Hallie BulkinAsk HallieAI:Your On-Demand Mentor in Pediatric Feeding & Myo

Stop Treating the Smoke! Find the Fire

26 Jul 2026 · 1 min

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In this monologue Hallie Bulkin outlines how an integrated therapist should move beyond treating the visible symptom of tongue thrusting (the "smoke") and instead systematically investigate the underlying causes (the "fire"). She describes a step‑by‑step mental checklist that includes assessing whether the airway is open or the child is mouth‑breathing, evaluating the oral structure (palate size, neural palate crowding), examining nervous‑system organization and possible dysregulation, checking muscle tone and motor‑control, exploring sensory and behavioral narratives, and identifying any mechanical restrictions. By asking these questions early, the therapist builds a comprehensive picture of what truly drives the dysfunction. Bulkin stresses that interdisciplinary thinking—considering ENT, dentistry, occupational therapy, physical therapy, and other specialties from the outset—is essential for accurate diagnosis and effective treatment.

Chapters

The integrated therapist sees that same tongue thrusting, goes, okay, that's interesting. Now let me run my lenses, right? Is the airway open or is the kid mouth breathing? Is the structure giving the tongue room to live where it's supposed to, or is there a high neural palate crowding everything? Is the nervous system organized, or am I seeing like, you know, dysregulation? Am I seeing some tone and motor control stuff? Is there a sensory story here? Is there a behavioral pattern? Is there a mechanical restriction? You know, and you start asking all these questions, and then only then Do I, you know, start forming a picture of what's actually driving the bus? Because a symptom is just a smoke. It's a smoke signal, right? Our whole job is to find the fire. And usually it's not where the smoke is the loudest. That's the crazy part, right? So this is why interdisciplinary thinking matters so much. And so does integrated thinking. And so the integrated therapist doesn't think of the ENT and the dentist and the OT and the PTS people you call when you get stuck. They're a part of how you see the case from minute one.