[00:00:00] 

Intro

Kate Grandbois: [00:00:00] Welcome to SLP 

Amy Wonkka: Nerd Cast. I'm Kate. And I'm Amy. And we appreciate you tuning in. Whether you're an SLPA teacher, an EI provider, an allied health professional, or a parent or guardian of somebody with speech and language needs, we hope this podcast will give you some valuable information and keep you at least a little entertained.

In our podcast, we'll review resources, literature, and discuss issues related to the field of speech language pathology. 

Kate Grandbois: You can use this podcast for ASHA Professional Development. If you'd like more information about us or ASHA pd, go to our website, www.lpnerdcast.com. Uh, financial disclosures. Tracy is currently employed in a private practice setting in Boston, Massachusetts.

She owns her own practice and has an online [00:01:00] learning platform called Guest Monster Games. I am the owner, founder of Grand Wa Therapy and Consulting, LLC, and co-founder of SLP Nerd Cast. Amy is an employee of a public school system and co-founder of SLP Nerd Cast Non-Financial Disclosures. Um, uh, Tracy is a member of ASHA and the corresponding special interest group, SIG 13 for dysphasia.

Kate and Amy, uh, are both members of ASHA SIG 12, and we both serve on the a a C Advisory Group for Massachusetts Advocates for Children. I'm a member of the Berkshire Association for Behavior Analysis and Therapy, mass, a BA, the Association for Behavior Analysis Inter International and the corresponding Speech Pathology and Applied Behavior Analysis Special interest Group.

Okey dokey. Amy, what are we talking about today? 

Amy Wonkka: Well, today we have a special guest, woo-hoo. And we are talking about feeding and swallowing in the school environment. 

Kate Grandbois: That is right. This is our second virtual guest. Uh, we are very excited [00:02:00] to introduce Miss Mrs. Tracy Callahan. Hi Tracy. Hi guys. Thanks for having me.

Thank you so much for coming on the show. Um, why don't we start by having you tell us a little bit about yourself. Tell us how fancy you are and how smart you are. 'cause you're smart and fancy. 

Tracey Callahan: Very fancy. Um, I've been a speech pathologist for more than 10 years. I've worked in public schools, private schools, early intervention, outpatient, inpatient private practice, done a little bit of everything.

Uh, children and adults as well, uh, but have really focused on swallowing and feeding issues, especially the last few years. And I've also presented, uh, local conferences, Asha, and then also at an international conference. Where did you go? It was really fun, uh, Liverpool. Awesome. No way. Yeah, it was really awesome.

Yeah, that 

Kate Grandbois: is, that is 

Tracey Callahan: so 

Kate Grandbois: awesome. Well, it was, 

Tracey Callahan: yeah. The International Pediatric Brain Injury Conference, so, no, 

Kate Grandbois: that's so cool. [00:03:00] Um, we have known you for a while. We've had the pleasure of working with you in other settings, and I feel like you've been at least my go-to feeding and swallowing person. Mm-hmm.

Whenever I have a question. Um, so how you've been doing pretty much exclusively feeding and swallowing for how long? Um, maybe not exclusively, but primarily, not 

Tracey Callahan: exclusively, but I would say for the last seven years or so primarily, um, there's the setting, the inpatient, rehab setting, um, and also in private practice.

I've been doing a lot of swallowing in both of those settings. 

Kate Grandbois: And the tone of this episode is very much entry level. I mean, I can say Amy knows a, a wicked lot more than I do about this. I am, I am definitely the naive and uneducated one outta the three of us talking about feeding and swallowing. 

Amy Wonkka: I think that what we are going to talk about today and why I am so excited to have Tracy here to talk to [00:04:00] us is because feeding and swallowing is an area that is, you know, kind of scary.

You know, I haven't worked in feeding and swallowing since I was in grad school, and that was a really long time ago. And I know that it's something that keeps coming up in the schools. It's been in the, as a leader a few times, there have been articles about feeding and swallowing, and I think that it's an area for a lot of us.

School-based speech pathologists where, you know, we learned about it in school and then feel disconnected from that information and not sure what to do. So I'm excited to have Tracy here to give us information about, you know, kind of demystifying it a little bit and making people feel a little bit more comfortable.

Kate Grandbois: And I was that everything you just said made me wanna say so many more words, because I think this is gonna be a really, um, exciting topic. But before we jump into it, I wanna go over our learning buckets, um, our learning objectives for the day, so. First we're gonna identify the prevalence of feeding and swallowing disorders and the importance of the school [00:05:00] SLP involvement.

And I, that's the biggest thing. I was just about to say off of what you said, Amy, just about how, you know, we learn about these things in graduate school and then we go off and do our jobs. If we don't use that knowledge then, you know, if you don't use it, you lose it. And then you get a client on your caseload.

Um, and the risks of, you know, it is scary. 'cause if you mess up, you, you know, a lot. Most of us feel like maybe we could actually hurt someone. But anyway, so that's learning objective number one, learning objective. Number two, identify different elements of feeding and swallowing evaluations. Three, identify feeding and swallowing evaluation procedures in a school setting.

So we have a lot of content to get through. Um, but it's gonna be good. 

Amy Wonkka: Yeah. So Tracy, start us off. Help us with this first learning bucket where we're trying to figure out, you know, what is the prevalence of feeding and swallowing disorders. In the pediatric population. 

Tracey Callahan: Um, well, the CDC uh, did an interview and they say [00:06:00] that it's just under 1% of children.

So three to 17, uh, they're finding have some kind of a swallowing disability, so that's separate from feeding, but specifically swallowing issues, which is not a, that small of an amount. 

Amy Wonkka: And this is, so this is something that comes up that I think is a little confusing. Right. So we hear about feeding, we hear about swallowing, and you, you're saying those are two different things.

Correct. Can you talk 

Tracey Callahan: more about that? Sure. So swallowing is the process where you're actually moving the food or liquid or saliva from the mouth, and it's transported from the mouth to the stomach, uh, keeping the airway protected. And then feeding is the process. Um, any aspect of eating or drinking. Um, and it's, it's the process of getting the food to the mouth.

It includes a social experience as well. [00:07:00] Um, communication around that. Um, yeah, so that there are two completely separate things. 

Amy Wonkka: But I would bet that a lot of the time those things go together. 

Tracey Callahan: Yeah, definitely. Most, most people that have some sort of swallowing issue either have a feeding issue that goes hand in hand with it, or because of their difficulty with swallowing, develop, uh, a difficulty with feeding.

Kate Grandbois: Is it the other way also, if you have a feeding issue, do you als, is it also more likely that you have a swallowing issue or is it just the other way around? 

