Seeing It vs. Understanding It: The Gap in Myo Training

The parent conversation can sound overly certain. Your child has a tongue tie. That's why she's struggling. She needs a release. Then we'll do exercises. And that might sound confident, but confidence is not the same as accuracy, right? It reduces a multifactorial child to one finding, and it can create expectations no clinician can guarantee. I used to think confidence meant giving parents a clear answer as quickly as possible, but now I realize that confidence actually means being able to separate what I know from what I suspect. Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner, and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up-to-date information in the orofacial myofunctional therapy, airway, tethered oral tissue, and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest posture: tongue up, lips closed, Teeth apart, breathe through your nose. Let's get started. Hello and welcome back to the Untethered Podcast. I want to talk today about a gap that I've been seeing in our field, and it is the gap between knowing about myofunctional therapy and actually understanding it. Okay. And I understand how clinicians end up in this gap. Okay. You take a course, you learn something no one taught you in grad school, and suddenly you just, you start noticing tongue posture and restricted movement and open mouth breathing and jaw compensations and swallow patterns and things that you've just never really been looking for before, right? Or you've seen some of it through a similar lens, maybe if you're in pediatric feeding, but you know, now you're looking at it through a myo lens as well. And for many of us, it feels like someone turned on the lights. And once you see it, right, you start to see it everywhere. It's like we kind of apologize because you're walking through an airport or going through the grocery store and you're like, sorry, I know you see it everywhere now and we just can't turn it off. And honestly, that part is kind of exciting. It's also where things can go a bit sideways because recognizing a pattern can feel a lot like understanding it before the depth is actually there, if that makes sense, right? You see a restricted frenulum, a tongue forward, or some oral motor incoordination, and your brain just like, you're like, I want to connect the dots here. Like, what is going on? This must be the problem. This must be what needs fixing. This is why the child is struggling, right? But it's an observation right now. It's not yet a diagnosis, and it's definitely not yet a treatment plan. And that is a difference that I want to talk to you about today, because when you truly understand Mayo as in Orofacial Myofunctional Therapy, you don't just simply see abnormalities. You become more discerning about, like, what you see. You understand how one finding fits into a larger system and whether it is functionally significant and what, if anything, should happen next. Okay, that is a much deeper level of clinical practice than being able to spot a tongue tie, for example. Okay, and there is something very predictable too that happens when we first learn a new clinical concept. We become sensitized to it. You take a weekend course on tethered oral tissues and suddenly every child seems to have a tongue-tie. You learn about oral rest posture and every open mouth starts looking pathological, right? You're like, there is a problem there, which arguably there might be and there probably is, but let's just keep this all like in mind. Maybe you learn several Myo exercises and you begin looking for children who can use them that you work with, right? And it doesn't mean that you're careless, but it means that your brain is organizing new information. You finally have some language for something that you are not trained to see. So the pattern starts to feel incredibly obvious. I went through versions of this too. Most of us do. It's part of like the learning process and how we come back and we, you know, integrate this work into what we're doing on a daily basis. But the problem is not noticing the pattern, right? The problem is stopping there. Real understanding begins when you hold the finding without rushing to explain the entire child through it. You can see a restriction and recognize that it might be relevant without immediately deciding it's the primary driver, right? It's the root cause, because it may be or may not be. You can notice a forward tongue posture without assuming the child needs exercises. You can identify an open mouth posture without diagnosing the airway from your treatment room, right? You start allowing more than one explanation to remain possible while you gather the rest of the story. That is the shift from spotting one piece to reading the whole system. So I had a case that looked like a tie that I want to talk to you about. Okay, a clinician once reached out to me. When I say a case, I mean from someone that I, you know, helped. A clinician once reached out to me about a 3-year-old that she was seeing. The child had oral motor incoordination, reduced speech clarity, and this clinician had recently completed a weekend tongue-tie course and was convinced that the child had a restriction that absolutely needed to be released. By the time that she contacted me, she'd already started talking to the parents about going to the release provider, the dentist, for a consult. So she was not really asking me what I saw per se, she was asking me to confirm what she had already decided, okay? And yes, the child did have a restricted lingual frenulum. That finding was real, but it wasn't the whole story, okay? And that's what I want you to focus on. This child also had low tone, they had developmental differences, they had a broader oral