The Case That Was Never About Speech

I saw that kids were struggling with more than communication. I also had an entire caseload of kids dropped onto my lap unexpectedly. I had asked to work with feeding cases. They said, "We don't do that in this school." Somebody went on maternity leave and all of a sudden I had 12 kids added to my caseload that I didn't have the week prior, and they all had feeding goals. And I was like, "Okay." Anyways, fast forward, I worked in the schools for a couple years. I went to infants and toddlers, and then when my contract was done, I left. And so I took a little time off and then moved into private practice. And in private practice, I pretty quickly started seeing some of the same patterns that I saw when I was working with kids in the schools— drooling, open mouth posture, picky eating, difficulty chewing— like all signs of something deeper. I opened up my own private practice focused on speech, feeding, temporal tissues, and we did do some early language stuff, other people on my team, not me. And that's really when things really took off. But I remember that like first like full-on feeding case, right? Because my heart was racing, I was second-guessing everything that I was doing, and I was like, who am I like to handle a case like this, right? Spoiler alert, my confidence came after I took action, not before. And that is what I want for you, right? I want you to stop waiting until you feel ready and start building the identity of a feeding therapist one step at a time. Okay, so how do you actually become a pediatric feeding therapist? Like, that was a big question in my head. There was no guidance, no roadmap. It was like I piecemeal this together. I spent 10— honestly, I spent probably more than $10,000 and was still confused at the end of it because it took all these different courses. And so here's the roadmap that I wish someone had handed me 10 years ago. All right, step 1, foundations, right? I've started to realize I have a lot of like systems and everything I do. And so you're gonna probably start hearing me talk a little bit more in systematized type of language, giving you steps and things like that. Because in the past I just talk and my ADHD brain, it just, things just work like that. And then we've started to realize that I tend to say a lot of things like a lot of the same things. And so we're putting some frameworks or roadmaps or systems to things.

I always say this: semantics matter. And part of the problem is if you're not doing this every day, you don't know how to differentiate non-speech oral motor exercise from an orofacial myofunctional therapy exercise from an oral placement exercise from myofascial release. And it's even the patients that call, I have a baby, I need myofunctional therapy, or, um, I, you know, I need to go for a tongue-tie release and I'm looking for a myofascial therapist. Like, all of this jargon, if the professionals don't know the right terminology, the patients are not going to know what to look for.

And what do I mean by functional impact? I mean feeding is impacted. Sleep is impacted. Maybe down the line we see kids who've been in speech forever because they don't have full range of motion and can't actually hit certain sound targets, so it impacts their speech behavior because their sleep is impacted, right? We start to see these snowballing issues, right? Airway issues, always getting sick, all these issues that tie back to what's going on inside the mouth. But we have to remember, and I'm sharing this, we have to remember the functional impact and what that means because I still see a lot of professionals admittedly says they know how to assess and diagnose a tongue-tie but then spreads misinformation. We need to make sure that we are imparting the correct information and empowering parents. And so I see a lot of parents saying things like, oh well, my child was diagnosed with a tie but we didn't do the release and my baby, you know, was totally fine with feeding and speech and sleep and all the things, right?

And they still are fine. Well then it's not a tie.

If there's no functional impact, there's no impact on their overall health, we're not seeing systemic snowballing of issues and signs and symptoms that are, you know, impacting their ability to function every day and their optimal health, then it's not a tie. It's just a typical frenum, or, you know, frenulum if that's what you want to call it, right? Our tissues, those oral tissues, exist. Everybody should have them. It comes down to how pliable are they, how stretchy are they, do you have full range of motion, is there any restriction? And then beyond that, what is the functional impact? That is the question we need to be asking. And if we cannot answer that, or we don't see a functional impact, or we have the education to know how to answer that, that's when we seek out an evaluation.

Foundation, function, framework, and flow. So the foundation, number one, is understanding the systems. You have to learn how oral motor, sensory, posture, and airway systems connect, right? You start observing, like, what compensations do you see in the mouth, in the jaw, in the body, right? Then you got to build your knowledge around why feeding breaks down, not just like how to treat it, but like why is it even breaking down in the first place. If we don't know what typical is and we don't understand how we're deviating from typical, how do we know what to treat? Spoiler alert, we don't, right? So one, that's the foundation, like understanding the systems. We need to learn to assess, not guess. So feeding therapy, it's like being a detective, right? And we develop, you know, functional observation skills over time, especially with the right mentors, right? How does this child move? How do they eat? Breathe, swallow.