Tracey Callahan: It? It could be. Um, there, most often it goes hand in hand. So thinking of some of the kids that I've worked with. That have a longstanding history of, of difficulty with swallowing, even just from bottle feeding or nursing.

That whole process was really awful for them. And then, um, turns out that they later on had difficulty with feeding [00:08:00] because the swallowing process for them was so uncomfortable. Um, it, it created this feeding issue where they didn't wanna be putting things in or around their mouth. Uh, somewhat sensory based as well.

Amy Wonkka: So you said that around 1% according to the CDC, of those, of those three to 17-year-old folks are having challenges with swallowing. Are, do you see any differences in, in different sort of diagnostic categories, are there some people who are more likely to have problems with swallowing than 

Tracey Callahan: others? Um, well we know that specifically with feeding children with autism are five times, uh, more likely to have some sort of a feeding issue than people who do not have, um, autism spectrum disorder.

Kate Grandbois: Wow, that's a lot. I mean, that, that, that level of, of risk. 

Tracey Callahan: Um, and then also children with cerebral palsy. Um, the, the rates are [00:09:00] somewhere around maybe 20% to 99% of people or children with cerebral palsy will have some sort of either feeding, um, dysfunction or more oral pharyngeal dysphagia. So difficulty with chewing, oral manipulation, keeping food in their mouth.

Kate Grandbois: So if for most. In pediatrics, when would you say it's most commonly identified? Is it something that can be identified, you know, as a newborn, if you're having, you know, breastfeeding issues or bottle feeding issues, or is it also just as easily identified in toddlerhood or when solids are introduced, or does it depend?

See, I'm asking all the really stupid questions. No, no, no. Aren't you so glad? Just as a caveat, I have not done feeding and swallowing for 15 years. I mean, I just know nothing anymore, so I'm fine. I'm comfortable with it. Go on. 

Tracey Callahan: So I will say that [00:10:00] when, when I'm doing an assessment, going all the way back to birth, when I'm asking questions about feeding, when I'm asking questions about swallowing, um, because a lot of the children, maybe they had some minor difficulty with feeding and swallowing, and now, uh, at this point in their life when I'm seeing them, maybe when they're older, it's become a bigger issue.

But oftentimes there's like a little trail of breadcrumbs to let you know that there was something else going on, unless the feeding issues or dysphagia is brought on by some sort of acute event. Mm-hmm. Um. But I will say that not every child that has difficulty with nursing or breastfeeding or bottle feeding will develop a feeding disorder.

Amy Wonkka: Hmm. And is it also true that some people will develop a feeding or swallowing disorder who didn't have that dysfunction with breast or bottle feeding? 

Tracey Callahan: Yes, [00:11:00] absolutely. Um, there's a lot of different events that could have occurred, um, that could bring that on. Um, but for the most part, I would say most of the people that I'm seeing, there's some something that's occurred in their past that would let me know that maybe at some point they were having difficulty.

And that's why it's really important when you're doing any sort of feeding or swallowing assessment to take a really, really thorough, uh, case history, medical history. 

Amy Wonkka: And just to, just to help the listeners form a little bit of a picture in their mind, what might be some of those things? You, you know, you're working in a preschool or you're working in an early, you know, early elementary setting.

You're still getting that, like more robust developmental history from the family. Are there any things in there that, that should be maybe something that the clinician reads and thinks about a little bit. 

Tracey Callahan: Um, well, one of the first questions I always ask is to have a [00:12:00] parent tell me what it was like. Um, and a lot of times, a a lot of times they'll start to just talk about it themselves.

So if I say, okay, well what are your concerns? Uh, tell me more about it. A lot of times that sort of an open question will lend itself to parents speaking, but specifically I will ask questions like, how was bottle feeding? How was nursing and what was it difficult? How long did it take? Did you find that process stressful?

Was the child feeling calm after eating? Or was the child feeling upset? How was weight gain? Was weight gain ever an issue? Was there any point where they lost a lot of weight and had difficulty putting it back on? And then even more recently, how about when solids were started? Was that a difficult process?

Did you find that meal times were very stressful or is eating [00:13:00] enjoyable? 

Amy Wonkka: Those are really helpful. What about, um, kiddos who have very restricted food repertoires or, you know, he only likes Cheetos and Doritos? Sorry, is that, is that something you missing? Who doesn't like 

Kate Grandbois: Cheetos and Doritos? I know, and I love Doritos.

There's so good. We're recording this at time and I haven't eaten. So now, now maybe that was a mistake. 

Tracey Callahan: Um, so those, that's, that's something that. I see quite frequently and a lot of times children that are very restrictive with what they eat, uh, they do. They don't just wake up one morning and decide that they are only going to eat the Mickey Mouse, um, goldfish crackers and only the red ones, and only from the individual serving packages.

There are other things that have occurred before that. Um, oftentimes parents will tell me I attempted to do the [00:14:00] baby led weaning and that didn't work. And we tried purees and that didn't work, and it took forever to wean them off of the bottle. And in fact. At three years old, they're still having one and we've been trying for years and can't get them, um, to stop bottle feeding.

So there are other things there. Um, and then I just wanna make sure that I highlight that when asking the questions for, uh, to parents, it's really important to be open-minded and nonjudgmental. Mm-hmm. Because a lot of times, um, parents are just doing the best that they can. And if that's the only way that they've been able to get their child to eat, um, then maybe, uh, this restrictive diets their coping mechanism to make sure that their child is fed.

Amy Wonkka: Well, I think that's a really good point too, right? I mean, eating is such a loaded, such a, such a loaded thing, right? You don't want to, I would imagine, you know, no parent wants to create [00:15:00] all of these barriers around eating and it's, it's more, I feel like it's a harder dynamic than with a lot of other things.

You're like, well, you know, I'm the mom and you're gonna do this, and this is just the way it is. I feel like eating and feeding has this complexity to it. 

Kate Grandbois: And a social component too. I mean that's mealtimes for families, it's holidays. Um, and that's a perfect segue into what I was just gonna ask. So you have families who are going to hospitals, inpatient settings, outpatient settings, coming to see people like you.

Um, and then, you know, we had talked about this when we were preparing for the episode. They leave with this great set of recommendations and then what? Right. So, so what, what does that, what does that look like? What is the bridge like from the inpatient, outpatient clinic, whatever, what is the bridge like from that setting into the world?

Tracey Callahan: Um, well, the, the therapist that is working with the child, whether [00:16:00] it's an evaluation or, um, it's evaluation in treatment sessions to work things out, they would always make sure to provide a really robust assessment that includes all instrumentation that was used, if any instrumentation was done. Um, strategies that have worked.