motor challenge as far as coordination goes. Those pieces were having a much greater effect on function than the frenulum itself. So could a provider have released the tissue? Yeah. Would that release have resolved the low tone or coordination difficulties? No, because there were other things going on beyond just this tethered tissue Would it automatically have improved speech? Probably not in this case. Okay. The clinician had accurately identified a restriction. I do wanna highlight that, but she had not yet developed what was the depth that was needed to determine how much that restriction mattered for this particular case, because every case is different. Okay. She saw a finding and moved directly to a solution. That is where shallow understanding becomes risky. A restricted frenulum is one piece of the data. It can be a really important piece of the data, right, an important data point, but it's not the answer to every question we have about a child. And the more you start to understand Mayo, the less interested you become in finding one thing to blame per se, right? You stop hunting for the single problem, you start reading the system and realize there's usually a lot more going on. Okay, and so I want to talk to you for a moment about like what deeper assessment looks like. Because when your understanding is still developing, it's easy to focus on isolated signs, right? There's a tie. The tongue is forward. The mouth is open. The swallow looks different. Like, these observations matter. They're really important, but they're a starting point. Deeper assessment is about understanding how those pieces interact. You're now looking at a child where the tongue, you know, rests low, but you're also watching its relationship to the jaw and the lips. And you notice whether the child can breathe comfortably through the nose and what happens to oral posture when they can't. You observe chewing and swallowing in real time, looking not only at like whether the child completes the task, but like how the system organizes to accomplish it. And you begin to see the difference between efficient movement and compensation. That's a big one. A lot of people miss the compensations. That's where a lot of the deeper clinical understanding comes. You also look beyond the mouth, right? We have to look at overall tone, posture, endurance, regulation, sensory processing, feeding history. Overall development, right? All of these things influence what you see in the mouth. If those pieces are missing from your assessment, it's gonna be easy to assign too much meaning to the most obvious finding. Okay? So imagine you're assessing a 2-year-old for feeding concerns. The parents tell you that nursing was difficult and the child remains selective with textures, but they're currently, you know, the child's currently eating solids. One clinician may hear eating solids and decide oral function is no longer relevant. They're eating, they're functional. Another may notice a forward resting tongue posture and immediately prescribe myofunctional exercises. Neither of those responses gives us enough information. The more skilled response lives in the space in between, which I know is like that gray area that so many of you are like, ah, this is a tricky part. I know, that's why we need mentorship, right? So maybe you notice the forward tongue posture, some jaw protrusion, swallow pattern that appears to have organized around that position, right? We got some compensations going on. But before deciding what it means, you look at the conditions surrounding it. Like, maybe the child's mouth breathing and the tongue is sitting forward because the mouth has become the primary airway. Perhaps their tone and their posture are influencing the oral pattern. Maybe there's a structural restriction, right? Like we talked about. Maybe the pattern is still developmental and is not currently creating a meaningful functional limitation, right? The observation matters, but the observation alone does not tell you what to do. So a forward tongue posture, right, is not a diagnosis. It's definitely not a treatment plan. And sometimes the pattern needs intervention. Sometimes it is compensatory. Sometimes it needs to be monitored, and sometimes it's not the most important thing happening in the case. That discernment is what changes when you truly understand the work. Okay? Now here's the other thing. Myo does not replace the rest of the child. What do I mean by that? This is where a narrow myo lens can get clinicians in trouble. Once we become focused on motor patterns, we can begin interpreting every feeding concern mechanically, right? The tongue is not lateralizing. The jaw is compensating. The swallow looks different. So we assume the answer must be oral motor work, right? But a child may have the physical ability to manage a food and still be unable to tolerate it from a sensory or nervous system standpoint, right? Maybe there's oral defensiveness. Maybe there's a history of pain, of reflux, choking, pressure, negative mealtime experiences. Who knows? I mean, you should know. They should be sharing this with you. Maybe the child has learned that eating does not feel safe. That changes our plan. The child may need gradual sensory exposure, environmental changes, support from an occupational therapist, right? Or time spent rebuilding trust before we increase motor demands. Understanding myo does not mean filtering every child through a myo-only lens. It means knowing where myofunctional patterns fit inside a larger clinical picture, because there's often a feeding, a sensory motor feeding component to what's going on, which I've been trying to break down here. Integrated practice is not forcing every concern into your specialty. It is knowing when your specialty is