You have to be able to move it to use it, and this concept that people can just compensate with malocclusion or high narrow palates or oral restrictions doesn't make any scientific sense. We're in a field to help people remediate and overcome their disorder. No PT would teach a person to limp for the rest of their life. So why should we teach compensatory placements or mouth breathing because you can't breathe through your nose? It doesn't make any scientific sense.

I'm with you on that because I think one of these individuals who likes to be very anti-tongue-tie, anti-myo, and also seems to sit on many of these committees making decisions but doesn't have the skill set to do so. Is very big on teaching compensations and has even gone on their social media platform and basically saying like we should be teaching compensations. And I'm over here thinking like, um, in skilled therapeutic work— feeding, speech, myo, whatever— our goal is functional, like, restoration. Like, we are not trying to teach workaround habits to make things look good, um, and bypass the real issue, right? We're trying to figure out what compensations are happening, because ultimately over time that's going to break down further. And let's not teach compensations, let's fix the root issue here, right?

So psychologists, we're supposed to get to the bottom of the problem and then establish an interprofessional multidisciplinary team to help the patient or the student. There goes the lack of understanding of not knowing that soft tissue always trumps heart.

I work a lot with children with apraxia and motor speech disorders and just figuring out the language and how to come about that, helping them just focus. This is what's going on. We have a problem. I don't call it— it's not a real problem, but from a mental health perspective of problem solution, we are addressing what we see. We're helping your family kind of figure out carryover strategies at home. Yes. We could be stressed. We could also be anxious. Those are normal feelings. That's where the counseling comes in. But, but there is like a path and we just have to focus and trust the process and we're the ones guiding them. So that's like the hardest part too. You could be like, not sure about, okay, I don't really know what's going on today or like this didn't work, but figuring out, okay, I'll go to my toolbox and get something else and try it out. And I'm actually upfront with the family sometimes. Like I had a case. It's also hard because some things are ongoing. What you want to share, even if you don't share names, But I sometimes have like a case that starts off as like an articulation issue and then I realize, okay, there's actually something else coming in that's maybe not so much my expertise, like a voice resonance, or maybe there's airway that I've, through your help also and through your programs, like just kind of learn more about the airway and its impact. And most of the times we have like tools and we know where to go. We just have to be confident in it and like push forward.

You have to learn how oral motor sensory, posture, and airway systems connect, right? You start observing, like, what compensations do you see in the mouth, in the jaw, in the body? Then you got to build your knowledge around why feeding breaks down, not just like how to treat it, but like, why is it even breaking down in the first place? If we don't know what typical is and you— we don't understand how we're deviating from typical, how do we know what to treat? Spoiler alert, we don't, right? And that helps us connect our symptoms to root causes, right? Because we don't want to go chasing techniques. We need to learn how to reason clinically. And to your point, it's very interesting because a lot of clinicians looking to grow their accounts will do this and it gets them a lot of attention. But half the time I'm behind the scenes commenting with a friend or colleague going like, they're not doing this right. Did you see all the compensations on that person's face? Like, this is awful. Like, if we're going to educate, we need to do it properly. But also, can we not do therapy on the internet? And basically, because then everybody, to your point earlier, thinks that they can do what we do, which they have no idea what goes into this. Yes.

And then the naysayers come in and make fun of it because they don't know what they're looking at. Or you're like, oh, that person put this exercise up and it's not correct. And now you're opening the door Adding fuel to the fire.