Kate Grandbois: What, what's an instrument? What do, what do you mean? So like a, like a feast fleece feast. Fees, please. Yeah. Clothing. 

Tracey Callahan: So it, it could be a fees, test fees. 

Kate Grandbois: I am so smart. I am a licensed 

Tracey Callahan: speech 

Kate Grandbois: pathologist, so 

Tracey Callahan: who is so good 

Kate Grandbois: at so many things, but not this. Go on. 

Tracey Callahan: And that's, and that's okay. 'cause there are people like me out there who would love to do this and would be be terrified to do an A, a C assessment and would be a fish out of water.

So, so that's what I'm saying. You're my feeding and 

Kate Grandbois: swelling person. Go ahead. Drop your science. 

Tracey Callahan: Um, so a fees is gonna be the endoscope, um, versus what used to [00:17:00] be referred to as an MBS. We're now referring to it as A-V-F-S-S, so video fluoroscopic swallow study. And I know 

Kate Grandbois: we'll get to some of those details later on, but I'm So, I'm sorry to interrupt your train of thought.

I just wanted to ask so I could follow along. Of course, of course. So they, they leave with this set of recommendations or a description of what testing procedures happen. Yeah. 

Tracey Callahan: And also, so outside of instrumentation, uh, another really important part of an evaluation is gonna be the bedside swallow evaluation.

So even when it's sort of called that, even if you're not having the person in a bed, I just think that it's just one of those things that we, we say, so it's, you know, the, the bedside swallow. Yeah. 

Kate Grandbois: So, so why, so if you, if geniuses like you exist in the world, why is the school SLP so important? And to defend myself?

I am not a school. SLP. So, so Amy, why is the school SLP so important? Why is this an issue? 

Amy Wonkka: Well, I don't, I [00:18:00] don't work in that role at the moment either. But I will say, you know, when we think about. As somebody who works in the role of a a c specialist, you know, we talk about communication, and communication happens across multiple environments, and the same is true for feeding and swallowing.

Uh, if, uh, if a child is school aged and they're attending school, they need to receive nutrition in that environment. And if that includes some, you know, oral intake of food or liquid, um, and that's a student who's, you know, followed by somebody like Tracy, then I would imagine it would be important for those same strategies to be carried out across environments, including the home, you know, including the school.

Just like it would, you know, just like the recommendations we would make around the use of a, of a child's a C device. Um, and I 

Announcer: so. 

Amy Wonkka: No, go 

Tracey Callahan: ahead. Also, um, you know, outside of that IDEA and FAPE also indicate [00:19:00] that it should be addressed. Uh, all health related disorders, um, that are going to affect a child's ability, need to be addressed as part of their educational program, and that's huge.

Amy Wonkka: And there is also, I'm a big fan of SIG 12. I was plugging SIG 12 the other day. On our podcast, there is also an Asha special interest group for feeding and swallowing. Right. I am a member of that 

Tracey Callahan: special interest. What, what, 

Kate Grandbois: what number is it? 

Tracey Callahan: Of course, you would ask me, and I don't remember right now.

Sorry. 

Kate Grandbois: I'll get into a Google. I'll Google it. 

Amy Wonkka: Okay. Um, do, because I, I find I'm in 12, which is the a a C one, and I find it's helpful. There's a list serve and a lot of people are posting things and it's just a helpful place to go and kind of, you know, read through what other people are doing. I don't know.

Do you use it at all? 

Tracey Callahan: I do. I, I use it mostly for the articles and the research that comes out. I think that they do a pretty good job of organizing all of that information for [00:20:00] me and also screening it. So if I know that it's posted in this group and other people have read through it and they agree or disagree, or maybe it brings up a new technique, it's worth my time.

Versus some of the studies and information that's come out that, um, is just based on maybe one patient and, uh, hasn't really been tested thoroughly. 

Kate Grandbois: Well, and they have the, it's number 13. Oh, SIG 13, right after 12. Neighbors. Neighbors. Um, so you made such a good point before about it being part of IDEA and fape, and is it true that, um, you know, there are a lot of speech pathologists in school who feel, who come to you for advice because this isn't in their area, or, I mean, I have to assume.

So if anyone's listening to this podcast, they wanted to get more information about it, but I feel like this is a specialty. Um, you know, it's something that is scary [00:21:00] and, and hard. 

Tracey Callahan: Um, I, I get a fair amount of people that ask me questions about feeding and swallowing or for resources, but I think a lot of people are going to the internet first now and utilizing all of the really amazing information that Asha has on their website.

Mm-hmm. They have a really good paper on. Just, you know, all, all things swallowing, all things swallowing in the schools. Um, and then, uh, I have friends who work in different public school systems who one person has been identified as sort of the feeding and swallowing guru that goes through and helps the other therapists who may not feel quite as comfortable.

So if I, for example, was in a school, I have an a, a C person that I can go to, to talk to, uh, a lot of schools that I know of I've come up with. And, uh, a feeding and swallowing person that the [00:22:00] other therapist can kind of question or consult with or con have the child see for support. 

Kate Grandbois: So to sort of recap that, just to make sure I'm, the role of the SLP in the school is crucial for these kids for not just because it's in compliance with the law, but because they play a huge role in keeping them safe in school, allowing them to get their nutrition through eight hours of six hours of a school day, however many hours depending on your situation.

Um. Minimizing their risk in school, participating in curriculum activities like lunch bunch. 

Tracey Callahan: Yeah. E exactly. And, and one of the things that I often hear from parents where I'm seeing the child as part of private practice is that they've been identified as a student who could benefit from a lunch bunch for social skills.

Mm-hmm. And the child is so anxious around eating and swallowing. Maybe there's [00:23:00] no, you know, true dysphagia, but maybe they have difficulty with certain textures that they're not really able to access the social piece of that. So I think it's really important to identify that, you know, anxiety, sorry, that anxiety, um, and fear may go into it as well when identifying children that might be appropriate for a lunch group.

Amy Wonkka: Okay. So I feel like I have a much better picture in my mind between the difference between feeding, which is sort of all of that. Like outside the mouth work and then swallowing. I like 

Kate Grandbois: that. Outside the mouth. In 

Amy Wonkka: inside the mouth. Mm-hmm. Um, can you talk to us a little bit more about Bit what, what happens during an assessment?

Like what are all the parts of swallowing inside the mouth? You know, I remember from grad school there's a lot of different parts. There's something to do with a bolus. Mm-hmm. Uh, 

Kate Grandbois: can we just take a minute to talk about how funny that word is? [00:24:00] Does no one else find it amusing Bolus. Okay, just me. Moving on.

