Episode 98: A Holistic Approach To Pediatric Feeding Therapy with Lori Caplan-Colon

Hi and welcome to episode 98 of the Untethered Podcast. Today we have Lori Kaplan Collin joining us. Lori is a New Jersey State licensed ASHA certified Speech Language Pathologist with over 18 years of clinical experience. She obtained her BS in Speech Pathology Audiology from Ithaca College, New York. She earned her Master's in Speech Language Pathology at the Massachusetts General Hospital Institute of Health Professionals. She's completed the year long program at New York Medical College, achieving an advanced degree in Pediatric Dysphagia. This fall she'll embark on a new journey with the IAOM which is a track to orofacial Myology certification. Lori is committed to ongoing development of proficiency in the skills of both her staff as well as herself. She's extensive background in areas of oral, motor and feeding dysfunction. She's trained to use prompt. She's trained through Level 3 and Talk Tools and is proficient in SOS. She enjoys success working in the area of tethered oral tissues and in working with picky eaters. She's a three time ACE Award recipient as well. Quick Disclaimer all information, content and material of this podcast are the opinions other of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist 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, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Laurie, thank you so much for joining me today on the podcast.

Thank you Hallie for having me. I'm excited to be here.

You know, when I saw your article in Asha Leader and I looked through it, I was like, ah, we've got to have her on. So I'm really excited that you said yes and I'm excited to just dive into, you know, all things pea feeding today.

Yeah, me too. Thank you. That article has gotten a lot of people contacting me and it's been really exciting for me as well and I'm just so happy that people are finding it really helpful because that was the intent of the article.

Yeah. So hopefully, you know, the conversation we have together today will also be helpful for any clinicians out there or maybe even parents who might be listening who Kind of want to understand some of this better. One of the things that I did in a free training I gave last week was I talked about how parents don't even realize that SLPs and OTs do pediatric feeding. Like sometimes they come to us for something else and we go, hold up. There's a bigger issue going on here when we actually screen them or eval them. So I'd love to just jump right on into talking about recognizing when we evaluate them, what do we need to be looking at. I know that you talk about sensory and motor and looking at their medical history also including behaviors. I mean obviously we could talk about those things for days, but recognition of those things. Let's start there.

Sure. So in our office we have an intake form and it's pretty lengthy and we think we try and get out the big picture of the whole child. So we go through the milestones and the history and then we go in like their daily like schedule and things like that. And I don't necessarily think that the parents who are, when they're writing it really realize how much information we're getting out of it. But even with that all on paper, then you meet the child and it's a very different story too. So when they come into our office for say they're concerned about maybe just the overall like delays in language or you know, speaking challenges, you know, when we, when we're looking at the child eat and we see, you know, if. Because we'll often tell the families bring in preferred and non preferred foods just to really get an idea. And so we're, we're assessing, you know, how they're responding just when they're you know, seeing the food or how their body is in space and if they're like in that optimal position and how the, you know, so you know, the. I'm so sorry. So sorry. I'm like I lost train again where I was going. Sorry Hallie.

No worries. Hold on, I'm going to pause it. Okay, so we're going to restart here on the recording. Perfect. So let's start with talking about looking at the child holistically because that's something that we really do as well over in my practice. And you know, everything from just when, when that child presents to you from intake to actually seeing the child, screening, evaluating, whatever you're doing. I know that you have highlighted that you like to look at everything from medical history to how the child presents in front of you, sensory, motor, all the things. So can you just talk to us about what that process looks like for you and what you're really looking for?

Sure, yeah. So, you know, when a child is coming in, I often, you know, I tell other therapists in the practice, and I'll tell, like, our families, we really want to recognize that the child is coming to us with all of their past experiences, which includes the, you know, their medical history and any, like, organic reasons for any feeding challenges, whether that be, you know, tethered oral tissues or GI issues or anything that may have happened to create any, you know, whatever their experience was with feeding to start, right. That set them up for their future feeding experiences. We also want to take a look at. After looking through that medical history, we want to look at the child's sensory system. How is the child reacting at all senses to foods being offered, the way it feels, the way it looks, the way it smells, how are they responding at that time? That's really important as well as a speech therapist looking at the way their mouth is working, how can they manipulate food and how can they break it down in their mouth, and what are the motor patterns that they're using with the foods that they are preferring? And with all of that being said after we've had a handle on that, and that feels controlled, we do have to look at that behavior piece. Right. Which is something that I've only recently really started to establish and understand because for a while I was so involved, like the SOS approach. And I love it. I think there's a huge place for it. But oftentimes, like a lot of other therapists who do look at behaviors, will say that you get to the point in that hierarchy where they're just putting their mouth and they're spitting it out or things like that. So I love all things Melanie Potok, and I love that she, when we had her come to our practice, she did her picky eater course. And so that was the missing piece in my practice, really recognizing that, yes, a child comes with all of those medical, sensory, motor issues, and because of that, the behavior is a result. These behaviors are serving as a function for these. For these kids. And we really have to. Then once everything is handled, we have to treat those behaviors, whether, you know, we would like to treat them in positive ways, but really working on those maladaptive or those mealtime behaviors that are not serving the child or the family. So all of those things that we're treating and we're looking at on day one, and we're working toward improving everything throughout the course of treatment.