But then I saw on social media a lot of this information, like, your child should be eating this at this age. And, but it didn't give all the in-between information. And I see friends going from my child's eating X, Y, and Z to like, my child doesn't eat anything. I'm doing it this way. Oh, I'm offering them like a cube of cheese because I saw this. I'm like, but you've never given them any other type of, you know, like you're starting here, but that's for someone who was already eating prior, like all these steps require. So long story short, I realized, wow, there's such a need here. I struggled also, and I did not like the feeling. It was not easy from the sense of like the parent overwhelm piece, not from like the knowledge and content piece. And so now, like, with my son, I'm having a different experience. But in my practice virtually, I'm trying to also connect with as many families as possible. And it's tricky because you have to figure out, okay, is this an actual, you know, pediatric feeding disorder, or does this require actual feeding therapy, or is it that the pediatrician is not necessarily supporting you in this journey of starting solids and they're saying, okay, start with this, give this much, this many times a day, giving you a paper and then go. And now you're overwhelmed and you want to start from the beginning in a successful, positive way and responsive feeding and understanding kind of the value of positioning and placement and all those early things that have such an important place in the trajectory of feeding. So I've kind of also positioned myself in that sense. On my website, there's a section for coaching and a specific section for starting solids. And I can really figure out if this is a feeding issue where like, okay, you're virtual, I can't see you, but let me see who I can refer you to. Or I can take you on as a private feeding client if you're near me. But there's a lot of times where it's okay, you just need maybe a few sessions of like starting solids and support and like figuring out your family's needs and how to to get you on track. So just knowing that's like for my, that's like part of my why. I just kind of want to like put that little plug in as well. The why will guide your practice and also your, if you own a business, I think it will guide, and you can tell me more about this, but I think it guides a lot of your decisions.

If you don't know the reason as to why you're doing what you're doing, if you don't have like a mission that's greater and larger than you and like a vision for like the future and where you wanna take something, like what are you working towards? Like what do you— it's going to become really overwhelming for you when you're working every day in the ins and outs of work and you have no idea like why you're doing it or what, like I said, like what you're working towards, right? And so I just think even having like, for me, when I launched the private practice, I was like, I want to provide a boutique service that is actually providing like very high quality services in the pediatric feeding, speech language arena, myo arena, I was when I added that in, but I feel like that's what's missing. I feel like there's all these practices every 5 minutes down the road, but I'm not hearing from families that they feel like they're being heard, that their kid is making progress. I'm like, why? Why is that not happening?

This is—

I'm like, so I was like, I'm going to be that practice. But you know, I hear people say things like, well, tools can become a crutch. Not if you're actually using them to teach a skill and then phasing them out, right? Like, people— some therapists I know have said to me things like, well, it encourages compensatory behavior instead of true motor learning. No, it doesn't. Not if you know how to use it properly and you have like an end goal in mind. And, you know, I've heard people say like, well, it shifts your focus away from like, you know, them developing this like internal awareness and neuromuscular control. No, actually it doesn't. It builds awareness and it builds neuromuscular control. Yeah.

And then, yeah, there's safety issues. There's shaping. And again, going into OT/PT, I worked for several years in the same room with an OT at my school. And one day she was doing Handwriting Without Tears, and she had putty and like these little clothespins, taking them in and out. And I looked at her, I go, Diana, what are you doing? And she goes, you know what I'm doing. No, no, no, I want you to talk me what you're doing. And she's like, well, in order to hold a pencil correctly, you need a pin— a pincer grasp, and you need the strength and dissociation, the wrist, the fingers. And that's a task analysis. Lori Overland taught me many years ago, 30 years ago, task analysis of function. So OTs break down task analysis, PTs break down task analysis. Even in singing, when we're doing vocology habilitation, we task analyze. And interestingly enough, there's a lot of tools in voice therapy. There's a lot of oral motor in voice therapy because you're shaping the mouth to control the resonance, and you're working with breath, you're working with the vibratory source, you're working with the articulators and the resonators, and no one blinks an eye about it.

Mm-hmm.

Doesn't bother anyone. But yet in speech, like, a still voice program is so closely related to myo, and that's what sparked my interest in this, in doing some research with Dr. Zaghi. Remediation over compensation, always.

Quick disclaimer: all information, content, and material of podcast are the opinions of the speakers and serves as the informational purposes only and not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider. That wraps up today's special compilation. My goal with these episodes is to bring together the conversations and the insights that are truly moving the needle in our field right now. Next, whether you're a parent looking for answers or a clinician looking to sharpen your skills, remember that the most important tool you have is your own clinical reasoning. Don't just look at the surface level symptoms, look at the underlying systems. If today's episode shifted your perspective or gave you a new aha moment, I would love to hear about it. Take a screenshot of you listening, post it to your stories, and tag me @HallieBulkin. You can always find more resources and past episodes over at untetheredpodcast.com. Thanks for tuning in, and I'll see you back here next week on The Untethered Podcast.