Learning objective number two, ident. Identifying the different aspects of a feeding and swallowing evaluation. I'm just gonna chuckle quietly to myself. Every time you say bolus. Enjoy. 

Tracey Callahan: Um, so when we think about swallowing, it's most commonly divided into four different phases. So the oral prep phase, and that's the process of the food, the liquid getting, um, chewed up, manipulated, tasted as well.

Um, it could be, uh, sucking liquids from a straw. Um, that's the oral prep phase and then the oral transit phase. Phase two is when you start to move all of that food from the front of the mouth, um, form the bolus and initiate that swallow. So then comes the pharyngeal phase where the [00:25:00] bolus, Kate, the, the bolus is, is being propelled.

And then the esophageal phase, which is completely involuntary, where the bolus is going into the stomach. 

Kate Grandbois: I remember that's called peristalsis. 

Tracey Callahan: Correct? 

Kate Grandbois: That's my, my one nugget mean, there's 

Tracey Callahan: the 

Announcer: funny word, 

Tracey Callahan: UMIs. I. Um, so I will say, I know that you guys have cited in some of your other podcasts about the books.

Uh, the Loman textbook is a really, really, really great resource for that. I know that that's one that I still have, that my husband keeps trying to get rid of, and I refuse to let go of. Don't let him do 

Amy Wonkka: it. Don't let him do it. That's what bookshelves are for. 

Tracey Callahan: Uh, but I would, I would definitely recommend for anybody who is looking to kind of go back and learn more and feel more comfortable about that, that textbook is definitely very helpful.

Amy Wonkka: Now, when someone comes to you, so say, you know, I, I have a concern. I say, I think [00:26:00] you should go see, you know, somebody for a swallow study. Um, and they come to you. You are looking at all of these parts, but you're also looking at that feeding piece too. Are you doing that? Are you doing that kind of all in the same visit?

How are you figuring out, you know, when it's a bedside and when there's some of that instrumentation 

Tracey Callahan: involved? So, uh, when, when I am getting a referral, um, I would be one of the first steps in whether or not instrumentation would occur. Just like you don't say to yourself, oh, I feel like my arm is broken.

I'm gonna walk in and get myself an x-ray. You don't just sort of walk in and get yourself an MBS. Well, you don't get 

Amy Wonkka: yourself an X-ray that way 

Tracey Callahan: successfully, Tracy. Um, so what you would do is you would go to a speech pathologist, maybe like myself or a feeding clinic. There's quite a few different clinics out there that provide this service as well, and they would go through all of [00:27:00] that information.

So earlier I referenced the importance of a case history. So that's the first. Thing that I'm looking at. And then I'm going to, um, do my assessment, which would include seeing how they interact with the food. Um, but I also like to make sure that I'm taking a look at, um, what's happening before that. How are they breathing?

Is their breathing clear? Is their breathing junkie? How is their posture? Are they a child who is very slumped over? Do they have poor tone? Are they able to sit by themselves? Um, some children that I see will be in a wheelchair. What sort of supports do they have in that wheelchair? Um, or if they do have a wheelchair, that wheelchair needs to come with them when they come for the assessment, whatever that they are going to need at home or at school.

Kate Grandbois: So this is, when you say to talk about positioning, it's making me feel like, you know, think of an aac c about, do you work often with OT [00:28:00] in terms of positioning or are there other allied health professionals that you bring into these assessments? 

Tracey Callahan: There it can be a team-based assessment and some clinics will have it be team-based, especially if there are other medical diagnoses as well.

So a lot of the, the inpatient or rehab centers you might have physical therapy who's working on making sure their wheelchair is appropriate. Um, occupational therapy, making sure that they're able to use utensils, any special grips that they might need, plate guards, that sort of thing. And then the speech therapist will often do feeding.

Though I will say there is a ton of overlap between occupational therapy and feeding and phys and speech therapy and feeding it. They really go hand in hand. And we are good friends in the world of feeding OTs and SLPs. 

Amy Wonkka: So you're looking at the case history. You're looking at, you know, their, their prior interaction with [00:29:00] foods and drinks.

Mm-hmm. What they're doing now. You're doing kind of just a, just a basic oral mech on them and seeing how their structures and 

Tracey Callahan: Yeah. And, and I will say that, um, nobody loves an oral MEC exam. Nobody wants to have. To go through that process. Um, part of the case history that I take will be, is your child able to follow directions?

Mm-hmm. If that child is not able to follow directions, if they're not able to imitate and I'm trying to do an oral MEC exam, um, it might be because they do not understand or are physically not capable of following those directions. Mm-hmm. Um, or I can't rule out that it could be. Um, a difficulty with using, uh, the different structures for feeding.

But an oral neck exam is an important part of every, I would say almost every eval if you're going to be working on swallowing or communication or speech articulation, that's something that most speech [00:30:00] therapists are probably already doing as part of their evaluation. And it looks very similar, uh, to the one that we're gonna be doing in a feeding or a swallowing ev v.

Amy Wonkka: So after you've done all of that, what do, do you typically have the family bring along? You know, sort of some foods and drinks and just have, have the kiddo go at it and see what, see how it looks? 

Tracey Callahan: Yes. And there is some setup that's required because obviously people aren't just walking around with tons of snacks.

Well, I mean, I do, 'cause I have two young children, but. It's important to make sure that you have foods that you know that they're going to be successful with. 

Announcer: Mm-hmm. Foods 

Tracey Callahan: that you believe that are going to be difficult for them to eat. Foods that you know, that they either don't want to eat or will not eat, because you need to see the interactions with all of that.

Um, in addition, you also need to make sure that the food and the liquids that you are going to have available are ones that [00:31:00] they need to be either eating at home or at school. If, if you're not eating liver pate at home, don't bring that to a speech eval. Um, and also don't bring that anywhere. Yeah.

Kate Grandbois: Sounds terrible. 

Tracey Callahan: Liver pate is big in, in Russian culture, so it, it is in my house. Uh, maybe I would 

Kate Grandbois: like it. Is it hot or cold? 

Tracey Callahan: Um, I don't really like it for, for speaking of text. The texture for me is, is is a little bit rough. 

Kate Grandbois: Can you put it on toast? 

Tracey Callahan: Most people do. Yeah. Okay. It's like a, it's a spreadable thing because I 

Kate Grandbois: do other pate.

I don't know. 

Tracey Callahan: Yeah. So moving on, move, moving on. But, um, you'd wanna make sure that you have a few different textures and whatever textures that you're doing are safe and developmentally appropriate. So I'm not going to be giving steak to a 10 month old child. Mm-hmm. That's not a food that's developmentally appropriate for them to be eating.