And I love that, and I love how you highlighted behaviors, but you also highlighted that they're a product of the child's history. They're not just magically appearing out of nowhere and standing on their own as the main issue of this feeding, you know, this feeding disorder. And I say that because, you know, there are other practices around us and even hospital systems that treat from a behavioral, like a. Solely a behavioral standpoint. And they're just missing the boat on so many levels. And quite honestly, these kiddos, at least in our experience locally, develop further aversions to their foods because then it gets into, like, forced feeding, which is like a big no, no. In my book, we follow the child's lead, but we also make it a very controlled situation so that we have. We have control in a sense, but the child feels as though they're in control at the same time. You know, there's just definitely this, like, dance and find balance. I also love Melanie Poe talk in her courses. And, you know, I really love that there are other professionals in our space who, who are talking about behaviors but recognizing that they come from something like an oral motor issue or the sense something with a sensory system is going on or their past medical history. I mean, there's something. There's some antecedent to that behavior. Right. So that is, you know, so I get, like, chills talking about it because I get excited. Like, I was like, ah, I love this. It's. You know, we can't change that behavior unless we deal with that organic issue that caused it. However, we still need to address it in therapy. So, like, you're saying, like, there's this just find dance between the two things.

Exactly. I say that all the time. And I think what I love about, like, Melanie's approach is that, yes, she does treat the behavior in sometimes a very ABC fashion. Right. When you talk about that, however, she makes it so fun and like her books and the way, you know, I think that a lot of not only do our kids come with their behaviors, our families come with their behaviors and how they are perceiving mealtimes and the stress level of these families. And, you know, I'm. I don't have any boundaries and I really should get better at this, but my families are texting me and emailing me and, you know, we try to use like, you know, HIPAA compliant stuff. However, like, the things that I hear and the things that they're sending to me and, like, I feel their stress so, so much. And it is like, I. If I can just. I. If I can just, you know, Reassure them, you know, that it's going to get better if you just, you know, it takes a lot of time. I think that the family is, it just, it means so much and I just feel it makes. I'm so passionate about what we do because I know how much great, what the great things that we can do for our families. But it does take time. And that question of time. It's like we have to undo all of those negative feelings and all of the experience that they came to the table with before and really start to work on the other skills while addressing the behaviors as well. For sure.

Absolutely. And you know, how do you educate the families aside from just telling them like this is a journey and this is going to take a long time. So I'm sure they're tired of hearing that from all of us. But how do you really educate them on how all of these things that we've kind of touched on how that influences the child's meal time or eating just a simple, what seems like a simple snack. Right. Because it's so stressful for the families and we take that on as therapists. We feel that for them. But you know, they're living at every moment that we're not there as well. So, you know, is there. I know everyone always asks me, like, how do you convey this to a family? Because we know it's not just a quick, easy fix. It's going to be a journey.

Yeah. So I think the big thing I try to always do is really highlight. Okay. This is like, these are really big successes here in this little 30 minute session. You know, he was able to accept, touch or accept whatever it was. Right. I mean, we start so far back sometimes because of all the previous things. I have kids coming at over three who's never eaten anything. They're, you know, depending on their tubes. So, you know, I know I feel like the stress. Right. But I really, I'll highlight it in the session and I'll follow up with emails and I'll say like, this is great. Keep doing this until I see you like hopefully in a couple of days. Right. Obviously always insurance dependent, but sometimes I get really lucky and I can see clients every day, which is just amazing. And I'll say practice this till tomorrow and just do this because the families, you know, they want to go really fast and then it just doesn't. Then you're like they're undoing something. So I think the biggest challenge, I think for some of my families is understanding about the gain permission, dilute, worry kind of Approach, we have to make this really fun. They have to be friends with the food and they have to really trust the process or else they can continue to reject and continue to not accept. And we need to teach them that this is a responsive kind of thing and there are rules. Right. And we're going to get there. But first we have to make them trust us and get friendly with the foods again.

Yeah, absolutely. And I think that's also super important. And I know that, you know, you mentioned you get to see some of your families daily and that's, that's awesome. We, you know, we sometimes see our families twice a week. We sometimes will see them once a week sometimes. It just depends. Like we don't take insurance. So oftentimes, you know, if we have a family who says, hey, can you come? You know, X times per week and they have the means to do that, by all means we can, we can make it happen. But I think that realistically, like you're saying sometimes it's insurance dependent and you may only see them a couple times a week or once a week.

Do you.

Well, I love that you give them like, you really highlight like, what's working. I always teach my therapist. I'm like, let's use a sandwich approach. Let's talk about what's going really well. You know what, they're still really struggling with X, but we're going to focus on this and kind of like end on a positive note so that the family feels like they've got that to hold on to. Because I think that we, we are empowering the family just as much as we're empowering the child. And if the family feels defeated, it's not going to go well between sessions.

