing you walk away from this episode with, please take videos during your facial, myofunctional and or feeding evaluations, because you gain so much information from those videos that directly help me see how to then go on and create a treatment plan and go out treating this particular patient. Because not everybody is the same. So that's step three. In this step, we're also determining if we think that tethered oral tissues are present and if we think that they're impairing function. And that's a big conversation, right? Because I might get a referral from somebody who says, oh, the child has a tongue tie. Well, I've had families come where three or four of them have what appear to be tongue ties, but only one or two of them really have functional impact, and the other One or two, you know, did not. So it's all about function. Function drives everything. And if you've been listening to the podcast, go back and listen to some of the earlier episodes, especially with any of the myo functional therapists or feeding therapists like Diane Barr, Robert Robin, Merkel, Walsh. You know, I know I'm forgetting names, but the point is. And Michelle Emanuel, it's another really great one. She's an ot. The point is that if there's a functional impairment is not present, then what are you treating? Why are we going to put a tongue under a laser or scissor procedure, A frenuloplasty, a frenectomy, a frenatomy, whatever you want to call it. I will say that locally, generally, frenectomy or frenuloplasties are the procedures that are done with the greatest success in this D.C. metro area. From the results that I've seen, we won't talk about any specific providers on this particular episode, but again, if you've been listening to me for a while, you know who I generally work with because I've also had them on the podcast. So going back to step three, right, we do the eval. We're kind of figuring out, do you think there's a functional impairment? And if there is, what are the next steps? Right, because step four then determines, do we go into treatment or do we go. Do we refer them out first? So when people ask me questions about, well, like, what's your process and how do you do this? There's not one single process. There's probably a web of processes. And if I. Is that a word? Processes? If I were to sit down and actually map this out, which maybe I will do, because that might be interesting to look at for myself. There's probably three general routes that I send people on. One, they either we either begin myofunctional therapy immediately to see if we can either one, to either prepare them for a frenectomy or frenuloplasty, if we think that's the next step. And at the same time, they're then gonna go and have a consult with that release provider. Step or number two, path might be, I'm looking at this child and their tongue is forward or their mouth is wide open, and I have airway concerns, and I cannot treat until we know that airway is patent. We need to know that they can breathe. And if they can't breathe, you know, we're not going to. First of all, it's cruel. It is cruel. Like an Unusual punishment to ask a child or an adult to close their mouth if they cannot breathe through their nose. So we need to make sure that we're referring them to an ENT or an airway specialist that can assess. Usually I will say, please look at their airway specifically. Let's make sure they don't have enlarged adenoids or tonsils. I can generally visualize the tonsils, but I'm not an ent. And so I would like the ENT to take a look and see what else might be going on. Sometimes we also have enlarged turbinates. Sometimes there's other things going on that need to be attended to. So that ENT referral might be my second line of my second process or pathway in this process, I should say. And then the third one is typically referring them either back to the referral source if they were sent by a dentist who does expansion work or an orthodontist. Because at times if I see a palate that is so, so, so like it's really, really narrow or it's really V shaped. And I just think that that individual is going to have a hard time getting their tongue up onto the roof of their mouth. And again, it's not fair to begin therapy when they need expansion. They really need expansion to be done so the tongue can fit up there. There's a really great book that I love and I have it over here, but the book is Six Foot Tiger, three Foot Cage. Okay. And so if you visualize that in your mind, what you're. I mean, go grab it. So those of you watching on YouTube can see this. Let's see. Keep it right up here. Yes. So here we go. So Dr. Felix Liao actually happens to be local to me and we got to meet with him and discuss his book, which was really super awesome. The whole concept, I mean, obviously this is a book, so there's a lot more in it than I'm going to discuss in this immediate moment. But the whole concept is if your tongue can't fit up there, right, it's like trying to stick a six foot tiger in a three foot cage. It just doesn't fit. Right. So you're working against anatomy here. You're not going to gain function, you're just going to build additional compensations. And so when you build those additional compensations now, you just have more to undo later. So, so I will sometimes refer back to the dentist or the ortho and say, you know, since we know this child