relevant and when it's only one part of the answer, right? And when another clinician needs to be involved. Yeah. This may be the biggest clinical shift. When our understanding is limited, we tend to move quickly from a finding to a conclusion, right? There's a restriction, it must be causing the problem. There's a forward tongue, the child must need myo. There's an open mouth, so the child has an airway disorder. There's an atypical swallow, so we need exercises, right? But the finding and the conclusion are not the same thing, my friends. A restriction becomes clinically meaningful when it interferes with function. That requires us to do more than just look at the tissue. Start there, but that's not the end-all be-all, right? We need to understand how the tongue moves and what happens when it's asked to perform real tasks, okay? Like, look at elevation, lateralization, suction, chewing, swallow, speech, right? And the relationship between the tongue and the jaw. We also notice what the child uses to compensate. The question is not simply whether a restriction exists. The question is whether it's preventing the child from doing something they need to do. Okay? I see children with visible restrictions who function really well. They're feeding well. Their speech is developing appropriately. Their tongues have enough functional movement for what they need. The tissue exists, yeah, but a release is not necessarily indicated in every case. I also see children whose restrictions appear less dramatic, but whose functional limitations are significant because of the way the entire system is organized. And that is why appearance alone cannot make the decision. Hopefully, because you've been following me for a while, you know this, right? Structure matters, but function matters more, and context determines what the structure actually means. One thing also that clinicians do not always expect is that deeper myotraining often leads you to refer fewer children for release, not more. You become more selective because you're no longer referring based on the presence of tissue alone. You refer when you have identified a functional limitation. You understand its impact, and you believe another provider needs to evaluate the structure, right? I want you to consider for a second, like, a 3-month-old infant with breastfeeding difficulties. There may be a visible restriction, but that, that can't be the entire assessment. You need to understand how the baby latches, how the jaw moves, whether the baby can maintain a seal and suction, how suck-swallow-breathe coordination is working for them, whether milk transfer is effective, right? You also need the rest of the feeding dyad in that. Positioning, maternal anatomy, milk supply, pain, endurance, state regulation, right? All these things can influence the experience. Perhaps the infant has reduced tongue protrusion, but it's generating a strong suction and transferring milk effectively. Perhaps positioning or oversupply is contributing more to the difficulty than the frenulum. Restriction present, release not automatically indicated. That is what real assessment gives you. And when you do refer, the referral carries more value. Instead of sending a family out with possible tongue tie, please evaluate, you can explain the functional limitation you observed, right? The effect that it's having, the compensations the child's using, and why you believe further eval is actually warranted. Okay, that gives the dentist or the ENT or the physician or the surgeon, right, a useful clinical picture. It also protects families from being passed between providers with like some vague concern and no understanding of how the finding relates to the child. Because poor referrals create a lot of noise and they're frustrating, right? Strong referrals create clarity and help us get to the root of what's going on. This is where the difference becomes very real for families. When our understanding is shallow, the parent conversation can sound overly certain. Your child has a tongue tie. That's why she's struggling. She needs a release. Then we'll do exercises. And that might sound confident, but confidence is not the same as accuracy, right? It reduces a multifactorial child to one finding. And it can create expectations no clinician can guarantee. I used to think confidence meant giving parents a clear answer as quickly as possible, but now I realize that confidence actually means being able to separate what I know from what I suspect. I can explain what I'm observing, how it may be affecting function, and what we still need to understand before making a recommendation. Okay? And that's not weakness. That is honest clinical leadership. A more informed conversation might sound something like, Hey, you know, I'm noticing reduced tongue elevation and jaw compensation. I also see a restriction under the tongue that might be contributing to the pattern, but it's not the only piece that we want to look at, right? Breathing and tone coordination, feeding history may all be influencing what we're seeing. So I would love for another provider to evaluate the structure while we continue to address function. Okay, now the parent understands the child more clearly, and maybe I would make that a little less clinical, but they're not just being handed like a label and a referral. Does that make sense? Like, you can also set better expectations because you understand that changing structure does not automatically retrain function. A release might help. It might create more available movement. It may remove one barrier, but it may not resolve every concern, and therapy may still be needed to help the child learn how to use that new movement. In fact, in most cases, that is the case. Okay? Parents deserve to hear what may