Yeah, yeah, that's for sure. Yeah. So I, I will make, you know, like, I'm not good with tech at all and some of my younger therapists are really great at it. So I'll say, remember that, you know, homework, that food log that you had or whatever it is, can you like pass it over here so I can send it to my family? Right. It's, it's really. And I think some of the families are really surprised at how small the steps may be. Even if it's just like, I mean, we're just working on touch, like just gaining permission to touch cheeks. Right. And that's what you're working on right here, Right? If it's, I use like a freckle size volume, I'll say it's like a freckle, like, because if I say a Freckle, they're going for a pee. And I say, no, it's a freckle, right? Half of a freckle, right. Just to get it to her lips, like let them like these underwhelming volumes. I feel like has really. It gains like the client's confidence too, right. And then you're like, okay, so you handled that. Let's move it on up. Right. And like slow and systematically. I feel like as long as I feel like the families, if you stay on top of them most of the time and you say, here's where we are, this is where we're going, but stay here for right now. If they listen. I'm a constant in contact with my families and we have so many families coming into the office. I can't stand top of all of them. But for our feeders that are coming in, I'm really trying so hard because I know that if something just doesn't go right, it sets us back so far in the feeding world. So I try really hard and don't sleep much because I'm just trying really hard to stay on top of them. But I think when the families trust us and like, obviously, you know, the, when word of mouth and things are going really well with other clients, they're hearing like, this is, you know, this is going really great. That's really helpful. So they really trust us. I think our reputation has gotten to a place where people trust that we're going to help these kids. Whether it be, you know, four sessions or 400. Right. It's really, I think it's powerful for the families to know that it works. It just definitely takes time and lots of homework.

Yeah, no, absolutely. And I think being realistic with the families and just kind of setting that, you know, understanding up front is so, so super important. Now you mentioned tube, you know, kiddos who are on feeding tubes. Is that a bulk of what you work with or do you have like a mix of feeders? Like what is your typical population in your practice?

So in my, in my personal practice, I feel I am getting. Which I just love right now. I'm loving. I love the feet, I love the tubes as well as like, I love those 7 month old, 6 month olds, 8, 9 months, where the parents are. It's just so sweet. They're like, okay. Our doctor or pediatrician said, or RD said you can start at six months. And then they like, you know, they try for a month and it's just not happening for whatever reason. And it's like. And they really get so Stressed out. And I see the greatest amount of like progress with just, you know, just a little bit of coaching whether, I mean, if there's tethered tissues or something, obviously that has to kind of, you know, we have to rule that out and take care of that pre op, all that stuff. But when it's just like they just didn't get it together. Right. Their reflex like hasn't integrated or something and just working on like even like oral placement and like, you know, diluting the worry and getting all playful and stuff. It's just, it's so cool to see and through telepractice, a lot of my clients are coming in that way right now. So I get to see it over the screen and see my families and like, I mean he choose. It's like, it's so sweet to me to be able to be part of these moments even if there's like a screen between us. So like those little beginning, like transitioning to solids. Right. Is a big part of my practice right now. It always evolves. I love that population as well as like the really involved medical ones who are on, you know, tubes for whatever reasons and they just haven't ever gotten to the point of po. It's really great. It's if I feel like you get the most success with the younger because they haven't had that much. Right. Negative stuff or you know. Right, right. So, so easy. I love, I love fast results, but I get it when it takes time as well. And so the more involved. Right. I like that as well as like those little guys. But we get the whole, we get the super picky eaters too and like the elementary school kids who have about five foods. We get kids that are like, they are picky but then something happened like a GI bug and now they just drink milk and it's like, then we pick up those and try and gain those foods back and make plans and stuff. But so yeah, we have a whole range of clients coming in.

I love it. And I love the little infant ones too. Personally, like I've worked with, you know, across the age range, but my, my expertise was always like the infant toddler range. And I agree with you. If you can get in there early and start tweaking things, you know, they've got less to unlearn and more room for play. Yeah, I just, I love, love that age group. So let's talk then about, you know, since you do have some kiddos who are on tubes or we've got kids who have basically taught themselves to survive on milk or on less than five foods or whatever the case may be, a lot of the time they just don't get hungry. So what are you doing to teach hunger?