Mm-hmm. And, um, I wouldn't give, for example, [00:32:00] pureed eggs to a teenager, unless that's what they said was safe. Um, I would choose a food like applesauce or maybe pud, something along those lines. So you wanna choose something that's developmentally appropriate as well as safe. 

Amy Wonkka: So once you've done that, you've had your individual come in, you've, you've done all of your, you know, case history, your oral Mac, you've had them try whatever different textures they're willing to try in that context.

Um, if you do feel like additional assessment is necessary, what are kind of, what are the next steps and what does that look like? 

Tracey Callahan: So what would happen is you would refer to, um, ENT, um, so the ENT uh, clinic is often the clinic that would be doing the assessments. So if, if you are somebody who. Has a documented [00:33:00] dysphagia with aspiration, and that's when the food is going in food or liquid or is entering into the lungs.

You probably already have, um, a clinic that you're followed through. So a lot of these clinics will already have all of that in place. So radiology, uh, the speech therapist that's able to do the bedside, um, which may or may not be the same person that does the swallow study, so the VFSS or MBS, um, they might not be the same person, but it would all be coordinated.

And then the ENT, because orders do need to be written for this study to happen. So even if I believe that this study needs to happen, they would still need to be referred to some sort of clinic so the pediatrician could write the orders for it. Most often, um, you might either have it in an ENT clinic or an ENT might be part of the team that's consulted.

Amy Wonkka: Are you [00:34:00] able to describe a little bit for those of us who haven't seen these, these types of evaluations done, do you know a little bit about what that, what that looks like? If I, if I. You know, somebody goes to see you and you think they need one of these other evaluations. What is that, how is that different from the one that you just did?

Tracey Callahan: So, um, I have both personal and professional experience with this as my youngest was aspirating for quite some time. And, uh, so I got to experience both, both sides there. Um, so the way that it works is you would go into, um, a clinic, uh, a hospital that has an. A swallow study machine. So we've had, we've come a long way.

They used to be very claustrophobic and it would be like a very, very small elevator, sort of, um, it was quite unpleasant. And for children, um, it, it would make them feel quite nervous. 

Announcer: Mm-hmm. [00:35:00] 

Tracey Callahan: Uh, the positioning that you need to put them in is the positioning that they need to be in that when they're eating.

So if it's an infant and they're n uh, they're nursing and sideline, then you need to get them in sidely 

Announcer: Oh boy, position 

Tracey Callahan: for the swallow study, which, um. Good things. Speech therapists are creative because 

Kate Grandbois: kind. Oh my god, there's so much vulnerability there. Especially if you're a breastfeeding mother.

Tracey Callahan: Exactly. Geez. Yeah. And then, um, if you are a person that is using a wheelchair that you either are able to use the wheelchair depending on, um, how the machine is able to move, um, or you are in a seat that will mimic that. Hmm. And then the newer machines, which are very nice, are, um. They come down sort of almost like a letter C around the person.

So it's very open now and uh, is much less claustrophobic. These are the, the newer machines. But, but both would work. 

Kate Grandbois: I have a [00:36:00] question. We sort of touched on this before, so it's no longer an MBS 

Tracey Callahan: it Yeah. Most people will refer to it as A-V-F-S-S. 

Kate Grandbois: That's a lot of letters. 

Tracey Callahan: It is. So they, they're, they're used interchangeably.

They mean most, mostly the same thing. If I'm writing up a report, I'm calling it A-V-F-S-S. If I'm talking sort of with my colleagues, I'm either calling it a swallow study or, you know, old habits die hard. IMBS is falling out of my mouth. 

Kate Grandbois: So what's the difference 

Tracey Callahan: there is there's not really a difference.

Kate Grandbois: Didn't you say something today about like the barium? 

Tracey Callahan: Yeah. So they like 

Kate Grandbois: do something different with it now? 

Tracey Callahan: It's so, that sounds 

Kate Grandbois: so stupid. 

Tracey Callahan: So it's, it's not that they're doing something different with the barium, they just wanted to highlight more that it's a swallow study. So I think what you're thinking of is the thickener that we use now.

No, 

Kate Grandbois: I don't know what I'm thinking of. Go on mo, move on. [00:37:00] 

Tracey Callahan: We can move on. Um, so the, the focus is really, really on the swallowing aspect versus the idea of the barium. 

Kate Grandbois: Okay. 

Amy Wonkka: The barium lets you see what's going on. 

Kate Grandbois: Right, right, right. 

Amy Wonkka: The actual magic is hashtag 

Kate Grandbois: science. 

Tracey Callahan: So when you're drinking the liquids, you are drinking, um, essentially barium.

And it might be thickened if that's part of what needs to be viewed on the assessment. And if you are eating food, then barium paste would be mixed in with that. But one important thing that you need to think about is making sure that you're not affecting the, the texture too much. So if you're looking for them to be chewing a, uh, piece of steak to make sure that they're safe for a more difficult, regular texture food, you don't wanna be adding so much paste that you're almost turning it into like a thick stew.

It's just a, does it taste 

Kate Grandbois: terrible? [00:38:00] 

Tracey Callahan: I don't think it tastes terrible. I have tried it because I have a rule that I felt that I needed to try anything that I was going to be making other people eat because I didn't think that it would be fair to be asking them to eat something that I myself wouldn't eat.

That's so, that's so good of you. Like water, like chicken, water, which water. So it's, we've come, like I said, with the technology we've come a long way. The products that we use now are not that sort of corn starch based. Um, it's not the grad school. No, it's not. It's, it's more Zan anthem gum based. So the taste isn't affected as much.

Mm-hmm. Um, and many, many people say that they can't taste a difference at all. Um, though I think that texture and flavor are so linked together that if somebody told me I'm drinking water and it feels more gelatinous, I'm not going to be able to identify it as water. [00:39:00] 

Amy Wonkka: So you've covered what I think of as the MBS because it's been a long time.

Um, I, I did these things back in the day of the MBS. What about the, the fees? What is that? How is that, that's a Z 

Kate Grandbois: sound for all of you out there. I dunno what that, that's a fees. 

Tracey Callahan: Um, so the, the fees is, is the tube going down the nose looking more at sort of what's going on with the vocal folds? Um, it's not something that I've been trained to do because at the hospital that I worked at, that was not the standard.

If somebody was. We were having difficulty with imaging, we might send them for a fees, but it's, it's a different specialization, um, because you also would need to, uh, use a spray to numb the nose. So that's an additional medication. But for some people where we might not be able [00:40:00] to get good visualization with, uh, like A-M-B-S-V-F-S-S, we might do a fee.

So if somebody has a lot of hardware in their spine, or if they have a halo because of a car accident and for whatever reason, we're really not able to see, um, they, they might recommend the fees, but, uh, most often it's, it's, it's the video fluoroscopic swallow study. 