needs expansion, because oftentimes they will also say that they'll address that and say that, you know, we need, we're going into braces or we're going to go into an alf or a DNA or whatever, or a. Excuse me. But before they go into that, we like to do the myofunctional evaluation and then they can begin expansion. And then part of the way through the expansion, as long as they're not in something that blocks their palate, we can then begin myofunctional therapy so that we make sure they start to get the tongue up to where it should be so that by the time that the appliance work is done, before the appliance comes off the we know the tongue is living up in the top of the palate. And obviously I'm not a dentist or an ortho, I don't do the appliance work. I am not trained in that. That is out of my scope. But as a myofunctional therapist, I really, really love the appliances that allow the tongue to rest in the palate. Resting up against a appliance does not give the same biofeedback like you don't get that neuromuscular re education and feedback because one, the tongue is not touching the top of the palate, so it's not all the way up where it should be. And two, there's just no, there's no sens the tongue and the top of the palate, you can't feel what you can't touch. So, you know, it's really important in my opinion, that we use an expansion appliance. And again, I'm probably butchering the correct terms first. So I do apply apologize to all my dental and ortho colleagues. We want to. I personally prefer an open palate. So whatever helps us achieve that and works for that child's expansion goals and the dentist and orthodontist goals for that child or adult. Because I am an adult who's an expansion. Actually, you know, that's really what's going to give me. In my opinion, that's going to be the fastest route to, you know, taking a narrow palate to a wider palate so the tongue can fit up there so we can gain better function. We can determine if tether oral tissues maybe need to be released because again, if you can't even put your tongue all the way up there, sometimes there's a question not, well, is it because of anatomy right now or like, do we think we're not going to gain function despite dental and orthodontic expansion? So there's A lot of moving pieces to this puzzle. And that's why you'll hear a lot of myofunctional therapists, especially ones who teach, say, it's not a cookbook recipe. There is no cookbook recipe to this whole process. But I do have, like I said, those three routes. Typically you're coming in for an eval and then we're either starting myo, referring you out to the ENT or to an airway specialist, sometimes even for a sleep study. I should add that in there to the second step and then or back to your ortho or dentist to begin expansion before we get, you know, get down and dirty with miles at that same process. Along with those three processes, you may also be getting a referral to a release provider if one of those professionals that you're already going to does not do a frenectomy or frenuloplasty based on your needs. So, you know, we'll kind of add that in there. But that's kind of like along that same path with, you know, phase one or path one, path two, path three that I described. So that's kind of my beginning process right now. Let's say you we're not going to go through like what MYO looks like and all the MYO phases. That is a whole long training and that is not something we can do in one podcast. But what I will, what I do want to discuss is the process for bringing in and looking a infant versus a toddler versus a school age child versus an adult. Right. So I do get providers in my area who will refer infants and young toddlers for myofunctional therapy. And in their defense, MYO means muscle functional means just gaining function. Right. So we're trying to gain function of muscles. Muscle function. Okay. Myofunctional therapy. So by definition, coming from other providers who are outside of this space, it makes sense that they would refer for that. And it is orofacial. I am doing orofacial work. So, you know, some people call it orofacial myology, some people call it myofunctional therapy, some people call it orofacial myofunctional therapy. Some people call it oral motor work. There is a difference between straight oral motor work and the myofunctional therapy. So I do want to put that disclaimer out there. They are not exactly the same thing. There's definitely, I would say that oral motor work is what many speech pathologists might be trained in in school, but most are not trained in the myofunctional therapy aspects beyond, you know, the oral motor work. Now that said, when you're working with a child under the age of four, typically a lot of the therapy is passive versus four and up. It can become more active when the child is able to cognitively meet you where you're at. As a professional who's providing certain instruction and requesting certain things of them, we generally find that to use a more traditional myofunctional program, the child should be at a cognitive level of at least a 4 year old. Can younger children imitate things? Absolutely. But I can tell you there's a lot in my myofunctional program that a four year old probably can learn. It's gonna might take a little bit longer than a 6, 7, 8, 9, 10 year old, a teen or an adult, but they can do