Why Some Cases Stay Stuck: The Clinical Thinking That Changes Outcomes

Baby comes in, won't bottle feed. Everyone in the room is pointing at the frenulum. Lactation said there's a tie. Internet says there's a tie. Parents are convinced it's a tie. And sometimes they're right. Sometimes a tie is the real meaningful contributor and a release is the absolute right call once the baby and the family are prepared for that and set up for that. And we've done the pre-op, right? But the integrated therapist doesn't just take the loudest voice in the room as a diagnosis. They run the feeding 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.

Hi and welcome back to the Untethered Podcast. Today we're going to dive into something that I think actually separates a good clinician from a clinician who changes a kid's whole trajectory. And it's not a technique, okay? It's not a certification, it's not the newest tool or the fanciest assessment. It is a way of seeing. I call it being the integrated therapist, and here's what I mean. Most of us were trained to do a thing, right? SLPs do speech or language. OTs do sensory and motor. PTs work with the limbs. Dentists work with the teeth, right? And when we get extra training like myofunctional therapy, orofacial myofunctional therapy, we add another thing to our toolkit, which I love genuinely. But here's the trap: when you've got a shiny new tool, you start seeing the problem that your tool solves everywhere, right? You see a tongue thrust, your brain goes, "Mio!" You see a feeding issue, your brain goes, "Ty!" You grab the first pattern you recognize and you start treating it and you never really zoom out. The integrated therapist does the opposite. The integrated therapist looks at a kid and asks, "What is the whole connected system doing right now?" Airway, structure, the nervous system, sensory, behavior, mechanics, right? All of it. Time before committing to anything. Because here's the kicker, right? When you treat through a single lens, you don't just miss things, you can actually reinforce dysfunction. Yeah, you can. You can chase a symptom while the actual driver sits there untouched. You can keep a family spinning their wheels for a year on the wrong intervention. So today, what I want to walk you through, how an integrative therapist actually approaches a case. We're going to look at a real case. I'm gonna show you the lens through which I'm running things all at once, every single time. So before we go into a specific case, I want you to understand the mindset because the mindset is the whole thing, right? When a referral lands on my desk, I don't start by asking, what is this? I start by asking, what are all the systems doing here and how are they talking to each other or not, right? Those are completely different questions and they lead to completely different care. So think about it like this: a single-lens clinician sees a tongue thrust and the question is closed before it opens. Tongue thrust equals myo equals retraining, done. They've already decided. Or maybe tongue thrust equals some other outdated form of speech therapy approaches that are still out there. Either way, myo could be an advanced version, but it's still, it's still a single lens, right? The integrated therapist sees that same tongue thrusting, goes, "Okay, that's interesting. Now let me run my lenses. 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 there a behavioral pattern? Is there a mechanical restriction?" And you start asking all these questions, and then, only then, do I 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 PT as people you call when you get stuck. They're a part of how you see the case from minute one. Like you're holding their lenses in your own head while you assess. Like, obviously we're not being them. This means that like you can catch the airway thing. You catch that there's a structural thing. You catch the sensory thing. Way earlier, and then you can bring the right people in at the right time instead of treating in a silo and hoping for the best, right? So let me show you what that looks like in practice. I'm going to take you through these lenses one at a time, but I want you to remember that in a real session, like, I'm running all of this together. So let's start with the lens that gets skipped the most: airway. Here's a case, okay? 4-year-old, they've got a tongue thrust, anterior open bite. Parents want to know if they— if the child needs myo. Now a single lens clinician sees that and starts planning the swallow retraining. The integrated therapist runs the airway lens first because the tongue does not live in a vacuum, right? It lives in space, and that space is shaped by whether the kid can breathe through their nose. So I look at the airway picture, and this kid has significant adenoid hypertrophy, which I can't visualize myself, but maybe I know that from a scope or a scan or an ENT note or a mom's airflow through their nose. It's not working. Why is nothing changing? But the integrated therapist sees the connection. The integrative therapist addresses the airway. They help get the adenoids managed, right? That's probably through a referral to an