Yeah. Yeah. So, I mean, I. It's always, you know, they have to have these conversations with their medical team and things. And I find being in, like, a private practice and, you know, I have a lot of great people to refer to. However, getting in touch with people are coming from, you know, chop is wonderful. There are a lot of really great hospital, but, like, getting in touch with those different, like, partners of the, like, on the team is a little bit challenging. So it's so much of me trying to get the family to, like, get these threads going. But once that, you know, that medical piece, when everybody's on board and as long as it's okay, I like to be able to establish, like, a hunger satiety schedule where, you know, the child hunger is the number one thing I feel like where a child is going to need to, you know, to eat and come to the table, right. So I want. Again, that's a hard conversation because our families, you know, kids are like, they're getting 70 ounces of milk. Like, oh, my goodness. Well, can we make some room in there, right? Can we come, you know, so getting a schedule, and I'll always use Melanie's toolbox and saying, like, this is what toddlers should be doing, right? Every two to two and a half hours, we want them coming to the table, having positive experiences, but also feeling hunger. So, like, my little ones who are on a tube, like, I want them to be sitting in their feeding chair and getting their, you know, feeds and also playing with the food, you know, making meals, making that like their meal time, right? But bringing them to the table during the other families, even if they're not eating right or just, you know, playing. But so getting the. I think getting the family to accept that maybe even if they're not going to take the total volume that they were taking days before, I think getting the families to understand that it's okay because we need to make space in their bellies and we need them to get. We need them to have that hunger to want to eat because they really haven't wanted to. So we need to. We need to teach them that. But that's a tough conversation. I don't know how, like, it's. It's definitely ongoing and always checking in and being so respectful because, you know, as a, you know, I have two and my. When my daughter was just a few days old, they threatened to put a feeding tube my daughter because she wasn't gaining the exact amount that she was gaining. I felt like. I remember it was just for a few. Like, it was a little bit. But like, that lasted for a very long time, for years. When the pediatrician was like, I felt ashamed, like I wasn't doing my job. And I can't even imagine what that failure to thrive diagnosis feels like for families, but it just really, truly does. I read it somewhere like, you're a failure to parent, and that is like, you know, it's just. It's a horrible thing. Right. So it's like, I have to be so gentle and so respectful and, you know, come with an expertise and let them really trust me so they understand that. It's like, trust me, we're going to get there. Right. But it's such a hard conversation. It's ongoing in my practice.

Yeah, well. And I can't imagine how these parents feel. Even though my first one, who I've talked about at extreme length and who I use as our Screening Kiddo at 4 years of age in my pre training I did last week, and she was that kid who dropped from. You know, she dropped more than the 10% or whatever that they're allowed to drop before you leave the hospital. So immediately we go to the pediatrician the day after we get home from the hospital, and of course, like, lactation checks her. They say there's no ties or anything. I wasn't even really in the Thai world at that time, so I was like, like, okay, whatever you say. If there's not an issue, there's not an issue. But she never got over the first percentile her full first year. But she was on her own growth curve, so the doctor wasn't concerned, however, and that those first few days, this was a time where, like, everybody was getting online with their EMRs and parents had access to medical records at a drop of a hat. Like, you could just log in. And they didn't say it to me, but I logged in and I saw her coded for failure to thrive. And I was like, what? Like, I was beside myself. I was, you know, and that was, like you said, it was just a couple days worth, a couple of weeks. It wasn't a. She wasn't going on a feeding tube. There was no talk about that. Nobody even said failure to thrive to me. But when I read that on her medical chart, like, my heart literally fell out of my body. And I was like, I am failing her as a parent.

Yeah, it's so Ridiculous. It's so, so, so, like, it's so anxiety producing. I know. Like, I. Same with my daughter, but I just. It lasted for years. And like, I look back, I think, like, everything I teach my. My parents now, you know, my daughter's 11. She'll be 12 in June. And I think, like, I messed up so many times with you. I'm so sorry. Like, I really messed up. Um, but it's, you know, I. It all came from, you know, it came from like this. I was parenting from fear, right? And I was. Had so much anxiety about her, like, gaining weight. And I would get on the scale with like, why are you not? And like, when my family, like, I have kids now, probably weighed more than, like, they're under one, they weigh more than my daughter did at three. And like, it breaks my heart that like now like, all she. I worried so much. And now, like, I don't want to say it too loud, but like, she thinks the opposite now. Like, because there was such a hyper focus on food. Like, she had like this very young age thinking that she was overweight, which is so crazy, right? And I just like that because it's just such. It was just not. It wasn't like, what. How I designed my programs to look at this point, right? And I just, you know, I messed up. So now I'm spending a lot of time undoing all of that. And like, I talked to, you know, therapist to help me on the other side of like, you know, just dealing with that part of it. But for her, because it's. It's just like, it's so much of, like, part of like, you know, food is everywhere, right?