improve, what will still require support, and what cannot be predicted yet. We need to be honest about these things. They don't need us to pretend that we know more than we do, or like we have a crystal ball that we don't have. Okay? They need us to help them understand what we see and make thoughtful decisions about what the next steps are. And I also want to be clear that when I'm referring to infants or anybody under 4, that's more PEED feeding. When I'm referring to 4+, like cognitively ability to follow directions age, that's more MYO. Okay? And under the age of 4 or 5 years of age, like cognitively, you can adapt the concepts of MYO into PEED feeding. That's what I do in what I teach. Just wanted to give that little disclaimer. Okay. So when you truly understand myo, you don't present it as a package solution. You don't tell every parent their child needs myo. You explain the actual pattern, what is functionally difficult and why a particular type of intervention might help. Sometimes myo is appropriate. Sometimes feeding is the better path. Sometimes a child needs an airway eval before therapy can be effective. Sometimes the OT needs to be involved or the SLP, right? Or the PT or, you know, another provider. Sometimes the right recommendation is to monitor rather than intervene. And sometimes the answer is not more therapy at all. Right? The goal is not to funnel every child into MYO. I just see so much marketing around this and it drives me a little batty. The goal is to determine whether MYO, like myofunctional patterns, are meaningfully contributing to the child's difficulty and what intervention fits the whole picture. Families can feel that difference immediately. They can tell when a clinician is trying to understand their child rather than fit their child into a prescribed program. So how do you move from recognizing patterns into truly understanding them? It doesn't happen through information alone. Courses matter, books matter, podcasts matter. And I say that as someone who has recorded hundreds of podcast episodes, who has a course, all the things, right? But information is not the same as clinical competence. Competence develops when you apply what you've learned to real children, and then you have to explain your reasoning to someone experienced enough to challenge it. That is where the growth happens. Someone asks why you made the call you made. They help you see the assumptions underneath your conclusion. They point out another possible explanation or a piece of the system you had not considered. Okay, and over time you see how the same finding can mean very different things in different children. You learn that a visible restriction does not always create a functional limitation. You learn that a subtle restriction can matter significantly in the context of a particular system. You learn when to act, when to refer, when to collaborate, when we need to maybe watch and see what's going on. And that judgment cannot be downloaded in a weekend, my friends. Like, a weekend course can help you see something new, but it cannot give you the clinical hours required to develop discernment. It cannot expose you to every variation or sit beside you when the child does not look like the example from the presentation, right? That depth comes from real cases and repetition, feedback, mentorship, enough humility to let someone challenge the conclusion you reached a little too quickly, right? So what changes when you actually understand Mayo? You notice more, but you label less quickly. You assess the system instead of isolating the frenulum. You become more thoughtful about who you refer, why you're referring, and what you expect another provider to evaluate. You communicate with parents in a way that is specific, honest, and collaborative. And you become comfortable saying, "This may be a part of the picture, like one piece, but I need more info before I tell you exactly what it means." Okay? It's not lack of confidence, that is competence. The goal of understanding MYO is not to see a tongue-tie in every child. It is to know when the tongue matters, when it does not. It usually does, but like when the tongue-tie matters, right? And what else do you need to understand before you make that call? And that is exactly why I built the MYO Method the way I did. Not as another weekend of information, not as a library of exercises to start handing out on Monday, but as a deeper clinical training experience built around assessment, real cases, mentored practice, feedback, and learning how to explain the reasoning behind your recommendations. Because the goal is not to help clinicians sound more confident. Like, yeah, we all want to, but the goal is for us to actually be more competent, right? Don't you want to be more competent? If you're already, you know, ready to make myo a real part of your clinical practice, then you can learn more at The Myo Method if you go to themyomethod.com. And before you go, just think about one child on your caseload. Maybe there's a finding that seemed to explain everything when you first noticed it. Go back, look at the whole system, okay? The finding might be the driver, it may be one contributor, or it may simply be one piece of data that has been carrying more weight than it should. Learning to tell the difference is where the deeper work begins. All right, friends, that's all for today. I will talk to you next week. Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers. And serves as informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider. Thanks for listening to this podcast. If you found value in this episode and want to hear more of these MyoTots airway and feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @halliebulkin on Instagram to get all the latest updates.