ENT or an allergist, or maybe they go into early expansion and that starts to help. We have shows us that can also change the tissue and decrease inflammation in tonsils as we expand kids' airway, also opens, right? So we get the kid back to nasal breathing and the tongue thrust sometimes magically just resolves on its own. Or it's way easier to treat because the kid can breathe now. The nervous system recalibrates because now there's a reason to. You didn't even have to drill the swallow during this whole process, right? You just had to see the system. So the question that the integrated therapist asks is this: is the tongue posture an actual motor retraining need, or is it compensatory, or is it both possibly, right? Is it doing what it's doing as a compensatory method? And then we're gonna have to retrain it once the child can breathe, right? Is it driven by structure, by adenoids, by like a low— high, sorry, narrow palate? Is the palate low? Is the maxilla narrow? Is it driven by an airway situation, right? Is it postural? Because the answer decides everything, and you cannot get the answer if the airway isn't one of the lenses that you're looking through, right? You got to look through that lens. You got to hold that lens through which to see things. And this is exactly where interdisciplinary care really earns its keep, if you will. The integrated therapist who sees mouth breathing and anterior tongue posturing isn't going to white-knuckle through myo exercises. They're going to loop in an ENT or possibly an allergist, like I mentioned before, because they understand that from the start the airway might be the driver. And this is not punting, this is integration, this is collaboration, right? This is proper care.

Let's flip it.

Let's talk about feeding. Baby comes in, won't bottle feed. Everyone in the room is pointing at the frenulum. Lactation said there's a tie, internet says there's a tie, parents are convinced it's a tie, and sometimes they're right. Sometimes a tie is the real meaningful contributor and a release is the absolute right call once the baby and the family are prepared for that and set up for that and we've done the pre-op, right? But the integrated therapist doesn't just take the loudest voice in the room as a diagnosis. They run the feeding lens, which actually has 3 layers underneath it. And you have to know which layer you're in. Is this mechanical? Is this sensory motor? Or is this behavioral, right? And sensory, because those three things need three completely different plans. And maybe it's a combination of them, right? So it's going to be a very customized plan in that sense. So let me give you a real example, right? We got an 8-month-old bottle refusal. Parents are convinced there's a tongue tie, but the baby has a cleft lip repair history. Okay. So the integrative therapist is already holding more than one lens. And when I actually assess the kiddo, the refusal isn't— it wasn't a mechanics problem. The baby has significant oral motor weakness from the repair, some scar tissue involvement, and honestly, some real mouth aversion, right? After everything they've been through, it makes sense. The tongue tie, it's also there. And it was just the obvious thing to blame because it was the thing everybody knew to look for. Now, if we release that tie, on its own, would it have fixed the feeding? We don't have a crystal ball, but chances are in this kiddo's case, maybe not the easiest immediate fix because the actual story was sensory motor and the plan needed to focus on building oral motor strength and decreasing compensations, right? And so a surgical intervention on the wrong target, if you will, is not gonna solve the problem. The family's still gonna walk out with the feeding problem intact, unfortunately, even though the release has happened. I just wanna stop there for a second because I'm not saying that addressing a tie in this case is not the right approach, but I like to take the approach of less is more. Let's do the least invasive approach first. If we hit a wall and we're not making progress, then that might become the time that we go, ah, okay, it's time to refer to the release provider. This kiddo's got sensory motor stuff going on. We've addressed it in therapy. We're building out the oral motor strength. We are decreasing compensations. But maybe we're doing that, like I said, we hit a wall. That's when I would go, okay, let's consider it. But knowing this kid's history, knowing the involvement, the aversion they've already had towards things coming towards their mouth, it's not going to be this easy ride, right? And we have to make sure they're properly prepared if we are moving forward, right? I've got another lens to share with you though. Pain. If there's pain with feeding, the integrated therapist doesn't go, "Oh, tongue tie." Right. Maybe they're thinking, oh, I wonder if there's some torticollis or if there is some tension going on, or if there's other, there's other things going on. The pain is for the mom, right? If the baby appears like they're in pain, maybe they're thinking reflux or thrush or inflammation or infection, or just there's this whole differential