Because it's part of everyday life, basically. You need to eat and breathe to live. So that's why it's such an anxiety, you know, provoking topic. And with Lily, I remember they were like, well, you need to feed her formula. Like your milk hasn't come in. And I. What I didn't realize was my milk had come in. She wasn't pulling it. And so hello and tongue tie, lip tie, but whatever. Yeah, you know, so here I go, I go home and I'm like, beside myself because I have to give her a formula, which wasn't in my plan, but okay, I want to feed my child, so let's get her fed. And this was before I even saw the chart. And so we give her, you know, the formula and she screams bloody murder for three hours straight. And I'm like this mom who's like four days postpartum, my mom is sitting next to me. It's like two in the morning. The baby's crying. I'm crying. I'm like, this is horrible. Like, this is not what I envisioned this to be. Who knows what it's going to be after having a baby? And, you know, and so I was like, that's it. I'm not giving her that again because it's making her scream something is wrong. And then I call them in the morning and they're like, well, come in and get, you know, Gerber. Good start. That only has one milk protein, the Simile Cat 3. And I was like, so what you're telling me is you think it might be a milk protein issue, but you still want to give her more, just a lower volume of it. I'm like, I'm not. Yeah. I was like. So we went and picked it up and we weighed her and we did all, you know, the weighted feed and everything. We did not feed her any of a formula in office. And I took it home and I donated it. I was like, I am going to bust my butt to hump, like, hand express. I will do everything I have to do to feed my child if she can't get the milk out herself. And I mean, now, on the flip side, that's why I became so passionate about working with these moms, because I had 13 months of painful breastfeeding, because I didn't know that feeding your child for 45 minutes around the clock one was not normal. Because I was told basically it was and that everything was okay. She was like the car you take to the shop, right? You go for that appointment in office, they reposition her. She feeds beautifully with lactation. You go home and it's like the car starts squeaking again. Like, it doesn't work. I was like, so defeated. I was like, well, I took her to the professionals I was supposed to take her to, and that didn't fix it. So I guess I'm on my own. And that's where I realized there was zero support. And I should have had much more support. But everyone just said, well, you're a new mom. It's painful, it's uncomfortable.

No, no.

Now I know that's not normal. And that was part of my story behind this podcast that I went to go find the podcast and like, well, this. Nobody's created it. So now I have to create it because nobody else should go through this, whether it's a professional guiding a parent or a parent who's listening. So, yeah, you know, definitely a passion project of Mine, because with my second child, she popped out. And I texted the oral surgeon and I said, when can we come in? We've got another one.

That's something. Yeah, I get it. I do. And I think that just being that support for the families is just so important. I think that beyond anything else we do, that they. You know, they really. I mean, the amount of how much love we get from our families, right, is just. I mean, it's like the things that come out, like, I. Like, I would. The things that come out of my, like, client family's mouth are way better than what my. My personal family would say about me. Because I just. This is, like. It's just so. And I think about it so often. Like, you know, my. My mom would never say that about me, right? Not that she doesn't love me to death, but, like, I mean, the words that come out of their mouth, right, because we, like, just. We're there for them in this time where they just. They're really, like. Like, latching on to us to help them to help their kid. It's just. It's so powerful. And I just, like, I. I'm so thankful to be able to, like, be in this profession where there's such a range of, like, what we do. And I found this is like. I tell. This is like, I couldn't have. I can't imagine doing anything else, but I just feel like. Never has it ever felt like work. It just feels like I had. This is all. I, like. This is what I love. This is everything. So I just, like, this is. I think that's the coolest field. I tell anybody who's, like, confused, like, in college or anything, what should I do? I'm like, go into speech, check out some courses. Like, you're gonna love it. Come, like, you know, when it was. When we were able to have people come and, like, shadow us. I would like my little sisters, their twins, and they shadowed me when I was, you know, in New York. And they're from my dad's side, second or third, I don't know, second marriage. But they now. One's a. One's a speech, one's ot, and they're in Pennsylvania and working with the babies. Right? Because it's just. Yeah, it's such a great.

More like. That's why I keep saying to everybody, if you are interested in this space, like, go for it. Like, explore it. There's a shortage of pediatric feeding therapists, and these poor families are on wait lists on hospitals because they can't find people Outside of the hospital systems that are local to them, that can support them. And. And, you know, how cool is it that even if you're a small practice or you're just someone who wants to do some feeding therapy or something on the side, you can still do that. You can even travel to your families if you want to. You don't have to have a brick and mortar if you want to get into this space and get educated and go work with those families. It's so needed. And I think that people are surprised to hear that. But I also think that so many SLPs and OTs are just fearful because it's a little bit more of a medical. Not a little bit. It is medical. Right? So there's the medical side of speech pathology with pediatrics, and then there's the not so medical side that we could get, you know, so it's scary, and I get that. But if, you know, if you're passionate about it and you want to get into this space, it is so rewarding, and you're giving these families and these children such a gift. So. And I mean, you. You can hear the passion come through you and you're talking about it, and it is just. It's an amazing space to be in.

It is.

It is.

I knew nothing about it in. In grad school. Right. I just didn't know. I didn't even know when I had my own daughter. But, yeah, I think that, you know, I think that what you're. What you have here, you're like, you know, this podcast and helping for other, you know, for colleagues and just to hear it and to know. Right. Because I don't think in grad school, people hear about, even on those online, like, you know, people can be intimidated to post any questions.

Right.

Because I never like to respond to anything on, like, Facebook because I'm fearful of, like, their responses.

Right.

You just, you don't know, if you say something that's not exactly what someone else thinks, then it just becomes a lot of people commenting. So to just be able to listen in to podcasts and to hear. I think it's a really useful tool for so many.