it. And I know that because I have a four year old and she can do it. And we are doing that. We have started to work on some of those myofunctional exercises in the first and second phase. She's been doing the first phase of kind of by default for a while just because she's seen me treat for so long. But we have worked on, you know, making it so that she is doing it. We want to make sure she's doing it correctly and to build her, her orofacial structures properly. But I want to make sure that she's really, you know, now that she's actually in expansion, we want to make sure that everything's kind of coming together. There's so many different pieces to this puzzle. And you know, that way we can jump into phase two pretty soon. Because now her expansion is getting to a level where I feel she has enough room to put her tongue in her PA I referenced before, but I digress. So when I get these little babies, right, when I get these infants, I am doing a very different evaluation than I'm doing when I get a one year old, than I'm doing when I get a two year old, than I'm doing when I get a four year old. Most of my four on up clients, patients that I see are coming to me for a tongue tie and or feeding evaluation. The kiddos who are coming to me that are in their first year of life are traditionally coming to me because breastfeeding and or bottle feeding are not working. Things are, you know, it's taking a very long time. Mom is in a lot of pain because baby can't nurse baby, you know, maybe her supply is dropping. She's doing a lot of pumping, a lot of supplementation. There's just a lot of things that go on. It's a very, very different world when you're working with infants than it is when you're working with toddlers. And that's even different than when you're working with, you know, kids who are. So I want to put that disclaimer out there. I don't get into worrying too much about what people call it. I get more interested in describing to my families and my patients what the needs are, what we need to work on, and how this is going to benefit them so that they understand why I'm asking them to do certain things at home between our sessions or, you know, before they run and get their child's tongue tie revised. And if you go back to Michelle Emanuel's episode, she talks a lot about optimal timing of release. And I learned a lot from her personally. Not everybody should just jump right into a tongue tie, revision or release just because you go to the dentist and they go, oh, hey, you have a tongue tie. You want me to take care of that right now? No, don't do that. And I say that because for infants, if they're newborns, then okay, generally okay, depending on the rest of the medical history. There are other factors to consider. But once the baby is in, like, their second month of life, I have a lot. I've seen a lot of children who go for frenatomies with an ent, who cuts with a scissor, and they've had no pre op work, no post op work, and then a month later, they're in my office because they're not feeding very well, or they're not transitioning to solids, or they developed an aversion to the bottle or, or, you know, and some of these things. Let me put that out there. Some of these things were there maybe prior to the frenatomy, but the frenatomy didn't do anything. It didn't help because there was no other therapy surrounding it. And so if there's another tidbit that I can give you today that you walk away from this episode with, it's please, please, please do your pre op and your post op therapy, because that is so important to prep the body. Make sure that, like Michelle talks about its optimal timing, all systems are ready. And then, you know, it's like, you wouldn't fly an airplane with one pilot and on two jets. No. Like, you're not, you're not gonna fly to Europe if you have two jets. Actually, you're crashing I was once on an airplane where one of our, one of our engines went out. One of the jet engines. And again, maybe wrong terminology, but I'm pretty sure that's what it was. I think we have like four, four engines maybe. And one of them went out pretty quickly after we took off from jfk and they said, oh no, we got to go land back in jfk because if we lose, one more plane goes down. So we're way too early on in the trip for that to be okay. So this is the same thing, guys. We're basically taking these babies and taking patients and throwing them in on three jets when they should have four, and then they're coming out with two jets and they're kind of just crash booming afterwards because nobody prepped them, nobody's there to support them afterwards. And this is not okay. This is a major disservice that we are doing to these children and adults in some cases. So I beg of you, if you're a provider who does these releases, if you're a provider who provides the therapy, whether you're an ibclc, a speech language pathologist, an OT doing feeding therapy at any stage of life, or, you know, especially with these little babies, or you're a parent listening, please know that you cannot skip the pre op phase and the post op therapy. Absolutely not. You're not going to get the results. And then it's all for nothing. And now you've put your baby through this experience that you may have to redo or yourself or your other child through an experience that you might have to redo down the road because you were