because a tie can cause discomfort and maybe even pain. Sure., but so can a lot of things and they all require different approaches and management. Okay. Look at the behavioral and sensory layer. Like this is a big one. We have so many kids with sensory processing differences, with aversion patterns, with learned avoidance of certain textures and tastes. And these kids have real feeding difficulty, right? It's affecting their growth sometimes, their nutrition, family meals, the ability to go out and eat in a restaurant, right? So many things, but it's not mechanical and it's not myofunctional. It's sensory and behavioral, right? And the plan is desensitization, graded exposure, and maybe an OT at the table with you, right? Say— and I get a lot of hate for this sometimes, but I'm going to say it— very few of the cases are truly just sensory or behavioral. Sensory and behavioral typically are a response to something, to a different root cause, a different root cause. So we can definitely have this present, but I rare— I can rarely rule out either something mechanical or something else functional, like a sensory motor issue. When a feeding referral lands, an integrative therapist slows down and asks— they ask layered questions, right? Is it mechanical? Is it motor? Is it sensory? Is it behavioral? Right? And often the honest answer is it's more than one, which is exactly why we need to focus in an integrated way and oftentimes have more than one set of eyes on a case, right? This is the lens where I see real harm when it gets missed. Neurological presentations that get treated as myo when they need a completely different framework. Apraxia, dystonia, dysarthria. I want to go over each of these for a moment, okay? Apraxia. I see kids with apraxia referred for myo because they've got low tone, unclear speech, maybe there's some oral motor like awkwardness. Right? And listen, myosupport can sometimes be a piece of the puzzle, a piece of a bigger plan, right? But the core of apraxia is motor planning. It's intensive, repetitive, targeted practice of specific motor sequences. It's not retraining resting posture typically, right? So the integrated therapist asks the real question: is the apraxia caused by a myofunctional dysfunction, or is the oral motor stuff just one feature of a motor planning disorder? Because if it's the disorder, you need the evidence-based motor planning work, right? And doing MYO instead can actually muddy the water for a kid who's already struggling to sequence movement. So just something to think of there. Kids typically are not going to respond in the same way if you put them in a traditional MYO program. Can you adapt it to what you're working on with them and still address the similar goals? If they're mouth breathing, yeah, absolutely. If you want to teach the goals of MYO, absolutely., but it looks very different. Then there's dystonia. This one haunts me a little. Dystonia, involuntary movements, trouble holding a stable posture, oral motor variability, right? I've seen these kids treated for tongue thrust when what's actually happening is an involuntary tongue movement. And you can't really rehab the nervous system the same way that you reteach a learned habit, right? There may be some medication involvement in here. There might be a neurologist involved, right? It's absolutely not gonna respond to myo exercises in the same way that a lot of your other myo patients do., and the time that you spend trying is going to delay the thing that may actually help them, right? So we have to be really good stewards of assessment. We need to know how to differentially diagnose, and if we don't, if something looks different, if something is not responding in the way that we expect it to, that's when we have to pull in other providers, right? That's where collaboration becomes really invol— involved but important. Okay, let's talk about dysarthria. So this looks like neurological involvement that affects motor control for speech, right? And so these kids might have the tongue thrust, maybe they've got oral motor difficulty, they might need some motor support, but the approach is usually strength and coordination and intelligibility, right? It's a different build than simply retraining head-neck-forward posture. Okay, so why am I sharing this? Because there's an integrated rule here. Here it is: if a kid carries a neurological diagnosis like cerebral palsy or Down syndrome or hypotonia, dystonia, apraxia, anything, right, then any myo work you do— so I'm not saying you can't do myo work, 'cause a lot of times you can, but the myo work you do has to be integrated into that neurological framework for that kiddo, right? For that patient. You're not working on tongue position in isolation. You're thinking about how the whole nervous system is organized, how tone is being regulated, what this kid's motor signature actually is. And the neuro lens then reframes everything you do. And the integrated therapist, never takes it off. Okay, so the next lens I want to look at is structure. Let's talk about a high, narrow hard palate, right? Maybe there's a posterior crossbite, severe maxillary constriction. These