Yeah, well, and I think the important message there, too, is you don't know the training or the background of everybody on a Facebook page. Right. I mean, obviously I teach a course, we have an alumni group, so we know what they've. At least some of what they've learned. And so, you know, the conversations that we might have there, that we might have in my course, everybody's in the similar space. And we're learning something together. So it's very different than just a general Facebook group. And those Facebook groups, like you said, they can just, I call them dangerous because one, you don't know what the, what everyone's background is. Two, people are nasty. Sometimes they're just downright nasty. And I think that for the therapist who is watching from afar, that is a real big turnoff. Like, why would I want to get into this space just to be torn apart by someone who's supposed to be my colleague and maybe helping me help my families and children? And I also get, it's not a HIPAA compliance space to have really full blown conversations that might actually directly, positively impact your patient that you might have the question about. So, you know, I think as an industry, we just, we need to do better in supporting our therapists. And that's basically the mission behind a lot of the things that I've been creating because, you know, I just started this elevation movement where my whole goal is to focus more on identity. Like, who are your being as a therapist, as a human, you know, like, how are you being, what are you putting out there? And. But then also skill set and mentorship, because I think that those three things, like, we really can elevate each other and you know, maybe we do it in more private spaces and in spaces where we know each other's backgrounds and where we can have discussions, HIPAA compliant discussions about patients, or you can, you know, get one on one support mentorship. And you know, I know that we can do that in a clinic base, but I think that there's a lot of people who are lacking those opportunities local to them and that's where this larger conversation has come about. So, yeah, I mean, it's, it's nice to be able to connect on social media, but again, like, you know, kind of like we're talking about here, you have to be so careful and you can't always just take the advice you're given at face value because that might not be appropriate for the patient that you're asking this very simple question about. There could be a lot of complexities that are unknown here. So it's like I get it from both sides of the conversation, but at the same time, it's like we could just be elevating each other up and also providing each other with opportunities to learn from each other in a safe and helpful space. For me, that's kind of where I would like to see the future of our profession going.

Yeah, I hear you for sure. My son is coming right now. Hi, buddy. Say hi. I'm in the middle of 3 o'. Clock. Give me a few.

No worries. Children are always welcome. We're here in a pandemic. It's all good. So, yeah, so let's get back to chatting a teeny bit about, you know, you've shared so much about how you talk to your families on a regular basis in between sessions. But what other than, like, you know, telling them, hey, we had a lot of success with this one thing today. Like, let's continue that. Do you give anything else for a home carryover? Do you recommend they practice a certain number of times per day? If it's a skill they're working on, like, what does that look like for you?

Yeah, so when it comes to number of, like, times a day, I always want to recognize, like, if. Because I've had families say, like, I just, I don't have the time. And so I'll always say to the families, I'm going to recommend like three times a day doing this, but, like, it's a conversation. I want you to tell me, like, you know, if, if you're capable of doing this and if you try to do it, if you say, yep, I can do it, but then you can't. I also want you to come back and tell me, like, where, where like the breakdown happened. Like, where like, were you struggling with the number of times you're struggling with, like, how to implement it? But yes, I love to get my family's doing it. Like, I try and pair it with like, say we're working on just like gaining permission for touch. I'll pair it with like, bath time. If they're doing, like, if they, if they have to do bathing or if it's like they're doing diaper changes. Right. Pair it with something so that it kind of like, it'll trigger. Okay, this is time where I can. But I also think it's important for the kids to know as well. Like, okay, I like to have it on a schedule so that the kids know what to expect. They know that, okay, this is what we're going to do. There's a beginning, middle and end. I always encourage families to, like, use songs and whatever they can do to really get the kid ready, the baby ready to, like, receive the care and to know that we're going to do it like this and then we're going to be done and we're going to go to the next thing. Um, I love the number 10. I always. Not that I love the Number. I love the number 10 for number of reps that I'll have a family do. Um, and then, of course, like, you know, I'll always say, like, do 10 times three bilaterally, or things like that. But we're always working on. I try not to give them too many exercises. Right. But I always want to first have them be able to, like, recognize the sensory system. How are they receiving your care? And here's what to recognize. Like, if you, like, here, if they start doing this, then you're gonna back it up, right? And you're going to go to this place. Right. But again, I feel like I try that really hard to explain that to families, but they just want to get in there and do it. And even if it's like, I'm going to cradle you and do it, it's just not okay. And so when I watch, even when they send. So I'll say, send me a video. How did that look? And it's so simple. Like, I see it so clearly, but it's. They. They don't see it, right? So I said, well, you see, when he was, like, turning his head away, or if he, like, saw you coming and he was like this, that's saying. That's saying, hey, I'm not ready for this. So I try to get them to take videos and send them so I can see, like, if there are breakdowns, I try and get them to practice two to three times a day, recognizing that they all have their schedules and likely other kids and jobs and things. But I. And, you know, that for the exercise and things. And then if they're eating, you know, if the family's eating, I encourage them to bring the kid, too, right? So everybody's got to eat at some time. So, like, you know, bring them in. If you have to make your sandwich, have to go to the toddler tower and, you know, have them be part of that as much as possible. If you have to order, I try to figure out, like, where is the family? And really try and get the kid as involved as possible in all things feeding so that it's something that they're really familiar with when it comes time to taking their first bites.

