In this solo episode of the Untethered Podcast, certified myofunctional therapist and feeding specialist Hallie Bulkin addresses a common dilemma for clinicians: trying to treat every aspect of a complex feeding case at once, which leads to unclear outcomes and clinician frustration. She explains that feeding difficulties are best understood as four hierarchical layers—physiological stability, oral‑motor skill, sensory processing, and behavior/learned patterns. By identifying which layer is the primary limiter for a child, clinicians can prioritize interventions, create clearer treatment plans, and see more rapid progress. Bulkin walks through each layer, illustrating how lower‑level stability supports higher‑level gains, and shares a concrete case of a 3‑year‑old with gagging, pocketing, and refusal to demonstrate how focusing first on oral‑motor deficits unlocks improvements in sensory tolerance and behavior. She emphasizes that most training teaches techniques but not sequencing, and that building decision‑making skills is essential for confidence. To help clinicians develop this skill, she invites listeners to a free three‑day feeding training (feedthepeds.com/training) that models case‑by‑case prioritization and offers a certificate of completion. The episode closes with encouragement to keep an open mind, recognize that feeling stuck is part of learning, and a reminder to practice correct oral rest posture.
Layer 1, physiological stability. Layer 2, oral motor skill. Layer 3, sensory processing. And Layer 4, behavior and learned patterns. When you treat all 4 at once, you blur your outcomes. If you're feeling stuck in a case right now, that doesn't mean you're failing. It means you're still building your clinical lens.
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 friends, and welcome back to the Untethered Podcast. This is your host Hallie Bulkin, and we're gonna chat a bit today about what to do when you're treating everything and nothing is changing. Have you ever had a feeding case where there is just a lot going on, like sensory concerns, motor challenges, big behaviors at the table, family stress? Maybe there's sleep issues, maybe reflux, airway questions, right? And you're just like staring at your evaluation thinking, okay, where do I even start? So you do what most thoughtful clinicians do, you add more goals, maybe more strategies, you know, or tried, you work on a little bit of everything because you care, because you don't want to miss anything, because everything feels important, right? But then weeks go by and progress feels slow and you're not totally sure what's actually helping. Like you're tracking the data, but it feels kind of messy and you're starting to think, Hmm, am I missing something? Let me normalize this immediately, okay? This is incredibly common, especially when you're still building confidence in feeding therapy. And this is important. Treating everything usually means you're trying to be helpful, not that you're doing something wrong, right? The problem isn't effort, the problem is prioritization. So why is this happening, right? Well, here's why this pattern shows up, especially for newer clinicians. Feeding cases rarely present cleanly, right? They're complex. There's multiple layers to that onion. They are layered, right? Motor affects sensory, sensory affects behavior, behavior affects family dynamics, airway affects endurance, and it's all intertwined. But most of your training, right, most of the training out there taught you like what feeding problems look like. It did not teach you how to decide what matters most first. That is a completely different skill. So when everything feels important, it becomes very hard to choose or know where to start. And here's a trap that so many clinicians like fall into, and I know this from speaking to so many of you on like one-to-one calls lately. I hear people say like, if I work on more things, I'm assuming progress is going to happen faster. It sounds logical, but let me tell you, feeding doesn't respond well to volume, okay? More treatment, more strategies, that does not automatically mean better outcomes. Sometimes it just creates noise and upsets nervous systems and actually decreases outcomes. A little food for thought there. So let's talk about what happens next because there's something called like a confusion loop. Let's say you're in session and you're thinking, okay, maybe I'm missing something. Maybe I need another strategy. Maybe I should address this thing too, right? So your goals multiply. You're targeting oral motor and sensory play and food chaining and behavior shaping, and there's parent coaching, and you're doing all this in the same week or even the same session, and your sessions feel really busy and exhausting. Parents are trying 5 new things at home. Your data is like unclear, right? If the child improves, you don't really know why. If they don't improve, you don't know what to change. And when progress isn't obvious, confidence drops. And that's because when you're still learning how feeding fits together, everything can like feel equally urgent. But here's the truth, like not everything is equally urgent. And that's a big differentiator. That is what we really need to kind of go, huh, okay, not everything is equally urgent. Great. How do I reframe my thinking then so I can start to understand what is urgent and what is not, right? So there has to be this shift in your thinking. So here's the reframe. I want you to stop asking like, what can I work on, and I want you to start asking, what is most limiting this child's ability to eat right now? Because that question really changes everything. Feeding is not random. It's layered, right? That onion I was talking about, the multiple layers, feeding is like a layered onion. And the higher level progress really depends on, on lower level stability. What do I mean by that? We have to build the foundation first. Once you fix the foundation of the house, the house is now stable again, right? So that lower level stability helps the higher level progress. So I wanna simplify this for you. If you're a beginner and you're like, Hallie, what are you even talking about? Okay. I want you to think of feeding in like 4 broad layers. Okay. So layer 1, physiological stability, layer 2, oral motor skill, layer 3, sensory processing, and layer 4, behavior and learned patterns. When you treat all 4 at once, you blur your