presentations can look like myo because, yeah, the tongue is sitting differently and the swallow has adapted to the room that the kid actually has. But the integrated therapist knows the difference between optimizing function and trying to change anatomy with exercises, right? You cannot retrain a tongue into a space that does not exist. And this is not me saying myo has no role with structural cases. It 100% does. It must be there. Let's be clear, every child that has— that needs braces, that needs expansion has an orofacial myofunctional disorder. So I'm not saying myo doesn't go here. Hi, it does. But you might be doing like pre-orthodontic prep, right? You might be optimizing function inside the constraints of their current structure. You might be doing post-surgical work after frenectomy or a palatal expansion, right? The integrative therapist uses myo with structure around structure, in service of structure. What they don't do is expect a tongue thrust to be retrained to widen a maxilla or reshape a palate, because that's just not how it works, right? We also don't expect that they're going to start hitting all of their speech sound targets in an environment where the tongue doesn't fit in that space. The car doesn't fit in the garage, right? How are we going to improve something? You're just going to teach compensations, and compensations usually break down again in the future, and that's why a lot of these kids end up back in therapy. Anyways, here's a case, okay? Kid with a really high narrow palate, significant posterior crossbite, tongue thrust pattern, parents desperately wanting to avoid orthodontics, hoping myo can fix it. And I had to have the honest conversation. Here's what myo can do, right? It can help your child use their tongue as well as possible inside the space they've got. It can support oral motor coordination. It can maybe prepare them for what comes next, but it's not going to change the shape of the palate. Or the width of the maxilla, okay? That part needs a different intervention, possibly orthodontics, possibly an expansion appliance, whether it's an ortho or an airway dentist, possibly more. But what we can do is support function and set them up well for those other pieces, okay? And that's the honest conversation, right? That's ethical. And that's the integrated therapist working shoulder to shoulder with the orthodontist or the dentist instead of pretending they don't know each other, right? And it's the same story if you have a kid with a cleft, right? A repaired or unrepaired cleft creates all kinds of oral motor adaptation, but the cleft itself is structural and surgical. Your myo work supports function around the structure, right? Or oral motor work or whatever approach you're taking. It doesn't fix the structure, right? Knowing exactly where your lane ends and the surgeons begin or the orthos begin or the dentist begins, that's integration. So let's bring it all together because this is the part that actually makes you the integrated therapist instead of just a clinician who knows a lot of facts. And a lot of information that you've collected from course after course, right? When you run all of these lenses that I've gone over and you realize that the driver, the root, is sitting outside your scope, that is not a failure. That's the work, right? The integrated therapist doesn't experience a referral as, uh, I couldn't help them. No, you experience it as, I saw the whole picture really clearly, clear enough to get this kid to the right person. That's expert thinking. That's the opposite of stuck, my friends. But here's the key: the way you refer is part of being integrated, okay? So a thoughtful referral— and I actually had a question in my inbox yesterday, inbox I mean on like Instagram, where somebody had asked me, I'm referring this kid to the ENT, or not this kid, but I refer kids to the ENT and I tend to get them sent back to me with like, they're fine. You got to be an integrated therapist and take an integrated therapist approach to the referral, okay? If you get— you give the ENT, I'm seeing significant mouth breathing, anterior tongue posturing, and I'm wondering if there's an airway component. That's going to get you something very different. If you can give that information to the ENT ahead of the kid coming in, they know why you're sending them, they know what to look for, they have context now, right? Maybe the OT— you refer to an OT, you give them, I'm seeing oral motor pieces, but also it looks like some sensory defensiveness. I'd love your eyes on this, right? Maybe you give the pediatrician or the neurologist, I'm seeing some motor control patterns that make me wonder about underlying neurological involvement, right? You're not passing the buck here, you're not telling them how to do their job, you're not telling them what to assess, You're just telling them what you're seeing, how it's impacting the work you're doing, and it's basically you're being the clinician who's thinking out loud across disciplines, right? And they understand why you referred them, which is so important. And it doesn't have to be a 15-page report. Please don't send them 15-page reports.