I love that. I love how you're addressing the multisensory component. You're addressing having them involved just anytime food is around and without the expectation, there's no expectation, the child has to touch the food or eat the food, but they're going to naturally just smell it by being in the room. And, like, how cool is that? Just to have Those extra non homework based sensory, you know, exposures. Because that, that just really, it just helps from a multi sensory standpoint. Just continue to, you know, make a positive, develop that positive relationship, I should say, with the food. I really love that. And you know, getting them involved in like all things food related. Do you have your families, like, do they come to you with like, hey, because this is what we do. But you know, when they fill out their food log, we always ask them like, well, what foods would you like to see your child eating? Like, are you trying to like food chain towards those at some point? Or like, how do you go about that?

Yeah, so for sure we want to recognize like where the family is like culturally what their common foods are, right? And then of course paying attention to like the sensory system, but. And the motor patterns. But like, so I can't even remember where my one family is from, but they're really into like super spicy foods. And this baby's like been nursed since, I mean, he's like 12, 13 months now. So it's so cool that like all these like, I think, I don't know, Indian spices are like, like, so if, you know, I'll say to the mom, like, if they're eating yogurt or something and you know, they were working on just like spoon stripping or whatever, have him sprinkle on whatever those spices are into, right? Because he's, he's, he's had it his whole life, right? Since birth. He's so familiar with these spices. And mom will say, I'm so surprised that he was like reaching for my. I don't even know what it was, right? It was something in like a heavy. I don't know what, I can't even remember. But so just bring the spices out and like, let's like, let's make like a fun language task too, right? Let's like sprinkle some things and a sensory task and you know, make it really fun. And you know that because he's so familiar with that flavor profile that will lend itself to like enjoying like the yogurt maybe, right? But yeah, I always try really hard. I think we could probably be doing a better job because I don't know what, I don't know. But you know, so I feel like we can do better with like really recognizing where, you know, what are the families, like, what are their cultural, like specific foods that they expect for, you know, kids at a certain age. And I think, you know, we try, but we could, we could do better. Like anything else.

Yeah, no, thank You. I appreciate that. And then we will wrap up with one last question. So unless you have anything else you want to talk about. But, you know, we did talk about how we have to address the motor skills before we can really kind of get to those behaviors, but the behaviors are a part of it. Is that typically the trajectory that you follow? Do you generally address the motor skills, you know, work with the medical team if there is one, and then kind of deal with the behaviors if they're kind of still there at the end of all of this? Or are you? I mean, I know we deal with behaviors along the way, too, but from, like, a pure behavioral treatment standpoint, you.

Know, so, yeah, I'll definitely. So, yeah, medical stuff, you know, sensory first, so that I can get in there and map out the motor patterns that we need for this. Right. If not not letting me near their face, they're certainly not letting a chew tube in their mouth or whatever. Right. But yes, like, I'll always tell my families, like, these are things we're working on first. And then. Right. Of course, we're addressing behaviors of just coming and being present. Participating, of course, but gaining that, like, trust is so important. And then I'll tell my family. It's like, I think we're ready to bump it up. I think we're ready to really start to recognize. We know we have a solid understanding of his sensory, his motor, his. All those medical things. We have it under control. He's seen the allergist. He's gone to the GI. RD's on board.

Right.

We got this. Now here we are with these behaviors that are really. They're persisting, and, like, this is how I want you to treat them. And so that is like, I'm like, are you ready? Because if. I'll always check with my families if they're not ready to commit, and they say, okay, we're going to give a try. And I'll always like, are you really ready to commit? Because once if you say you're going to. And you're going to commit to this, even just like, working on it once a day with this, you got to commit. Otherwise the child will learn that these behaviors will serve me, and then it's gonna be harder the next time. So whether it be like, you know what, whatever, it's gonna be like working on, like, reducing capacity or working on transitioning off bottle, whatever that is, when the behaviors are present and the family isn't ready to really, really commit to working on it. I don't even want to go there. Because then it's like, you know, you're there a month later, and it's like the behaviors are worse. And we know that those behaviors will escalate. They will get more intense, they will get more frequent until they really extinguish. And, like, you have to be so solid in understanding that this is a behavior. And that's why I always train my families and the videos that they'll send me, like, he was doing XYZ and total behavior. And this is what I want you to truly, truly want you just to do this. And that's where we talk about Melanie's stuff a little bit. And we are actually now, we just hired a BCBA to have come on board just to help out with that. Because that behavioral stuff. Not that I want to be a behavioral program, but I want to be a hybrid approach. And part of that child's feeding is there's definitely those behaviors. So when the family. When the family is ready, I would say when you're ready, the kids will be ready. You just got to. You have to really commit and remain calm and consistent. Right?