Amy Wonkka: So it's nice though to know that there are two, those two different options.

Those are two options. There are 

Tracey Callahan: options, yeah. So the fees is looking a lot at the, the laryngeal adductor response. 

Kate Grandbois: I'm not sure what that is. Um, I'm just really glad that we have documentation in this podcast that I do know things because I feel so out of my element, but that's okay. It's a comfort zone.

I have a question that might transition us into our third learning bucket, so I'm not sure if there's anything else you wanna say, but, so our third learning, learning objective [00:41:00] is feeding and swallowing evaluation procedures in a school setting. 

Announcer: Mm-hmm. 

Kate Grandbois: So. Most there. I don't think there's probably a single school that has this kind of equipment in terms of, so what is that?

How is it different in a school setting? Are we ready to go into that question or I, 

Tracey Callahan: I will say just, just one additional thing about a. About the whole swallow evaluation process is that any time that you are going in for an M-B-S-V-F-S-S, um, it, you're going to be exposed, um, to, uh, the, the ra the whole radiology process.

You don't wanna refer somebody if it's not absolutely necessary. So it's not that if you clear your throat once we have to get an MBS, if you are noticing a slight change of voice that you would refer them for this swallow study. So there are other things that we would wanna make sure that we tried in the evaluation [00:42:00] before we referred them.

As you are getting a, an evaluation as a school practitioner, you might not have this other swallow study to look at. It might just be the bedside if the clinician feels comfortable and confident that that person is safe to swallow with strategies. 

Amy Wonkka: But it's not really just going to be a bedside, it's going to be all of the things that you, you know, it's gonna be that detailed case history.

Yes. Be all that information that you've collected and kind of synthesized together. Yes. I think that, you know, that's, that's a robust amount of information. 

Tracey Callahan: So a bedside swallow is not just gonna be, here are the four stages. Mm-hmm. Good luck. It's going to be here. Here's how long it took. Here's what they ate, here's what they didn't eat.

Here's what worked, why it worked. Here's what did not work, here's why it worked, and here's some goal areas that I think that they [00:43:00] need to be working on, and this is how you could start working on it. Now, that's a good evaluation and. Many speech therapists that are feeding and swallowing experts know that when they're handing off to somebody, they might not be handing off to somebody who's as comfortable and confident as them.

So I'll try and make sure to include all of that information. Now, on top of that, there might, you might get more information from the VFSS or from a fees. 

Kate Grandbois: So as a, as an inexperienced clinician, I have referred for one MBS, and now you've said, you've reminded me that there is risk in, in exposure to radiation and, and you know, you shouldn't just be referring willy-nilly.

So of course I'm looking back on my decision to be like, oh, maybe that was the, maybe that was the wrong call. What. What are some like clear referral guidelines in terms of [00:44:00] when a school, when any SLP not necessarily school-based would say, I would definitely recommend you go for a swallow study. 

Tracey Callahan: So, for example, if somebody is in an acute, um, hospital and comes to a rehab hospital and there has been documented issues with swallowing, such as frequent choking, uh, change in vocal quality where it sounds like they're underwater, um, or if they're having difficulty breathing, um, not just during the feeding, but maybe even after, shortly after the feeding.

Um, and then also if they start running a temperature because that can be p pneumonia, indication of aspiration pneumonia. So tho those are the things that I would say. I'm probably going to take a look at them. I might just look at how they're swallowing their own saliva, and then based on that, I, I [00:45:00] may refer there before I feel super comfortable and confident, um, you know, doing something like the water test with them.

Kate Grandbois: What's the water test? 

Tracey Callahan: Are you laughing at me? 

Kate Grandbois: What's the water test? No. 

Tracey Callahan: Um, so the, the Frazier water protocol is where, uh, at bedside or, you know, not bedside tableside, I guess you are gonna be drinking water with continuous sips. So not like tipping your head back and chugging, but taking continuous sips of water.

And I, the speech therapist am fe feeling your swallow. So I'm palpating your swallow and I'm listening to, uh, the way that you sound before and after, and even maybe shortly after that, seeing how long it takes. Okay. So that's sort of one of the gold standards. If you can pass that, then you are [00:46:00] likely to be safe to drink.

Uh, drink thin liquids. 

Amy Wonkka: Well, and what about, you know, if I'm in a school and I'm not sure that somebody needs to go see an ENT and you know, go to radiology and do all of these things, um, but what about, you know, can I just refer that somebody go to their doctor and see about a swallow evaluation? I mean, what is the evaluation that you were describing?

Is that a good first step? Unless there are obvious signs, but, but we feel like we need more information. 

Tracey Callahan: So if, if, for example, there is a school-based speech therapist who believes that the person that they are working with is experiencing dysphagia, they could and should refer to a feeding and swallowing expert.

So that could be a speech pathologist, it may be a clinic. And that clinic will do that robust assessment. So they're going to look at everything [00:47:00] and they will have access to, um, either the people that would be doing the swallowing, um, instrumentation, or they could refer you to somebody that would, but even if, even if you felt like they were aspirating, you need that assessment to be done before you can go in, get something like a fees.

Amy Wonkka: That's really helpful, Tracy. That's, that's really helpful. And I think, you know, it's nice to know that, that, that there's a progression in steps and that the person who may be in the school and is responsible for being sort of the jack of all trades doesn't need to feel all of this pressure to be an expert in everything.

Um, because like, you know, Kate was saying earlier, like our field is really broad and we learn a lot when we're first in school, but as time goes on and you spend more and more time in your practice area, it's, it's unrealistic to expect people to be experts in every area of our [00:48:00] broad field. Um, so that, that makes a lot of sense.

And then 

Tracey Callahan: we're thinking about what ASHA tells us with that code of ethics. If it's not something that we feel comfortable and confident, uh, with our own clinical abilities, should we really be taking on that role? 

Amy Wonkka: Right. And I think, you know, back to the code of ethics, I, I believe, I can't cite the number, but part of our code of ethics is exactly that, to know when to refer out.

So I think just knowing that that is the referral that we make, we make the referral to a feeding and swallowing specialist is, is helpful. And then that person can, can sort of be that expert on the team. So that's great. Um, so go ahead. 

Kate Grandbois: Oh, I was just gonna ask a question about how that relates to vape.

So if you're a school speech pathologist and you have a student who has been, and maybe this is a transition into the third bucket, but which is the swallowing, [00:49:00] feeding and swallowing treatment procedures in a school. So you're, you're me, you don't know anything and you just got a job in a school, aside from having, you know, the resources that we all have through Asha, if you get a student on your caseload who has documented feeding and swallowing, um, issues, and you feel compelled to write objectives for those issues, but it's not in your scope of competence, what do you do?