not prepped properly and the compensations are still there. And so now that the tongue is free and we think like, oh, it'll just go where it magically should go. Well, sometimes that happens in the first couple weeks of life. Sometimes. I've seen it happen. I can't. I haven't even taken the data to know if it's 50, 50, 30, 70, 60, 40, 80, 20. I don't know. I have seen cases where the child did not appear to need a lot of therapy afterwards, but we prepped them before regardless, and that's not the norm. Usually my cases who need the frenectomy or frenuloplasty require, require therapy to benefit from that procedure pre op and post op. So I hope that, you know, I know I'm beating a dead horse here, but I hope that this message is really getting through because it's something I'm very passionate about because I'm just tired of, you know, seeing kids get this done and then, you know, pediatricians, like, rightly so, saying, well, that doesn't ever work. Yeah, it doesn't work when you don't do the right therapy surrounding it. It's one piece to the puzzle. So I hope that helps a bit. As far as my process for the four and up crowd, you know, 4, 5, 6, 7, 8, 9, 10, through teens, through adults, you're getting a traditional myofun evaluation and then either being referred for one of those three pathways that I mentioned before or, you know, or sometimes people just want to gather some information and then kind of meet with other providers and see, like, what next best steps are. I do sometimes get kids who are in braces. Like, I really recently had a call for somebody in braces where they wanted to have the evaluation done prior to the braces coming off. And they called us like a week and a half before. At that point, what I'm going to tell you is we are happy to do an evaluation, but if there's a tongue thrust present and myofunctional things going on, and I don't know because I haven't seen, so I don't really know what that particular patient looks like, I wouldn't be taking those braces off just yet. I'd be keeping those on until we get most of the way through the MYO program. And we make sure that tongue is really resting where it should be and is where it should be when you swallow, because otherwise you're just going to shift those teeth right back to where they started. And that orthodontic relapse is gonna happen pretty quickly. Teeth, you know, the tongue is stronger than the retainer is what I have found for many cases. Sometimes those permanent retainers can hold pretty strong. But oftentimes the retainers you just wear at night, if you're not wearing it 247 and your. Your tongue is still thrusting forward. Oftentimes that orthodontic relapse still occurs. So that's a bit about my process. Therapy really ranges depending on the needs of the child and. Or the teen or the adult. And when we're working with moms and babies, there's a dyad. So it really depends on that as well. So, you know, sometimes with our babies, we will see them for a certain period of time, and then we might kind of dismiss them or go to monitoring and just make sure that they transition through each phase with ease. And so if the parent needs any support in moving to solids or moving off the breast or moving off the bottle as they try introduce new foods closer to a year, not at a year, but prior to. So if your baby doesn't have other medical things going on, we all know that the American Academy of Pediatrics recommends starting solid introduction at six months. And some say food before one is just for fun. That drives a lot of speech pathologists and feeding therapists crazy. I don't know, I haven't asked my OT colleagues, but I'm guessing they probably would agree with that too. And so yes, it is for fun. We want you to get messy, we want you to have a good time with it. But there are a ton of oral, motor and, you know, developmental skills that happen when you are interacting with those foods, when you're putting things in your mouth and you're chomping down, whether it be on like a num num spoon or whatever, or a teether or whatever, you know, these are, this is actually, this is developing your jaw, this develops your cheeks, it develops, your entire face develops. And so it's a very important, critical stage to not be skipped. And we don't want you to stay on purees for those six months either. We want you to maybe start there and then move beyond purees so that your child is actually chewing foods by 12 months. So when, you know, when I get a call that, well, feeding has been really hard and we didn't end up, and there were no medical really complications, but we just figured, you know, we had till one. So now we're introducing cow's milk and real food and none of that's been done before. Well, that's a lot to put on a child. So it's, you know, you have a lot of transition time and you build a lot of motor skills and you do, there's a lot of reflux integrations and all kinds of things, developmental milestones, things that happen in months six to 12. And actually I'll put a little plug in it for it. Now we're launching a course in March. And so you guys have probably seen that some of you, if you've opted into our free pediatric feeding screener that we just launched and we have a wait list up for the course, but we will have a course dedicated, an entire 90 minute module dedicated to just that 6 to 12 month developmental