Yeah. It's not easy, and it is definitely a big commitment. I love how you pointed out that, you know, if you say you're ready to commit, but then you don't commit, the behaviors just escalate. They become so much more harder to extinguish. It's. Yeah, it definitely. So definitely having them on board is. That's a really good, great conversation to have with the families. And I lied. I said one last question. But I really have one last question now, because you mentioned. You mentioned that you'll use, like, a chewy tube or something. And I love that you use tools. For me in my practice, I have found that, you know, especially when you get these sensory aversion kiddos who either they've had a bad experience or, you know, just whatever the case might be, we don't go at them with food right away. We develop the skill first. And that could be quick, or it could take weeks. It doesn't matter. I mean, and every child's different. But I love that you mentioned that you'll use tools in your practice, because for us, we even use those tools once they're comfortable to then bridge the food. Right? Bridge, like, start using the tool with the food, and then bridge to removing the tool and just using the food. And I know there's just been this whole, like, debate in our field about tools, no tools. And do you have any, you know, thoughts on that based on your experience?

I Love the tools. I definitely love the tools and I love, you know, I've taken a lot of the talk tools courses and I refer to Lori overt overlands when it comes to like the pre feeding or like non nutritive and then nutritive, like where they are in the mouth of non nutritive is going to be one step above where they are with the nutritive. Right. So I will. I just got a huge box from talk tools. I just love like, I love the way that tools can. And for me as a therapist, I don't feel threatening if I'm like, okay, we played with it, you know, you know what it's like it's not scary, right? This is safe. It's not going to break off or you know, disintegrating your mouth at all. Like this is like, you know this, right? And we can as a therapist get like once I've realized, okay, like they can, right. And I want to present it in a way even if I'm just like tapping lips to get them ready. Like I can recognize that, that behavior if they're like really getting upset, right? We, we. It's easier to offer like the non nutrient, right. From like even from like the perspective of the delivery. Right. But I do use tools all the time and I find them to be so helpful in doing all of the exercises and also facilitate into like getting into like the nutritive. Right. You know, my kid this morning, mom was like, you know, you know, even all my kids are almost like they're putting like their raisins in or they're putting like their things inside the tube and then like even delivering it or you know, if they're familiar with the whatever it is that we're using, whether it be the nook or like a, even a toothbrush, whatever it is. If they're okay with bringing that to their mouth, I'm super excited because that'll get us toward like the next things that are going to go into their mouth. But I know, I have heard about not using tools, but I feel like it's so safe and it's just so smart. You can map out the motor patterns that you need in a really safe way. Then the families can do it as well. Here, do this. This is what you're going to do tonight or for the next three days. And I think that's versus say I wouldn't even want to think about if they tried to do it with an apple with skin or something and then something really not good happened, right. It's Aw. And that can set them back a lot too, right? So much so, yeah, we're big. I have bins and bins and bins of, like, talk tools and all tools in our office, for sure.

I love that.

I love that.

I'm the same way. So I'm always excited to hear when someone else uses the tools too, because I just think it's created so many positive experiences for our kiddos versus just going straight in with food. And really, I've seen so many kids shut down from that and so not, you know, firsthand early on in my career. Yes. But also just from other practices where families will call us and say, hey, what do you do? Because this didn't work for us and we want to make sure you're not going to take the same approach. And we get a lot of those calls, especially from one area hospital system, unfortunately. So, you know, we're happy to help the families, but it's. Yeah. A lot of these kids get food into their mouth that they don't have the motor skills for yet. It creates a horrible sensory experience. They become averse. And it's just like this, you know, you're like this. Catch 22. We got to eat. So how do we get the food back in the mouth? Tools. I love it.

For sure.

Awesome. Well, all right. Well, thank you so much, Lori, for being on today. Is there anything else you want to cover that we haven't covered?

No. Thank you so much. Thank you so much for reaching out and for having me. It was a lot of fun.

And where can families find you or just therapists? I don't know if you do any mentoring, but where can everybody find you?

Yes. So our website is montclairspeechtherapy.com and then my. My email is lorionclarespeechtherap.com and I mean, I am way available all the time. Ask any of my families, like, at any hour, because I truly don't sleep and this is a great thing to me. So if anyone has questions, I'm always available.

Well, thank you, Lori. That's amazing. We'll also put the contact information in the show notes so that anybody who wants to reach out to you can get some sleep. I'm also someone who, like, doesn't sleep a lot, and I'm working on that. My whole mantra this year is do less better, so.

Oh, yeah, I heard that.

I'm trying, I'm trying.

When I say to that is like when I'm not sleeping at like 2, 3, 4am Shark tank is on. So Robert Herschwick says that like the those who sleep less are the most successful. So I'm going with that.

Right.

Exactly.

Exactly. Well, and it's funny too, because now that I am not always doing business all night, I then find myself on Netflix or watching Shark Tank or those same types. I love those shows. So I understand. I get it. All right, Lori. Well, thank you again so much. It's been an absolute pleasure having you on the show.

Same. Thank you so much. Stay safe.

Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com forward/the untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page at Hallelujah, Balkan Biz on Instagram at Hallebulcken. And you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes, where you can also subscribe to be kept up to date on the latest podcast episodes.