Tracey Callahan: There are, there are a lot of resources out there. Um, but the first thing I would recommend that they do is to get on the phone or send an email if you have the release, to talk to the person that did the evaluation. 

Announcer: Mm-hmm. 

Tracey Callahan: Because we have a lot of information. This is something that we are really comfortable and confident with, and we will be able to help you, so we'll be able to talk more about it.

Amy Wonkka: Well, and I'd imagine that you guys are [00:50:00] really skilled at breaking it down because so much of feeding and swallowing happens in the home, and most parents or guardians are not trained. Speech language pathologist who specialize in dysphagia, you know? So I would imagine if you're able to make it manageable and doable for families, you can help a lot with school-based practitioners.

Tracey Callahan: Absolutely. And we also have that information readily available, and I know that school-based SLPs have a lot going on. So instead of maybe spending 30, 40 minutes on the internet trying to figure out if something is good and helpful for that particular student, uh, you know, 10 minute conversation and a couple of emails could get you everything that you need to sort of read and get up and running.

Kate Grandbois: Are there certain things that you would recommend a school-based speech pathologist do in terms of goals and objectives? I, I have never, not one time written an objective related to this, so this [00:51:00] is a blind question, but 

Tracey Callahan: no, I think it depends on. If it's a feeding or if it's a swallowing issue, because you're, you're gonna wanna write two different goals.

Now, I'm sure I haven't gotten to the podcast that you guys have done about data collection, but it's just, it's as important to collect data on feeding and swallowing as it is for any other goals. So you wanna make sure that you're being very specific. So you're gonna include information, you know, the who, what, when, where, why, like all of those things you need to be covering.

So, uh, you might write a goal for, uh, swallowing. You might write a goal for feeding and you wanna take into account, um, where you're going to be doing that. What level of support are they going to have? Is there going to need to be a change in the texture of the food? All of those things should, should be, uh, documented.

And, uh, you should be collecting data on all of those things. 

Amy Wonkka: Is that something that the person who did the [00:52:00] evaluation could potentially help with? If there's a release on file, we could just call you up and have a conversation? 

Tracey Callahan: Absolutely, absolutely. But I will say that, um, we as therapists not in the schools, we, we might be writing our goals, you know, for six months, or we might be writing those goals even shorter term than that three months.

So the school-based speech therapist might need to think about that when they're writing their goals. So maybe, uh, to, uh, broaden the terms or even speak to the speech therapist about, okay, this is what I'm thinking. Do you think this would be an achievable goal? If we are targeting this X amount of time for this long?

Is this something that you think that they should be able to achieve?

Amy Wonkka: That's great if you have somebody. So thinking about swallowing, being kind of [00:53:00] inside the mouth and feeding, being kind of outside the mouth, um, would that also be somewhere in the school setting to sort of loop in other allied providers? You know, I know you talked a bit about your close work with occupational therapists.

Just thinking, you know, in the schools a lot of times that division is, if it's fine, motor. It's okay. Um, and I'm just wondering if there's a place there too for, for, for you to serve as a resource for the occupational therapist. Um, 

Tracey Callahan: absolutely. And then also to, to link into another one of your podcasts that I've definitely listened to is there's another professional who is often paired with the speech therapist in the schools when working on feeding and swallowing and that.

Going to be your a BA provider. A lot of children, especially children who have autism spectrum disorder, benefit from a BA style. Um, when we're talking about feeding and swallowing, and almost [00:54:00] every single child that I work with who has autism spectrum disorder, I'm working with their a BA provider and we're talking to each other.

I am asking what strategies they're doing, how are they going about it, um, when they're working on a particular goal, if they're trying to decrease a certain behavior or increase a certain behavior, and I'm trying to pull from them. So it's a provider I really work with. Very frequently to help 

Kate Grandbois: and, and I just, um, as the, I guess resident, BCBA, just as I know that that relationship can be really contentious.

And we, you know, our first episode was on collaborating. So I think it's important for our listeners to know that B CBAs have a very rigorous code of ethics, and one of those bullets is about ruling out medical-based issues before they implement a treatment. Um, and so if there is, you know, you should be able to talk with your BCBA if there is [00:55:00] an issue about ruling out medical issues prior to implementing a feeding treatment, because that is in their code of ethics, just as like a random plug.

Amy Wonkka: No, I think that's actually very helpful to know because I was gonna ask a question just around how important is it if you are implementing a feeding intervention that that kind of, everybody's on the same page. So whether that's the OT or the BCBA, you know, how important is it for people to be, you know, sort of doing the same thing?

Tracey Callahan: Um, so one thing that I, I always try and say to speech therapists who are maybe feeling a little bit uncomfortable about it, where their bread and butter is maybe articulation or aac mm-hmm. Is if a child is only using their A a C just with their speech therapist and with nobody else, are they going to be making progress?

The answer is no. Mm-hmm. It's not true progress. They may be getting better with the speech therapist, but if they're not generalizing it to other areas, then no, they, they're not gonna be [00:56:00] improving. And the same thing goes with feeding and swallowing. So we need to get everybody that's on their team, on board, anyone that's going to be.

Interacting with them, with feeding, swallowing, even a drink of water at the water fountain. If this child is not safe to be getting in line for at the bubbler, then we need every single person to be aware of that. That way we can keep this child safe. 

Amy Wonkka: I think that's really helpful information. Um, similarly, when I think about a a c, a lot of times we'll do sort of an implementation plan, which is just sort of an overview of the rules, you know, and I wonder if something like that would be a helpful thing for listeners to think about drafting, you know, when they're talking with the person who did the assessment, like kind of getting the most important points and writing those in a document.

Because when you're in a school, there are a lot of people, you know, there's the school nurse and the principal and the paraprofessionals. And so [00:57:00] just having, you know, like a, a high. Tips, like you said about the bubbler. Remember when you're in the hallway, this is what we do, might be very helpful and make it feel a little less scary and like everybody's on the same team.

Tracey Callahan: And then also one thing that's very common is to have what's known as a swallowing safety form. That form is usually in some sort of really bright color and it says that the, this is the texture that is safe for solids. This is the liquid that is safe. Um, and this is how they do it. These are the strategies and this is who can feed them and who cannot feed them.

Amy Wonkka: That's a great idea. 

Kate Grandbois: I 

Amy Wonkka: love that. 

Kate Grandbois: Are those signs, those visual supports, if you will posted generally, would you recommend that they're. In multiple places around the school, I would imagine? 