period, we're going to break it down to, you know, like pre in utero birth to 6 months, 6 to 12 months and 12 to 36 months because we feel that it's very important that as feeding therapists, you know, what normal function looks like, so you know what abnormal function looks like. And when you are looking for what to work on in therapy. Well, how do you pick your goals if you don't know what your end goal is and you don't know the progression that skills develop from an oral motor feeding standpoint, and you don't know anything about the sensory system? I mean, it can't separate. Lori Overland was one of the first feeding classes that I ever took out right out of grad school. And I remember she was the first person who said, you cannot separate the oral motor and sensory systems from each other. Right. They're intertwined, but everybody teaches it as if they're two separate things. And they talk, people talk about it like you can treat them separately, but really you can't. So we have to know how they develop separately, but we also have to know how they interact. And we have to know in treatment the best way to work with children, because the last thing we want to do is create an oral aversion, right? I mean, I know that's everybody's fears and like, we don't want them to choke, we don't want them to develop an oral aversion. We don't want them to hate food because something that I did in a session. So, you know, that's something that we're going to really dive into all of the above in our course. And so if that's something that you feel like you need more information on, I highly suggest you go to feedthepeds.com and you can jump on the wait list to learn about when we open our course that will launch in March 2020. Okay, so. So getting back into it, the whole point of this is that feeding therapy in infants looks very different. And we need to be aware and we need to educate our families on when to introduce solids, how to introduce those solids. You know, yes, food should be fun, but that's not the only purpose, right under a year of age. So just something I like to put a plug out there for because I have this voice and I have this platform. And I think it's. It's very important that everybody know your calories are not necessarily needing to come from the foods. So that's, I think, where that food before one is just for fun thing developed out of is that, you know, your calories should still primarily be from either breast milk formula or a combination of the two, depending on how you're choosing to feed your child. But as they get closer to a year, that starts to shift. Right. Once you hit a year that shifts. So we want to be prepared. We don't want to just throw the kids into the fire and go, okay, go, go eat. You're to going. Because oftentimes that's a mess. It doesn't always work as planned. So that's my little disclaimer on that one. All right, what else can we talk about? So we talked about infants, toddlers are. We do a lot of play based feeding and we will teach on this in our course. But I will give a plug for Melanie Potok and Diane Barr because I think that they work a lot with little guys and, and Melanie Potok has some fantastic resources out. She also just recorded an episode with me. So go back and listen to her episode where we talk about her new children's book. And in the show notes we also included her various different texts that she's put out, like Raising a Healthy Happy Eater. I think that one's with Namali Fernando, the pediatrician. And also Adventures in Veggieland, which we really love at my house. And I'm looking at that book right now. Just shared it with a client the other day, a patient, because their child is very picky and you know, it makes a very fun approach to exploring vegetables and not always expecting that they're going to be touching them or eating them or licking them the first time they explore them, which a lot of feeding therapists expect in a session. So I think it's a great resource for therapists and parents and teachers and anybody working with children that are, you know, I know some people like to call picky eaters. I like the term select eaters the other. So going beyond those kiddos on into the older crowd, I'm not doing a lot of the medical based, you know, and yes, I do is medically based. But I should say the medically complex, I'm not working with a lot of medically complex, you know, school aged teens and adults when it comes to feeding. And somebody would argue that maybe some of the adults are more medically complex. But when I say medically complex, I mean with a diagnosis of cerebral palsy or, you know, I do work with people with autism trying to think down syndrome. You know, I work with little ones with down syndrome. I don't really typically work with older adults with down syndrome. So, you know, that's just some food for thought. Just so you kind of know where I'm coming from in my background. But typically for on up, I'm generally working on expansion of diet with the little ones and some of the school aged kids, but only after we've done the myofunctional, or let's say like 2/3 of the way through the myofunctional program. Because now I know they have the skills to actually eat those foods. So I'm taking a very myofunctional approach to working with them. And once we, you know, when we go through this process, I have adults