outcomes. When you identify which of these layers is the primary limiter, if you will, your plan of attack sharpens. Right? Your treatment plan becomes way more clear. So let's kind of dive into each of these 4 layers, right? So layer 1, physiological stability. It's just simply asking like, is the child comfortable enough to eat? Are they breathing well? Are they fatigued? Is there reflux or pain or airway instability that is present? Because if the child is physiologically dysregulated, any behavior work you do is not gonna stick. It's just not. That's layer 1. Layer 2, oral motor skills. So does a child actually have the motor ability, the skills required for the textures that you're presenting? Can they lateralize their tongue? Is their jaw stability present? Are we sliding and gliding all over the place? Is their bolus control sufficient? Most kids, the answer is no to all of the above for those kiddos who land in feeding therapy with me. If this skill is missing, exposure alone is not going to fix it. This is where beginners often mislabel motor as sensory. So that's why I'm highlighting this. Okay. Now layer 3 is that sensory processing piece, right? Is the response protective, like, or is it secondary to poor motor control? Like we really have to tease out if sensory is the primary driver here, or is it a response to something else, right? Is it secondary to motor control, for example, or other medical complexities that are presenting? For example, A child who can't chew effectively might gag because they don't have good control and they're triggering that gag reflex, right? The gag gets labeled as sensory, but it might actually be skill-based, and that distinction is really important. Okay, number 4, or layer 4 I should call it, behavior and learned patterns. So behavior is often really loud, right? Refusal, crying, avoidance, like super overt, obvious, in your face, right? But behavior's not always the root. Sometimes it's protective, sometimes it's learned, sometimes it's secondary. And if you treat behavior first, when motor or like physiology is the primary driver, you're gonna feel stuck cuz not much is gonna change. Just gonna throw that out there. Okay. So I wanna share a case with you to kind of help pull this all together. Like let's make this real for a second, right? You've got a 3-year-old, they're eating 6, they're gagging on mixed textures. They're crying at the table. They're pocketing solids in their cheeks, right? Parents are saying like, oh, he's sensory. We've been told he's sensory. Okay. So your beginner instinct is like, okay, I need to start exposure hierarchy. Like I need to start exposing them and bringing the food closer to their hands and then, you know, up towards the face and have them smell it and then bring it to the lips and then have them lick it. Or, you know, before we even do that messy play, maybe we bring in some sticker charts. Then we wanna desensitize them. But like, hey, pause for a second here. Okay. Before you do all of that, I need you to answer, can he chew? Can he lateralize his tongue? And the food from his tongue to his teeth or his future site of his teeth? Does he have tongue mobility? Like, is the tongue able to move around? Not just lateralize, but like, can we elevate? Does it go in and out, like forward and backward? If chewing is immature and lateralization is absent, motor is your primary limiter right there. That's all you need to know. And when the motor improves, guess what happens? We tend to see the gag reduce, pocketing reduces, confidence increases, behavior softens, and now we can work on exposure because now exposure works. Right? That's sequencing. That's prioritization. That's clarity. And clarity, my friends, when you're super clear on what's going on and how to address it, that builds confidence for the patient, for you, right? Clarity doesn't come from doing more. It comes from knowing where to start. Okay? So if choosing that one thing feels hard, that is normal. Listen, whether you're new or you've been doing this for 20 years, I have— I speak with all types of clinicians. When I say types, I mean, SLPs and OTs who are in feeding, and some have been doing this for a long time and some are brand new, and this still comes up for everybody. It's not just you, right? This is normal. Most clinicians were never taught how to prioritize feeding cases, right? You were taught techniques, strategies, not sequencing. And confidence, my friends, comes from watching someone think through cases, like repeatedly, from seeing the decision-making modeled in front of you, right? And you don't have to figure that out alone. This is exactly why I actually created my free 3-day feeding training, because the hardest part of feeding therapy isn't motivation. It's learning how to think through real cases, especially when multiple issues are overlapping. So inside my free 3-day training, I walk through feed— like, real feeding cases step by step, and you're gonna get to see how to decide what matters first, even when everything feels important, even when there's so much information. You're gonna see how to identify the primary limiter, okay? You'll see how to simplify your plan. This isn't about being advanced. It's about building clarity early so that feeding therapy doesn't feel chaotic. All right. So if you're feeling stuck in a case right now, that doesn't mean you're failing. It means you're still building your clinical lens and overwhelm is part of learning feeding. It's just a reality, right? But decision-making, my friends, like that is a skill and skills can be built. Feeding therapy gets clearer when you learn how to decide what you wanna focus on first. And once you do that, everything changes. Everything changes. So I want to invite you to join me in the free 3-day training. If you go to feedthepeds.com/training, that will take you right there to the upcoming training. Join me. Bring yourself. I'm bringing the patients. It's completely free. You'll get 4 hours on a certificate of completion at the end, which is a bonus, and you'll even have some other really cool opportunities if you join us. So be there. Can't wait to see you all there. I can't wait to talk to y'all on the next episode. Until then, this is Hallie signing off.
Quick disclaimer: all information, content, and material of this podcast are the opinions of the speakers and is for 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.