Tracey Callahan: Um, well, you have to make sure that they're de-identified. So if, if, if it's something you are able to post, um, and everyone in the [00:58:00] classroom knows it's for that particular person.

Yes. Um, but it's, it needs to, people that are going to be interacting with them need to know where it is. Um, and, uh, maybe it's something that goes with them, like a highlighted form. Thinking about a child's gonna take their a, a c device with them. Maybe this is a form that goes with them, that's laminated, that goes with them to the lunchroom.

That's with, with them, they're available. 

Amy Wonkka: Well, and I think in the schools, a lot of people are familiar with, you know, a list of life-threatening allergies, right? That's, that's such a big thing. But similar because it's medical information, it needs to be kept confidentially. Um, so maybe that's another place too.

If you're in a school and you have a list of life-threatening allergies, perhaps it kind of goes with that medical information in a place that's secure. Um, but important. 

Tracey Callahan: And especially if this is a child that has dysphagia, that's going to help the family feel more comfortable that they're gonna be safe at school.

Uh, and it's also a [00:59:00] really great way to target your goals, to ask the, ask the student, okay, what are we working on? Mm-hmm. 

Announcer: What 

Tracey Callahan: are our strategies and thinking about therapy and goals. That's something that I always recommend even for young children, is that they are able to communicate, whether that's verbally or on their aas.

C device or whatever communication means they have, they need to be able to describe what their strategies are. Mm-hmm. What they need to be doing. Um, because there are going to be times where, you know, worst case scenario is going to happen if there's an emergency, and they need to start to self advocate to keep themselves safe.

Kate Grandbois: Self-advocacy is so important for any, I mean, for so many of our, our students slash clients. But feel like for 

Announcer: everybody. 

Kate Grandbois: Yeah, for everybody. That's a, that's a really important human skill. Yeah, you're right. Well, is there anything else you wanna share with us? I feel like I personally have learned a bajillion things besides what an MBS is and is [01:00:00] not.

Tracey Callahan: Um, well, I love feeding and swallowing. I love helping people with feeding and swallowing and, um, I think that the most important thing is that you also are, if the child can communicate, you ask them what their goal is because they might not have the same goals that their parents have. Mm-hmm. Or that we have for them.

And, uh, patient, client student buy-in is so important. The process of eating and feeding is very invasive. Would you like someone coming at your mouth with a really hard plastic spoon with that liver pate forcing it in your face? No. Or pureed 

Kate Grandbois: eggs. You said pureed eggs before too. Yeah. 

Tracey Callahan: Yep. That's a common breakfast food in hospitals.

Yeah. Um, and so we really need to make sure that we're talking to them about what they're comfortable with, what they're not comfortable with, and then, um, possibly reward systems for them and making your goals clear to them, whether [01:01:00] that's through like a first then board. Or if they're an older kid or someone who is, um, able to help with their planning to make sort of like their own vision board of what they wanna do or the steps to work towards that goal of eating.

And then to make sure that they are, you are bringing in that social piece as well so that there are peers there to help support them and to always model positive language around feeding and swallowing. So not you did that wrong, that's not it, or, I'm really glad that you tried that. Um. Tasting. That was great.

That's a great step. Or I really love how you used your strategy of tucking your chin when you swallowed that time. So lots of positive language and positive reinforcement's. Really important. 

Kate Grandbois: I was just about to say, I wonder if this is an area where you could get some good collaboration with [01:02:00] the BCBA in terms of identifying things that are motivating for the student or putting a, a plan in place where they, you know, achieve they feel like they've achieved something, they can get acquisition or access to something that's special because.

They overcame their fear or they participated in something that was challenging. 

Tracey Callahan: And then also as well, um, social work or psychology because mm-hmm there are a lot of children who have really deep seated, real fear and anxiety and are having panic attacks and physical responses around mealtime or going into the lunchroom.

So it's really important to pull in all the professionals and understand that this is something that's affecting them at school. It's probably affecting them at home as well. 

Kate Grandbois: And that has so many other implications for social interaction too. I mean, mealtimes are so social. I mean, and even in my daughter's school, you know, she has a handful of times during the day where she doesn't have, you know, instruction.

[01:03:00] And one of them is, two of them are around eating, you know, where she gets to sit and, you know, she doesn't eat her lunch because she sits and chats with her friends the whole time. So if you're sitting there. Having these panic attacks or having all of these negative feelings around mealtimes, that just, that's just a struggle.

So I think, you know, bringing in all those extra professionals is such a good idea. 

Tracey Callahan: Yeah. And then also knowing that panic attacks and anxiety look different in small children than they do in adults. So that's why it's really important to be pulling in those types of professionals to help support with that.

So it might look like throwing or yelling or having some sort of a temper tantrum, but they really could be having, you know, a high anxiety response to this situation. 

Amy Wonkka: I think that's a really good point. And I think just the point that those times in a school do tend to be down times for so many students.

And if this is the exact opposite experience for somebody who's having challenges with feeding or with swallowing, not only are [01:04:00] they having this opposite experience from their peers experience, but they're not accessing that downtime that everybody else is able to access. So perhaps it's important to plan that in somewhere else 

Tracey Callahan: in some other way.

And that's, that's a really good point, because that might not be a down and rest period for them. And whatever instruction may occur after lunch, they might not be able to fully calm down or focus and participate in if their previous instruction was so stressful or so difficult for them. 

Announcer: Mm-hmm. 

Kate Grandbois: Well, this has been so tremendously informative.

Thank you so much for making me feel a little smarter and educating all of us. 

Tracey Callahan: Well, I, I really enjoyed talking about it. It's definitely a passion of mine. It's something that I really want other speech therapists, speech pathologists, to feel comfortable and confident in doing because there is a population out there that really needs our help and support.

And parents, uh, caregivers who really aren't sure what to do, aren't sure where to go that [01:05:00] we could help empower with our knowledge. 

Kate Grandbois: Is there, Tracy, this 

Amy Wonkka: was so awesome. 

Kate Grandbois: Thank you. Yeah. This has been really so great. Um, and as. As usual with all of our episodes, there will be references and resources listed on our website.

Um, Tracy, we again, we really appreciate you coming on. Um, if anyone has any questions or anything specific that you'd like to follow up with, please contact us. Um, you can send us an email anytime [email protected]. You can find us, um, on our website, www.lpnerdcast.com. You can find us on Instagram, leave us a review, send us an email.

Um, we love to hear from our listeners. So, um, thanks so much for joining us. Anyone else have anything to say? No, we're good. Alright, well that pretty much wraps us up. Stay tuned for more episodes. We have additional content coming up soon related to implementation plans, um, and all kinds of good stuff. So we will see you [01:06:00] here again soon.