Nobody reads them.

But here's the thing, a lot of the time the integrated answer isn't actually you referring out at all. It might be a co-treat. Maybe you're doing the feeding work while the OT does some sensory work and you're actually talking to each other, right? Maybe you're doing myo around a cleft repair while a surgeon and ortho do their part and everybody's coordinating. Maybe depending on the, the kiddo, maybe you're doing some feeding work too, right? Maybe you're doing some speech work, right, around that cleft case and that cleft repair. ENT plus an SLP plus a dentist all pulling on the same case— like, that's the sweet spot, right? That's the whole connected system working the way it's supposed to when everybody's collaborating and things are integrating. It's so cool. So the question that the integrated therapist asks at the end of every assessment is this: do I treat? Do I refer? Do I co-treat? And do I have enough information to even know that yet? And when you're not sure, you ask for the consult. You bring in another set of eyes. And that's not weakness, my friends. That's the entire point. That's collaborative care. Okay, and so here's what I want you to carry out of this episode. One, the integrated therapist asks, what are all the systems doing? Not What is this? A symptom is smoke, right? Your job is the fire, find the fire. And remember, it's not, it's usually not where the smoke is the loudest, okay? Number 2, run the airway lens first and always. The tongue lives in a space in our mouth, right? And breathing shapes that space. And so much of what looks like myo is compensatory for an airway you haven't looked at yet, okay?

That's number 2.

Number 3, Feeding has layers: mechanical, sensory, motor, behavioral, right? And you gotta know which one you're in before you commit to a plan. So stay open to it being more than one of those areas. 4, the neuro lens reframes everything. If there's a neurological diagnosis or pattern, your myo work has to live inside that framework, not next to it. And that's a whole nother level of skill. 5, structure is structure, my friends. Myo optimizes function inside the room that a kid has. It's not gonna build new rooms, right? Making bigger expanded spaces by getting the tongue up in the roof of the mouth, especially when it doesn't even fit there, right? Just know exactly where your lane ends and where the next one begins so we can call in those referrals. And 6, referral and collaboration, they're not a backup plan. Now listen, don't go referring somebody to 3 different people at once, right? Pick a singular referral and make that referral and focus there. But they're not the backup plan. They're how the integrated therapist practices on day 1. Seeing the whole system clearly enough to bring the right people in at the right time, my friends, that is a skill. Okay, this was never about Mayo being the answer to everything. It's about Mayo being the right answer to the right problem and having the clinical discernment to see the whole child well enough to know the difference. That's the integrated therapist, and that's who I want you to become. If this lit something up in you, if you want to build this kind of integrated whole system clinical thinking, I want to invite you to join me inside The Integrated Therapist. This is where we do the deep dive casework together. We look at and go through real cases. We run the lenses. We build your differential thinking and your sense of when to treat and when to refer and when to co-treat. And it's the place where you stop dabbling and you actually become the clinician who sees the whole child. So head to theintegratedtherapist.com and join us. You can also follow me on Instagram @halliebulkin. And if this episode landed for you, leave a review. It genuinely helps get these conversations in front of the clinicians who need to hear them. Also, feel free to share it with your friends because they need to hear it as well. Thank you so much for being here. I will chat with you all 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 MyoToz 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.