who are done with myofunctional therapy in five weeks. They just fly through. Because with an adult you can sit, you can do a lot of things with them and you can give them homework that they can very easily, you know, do very quickly. Doesn't depend on somebody else telling them to do their homework. So it's just, it's a different beast in that sense. But you know, I can often get my adult patients who are super compliant in and out very, very quickly. Whereas with a four year old they could take six months, with a ten year old, maybe four months, with, you know, and these are just guidelines. I'm not attaching a timeline to anything. I'm just telling you in my practice what I typically see. And I have actually sat down, looked at the data in the past, not recently, but in the past to see how long does it take me to typically go through my MIO program with somebody and kind of take them from assessment to, you know, graduation. And when I say graduation, I mean from the sessions. Because then I do go back and I do a three month follow up to make sure they're maintaining their skills. And if they feel necessary, you might do a session, six month follow up and, or a one year follow up as well. Because I want to make sure too, if they are, if they do have appliances or any dental work, orthodontic work during or after, I want to make sure that everything's still holding, if any changes have occurred. But also, you know, if they had just gotten their appliance off around the time they graduated from myo, I want to make sure that the tongue is where it's supposed to be and that's holding too. So anyways, I wanted to, you know, kind of hop on here and just share my process with you. I hope that this is, is helpful and something that will kind of help direct you in your area. You know, in many of the episodes we've also talked about the importance of collaboration with other professionals. And so building out that team really makes this way easier because when you can just, you know, get, get consent from your patient to consult with on their case with a provider and you can then, you know, send them an encrypted email and say, you know, know, hey, you know, here's the, here's the evaluation report. Oh, hey, you know, they said they're coming in for their release on this date. You know, please update me on the following. You know, there is, there's a dialogue that goes on, right? My providers tell me when they're referring somebody and when the, you know, the procedure has been completed, I get an updated note for my files. And so we're just, everybody's on the same page. And that really provides the most comprehensive service, the best patient care and really the most efficient care as well. Because everybody, you know, on the same page and kind of talking the same language or we're going, well, hey, what do you think about X? And we have this open dialogue so that we're collaborating, which is so important. So again, I hope that learning about this process is helpful and I look forward to doing more of these one on one episodes with you and answering any questions and sharing more about my process. If you have any struggles with, you know, feeding therapy, myofunctional therapy, understanding tethered world tissues and how it plays in, you know, really when it comes to pediatrics, also just building that team, creating treatment plans for feeding patients, you know, all of the above. And you're like, I don't really have a good assessment tool for feeding and I don't really know how to write a report template. This is what that feed the peds course that I mentioned before. This is what it's going to give you. We're basically pulling together everything I wish I had 10 years ago, prior to me taking the past 10 years to create it all. And so what you're getting in there is that, but you're also going to hear from a variety of speech pathologists and occupational therapists, not just me, there'll be two other speech pathologists and two occupational therapists also teaching the courses so that you can hear from different people in the different areas that we each specialize in because some of us have had hospital and NICU based experiences and others of us work in schools or have worked in PICU or have worked, you know, we just clinics, we have all different experiences across the board of where we've worked as well as with the populations that we've worked with. Some of us with more myo and tongue tie, others with, you know, IBCLC feeding type of an approach or CLC feeding and even others with, you know, we've got the OTs who do a lot of sensory based feeding and have some really great experience there and work a lot. You know, they'll talk a lot about positioning. And so there's just so much in the feeding world that it can be overwhelming. And so we really want to take it and do this course so that, you know, we can help anybody interested in becoming a feeding therapist that is in that is an OT or a speech language pathologist, an SLP or occupational therapist. We want to help give you basically the information and the tools so that you can kind of jumpstart that career for yourself or continue down the pathway with more confidence and more competence so that you are able to help more patients. So I hope this process was helpful today. I look forward to chatting with you guys soon. This is Halle signing off.