SLP Toolkit Podcast, BOUNS: Virtual Exams, Transcript

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Lisa 00:11 Well, hey Lisa.

Lisa 00:37 What up Sarah?

Sarah 00:39 Not much. How’s it going?

Lisa 00:40 You know, just living the dream here in the desert.

Sarah 00:43 That’s good. I like your positive attitude.

Lisa 00:46 Thank you.

Sarah 00:46 It’s nice to see you in person. We are actually in the confessional together.

Lisa 00:50 We’re like really close to each other too.

Sarah 00:52 We are.

Lisa 00:53 Which sometimes gets a little awkward.

Sarah 00:54 Well, have you had a COVID test lately?

Lisa 00:56 No.

Sarah 00:57 Okay. That’s probably not safe. We hope that we don’t make an announcement later. No, no, we both have been very safe. We feel safe. We’re like family. We’re fine. So this is– I am really excited about this episode because this is kind of like, well, it’s not kind of, it is a bonus episode. Because we have been invited to use this episode in the SLP connect pod con. We did this last year and had the best experience because I just think what Benita has done with getting CEUs for podcasts is brilliant.

Lisa 01:28 Super cool.

Sarah 01:29 But you get to listen to this in your car and actually have an opportunity to earn CEUs. So heads up, if you’re listening to this past what, October 15th?

Lisa 01:38 I do not know the deadline.

Sarah 01:38 There’s going to be deadlines at the end of this episode for when you have to submit your CEUs. If you’re listening after that date, sorry. No more CEUs for you, but don’t bounce. Because it’s still a great–

Lisa 01:49 It’s some great knowledge.

Sarah 01:49 it’s a really great episode. So we’re going to leave this up on our podcasts, even after SLP connect ends. For those of you who have never listened to one of our episodes, the title of our podcast is True Confessions with Lisa and Sarah. It is very much a conversation. We throw ourselves under the bus. We try to talk about all the angst and feelings of our profession. So this is going to be very similar to that same typical kind of style we have. But because it’s for ASHA CEUs we do have some disclosures we need to do and some learning outcomes and an agenda we’re going to follow. So I’m going to have Lisa go over disclosures and learning outcome, and then we’re going to introduce our guest and the topic.

Lisa 02:30 All right. So the only disclosures we have is SLP Toolkit, Sarah and I, is that we have ownership in SLP Toolkit, which is a web based app and it might be brought up during this course, we’ll see. But we have no non-financial disclosures to talk about. But Amy Graham, our guest, is the owner of Graham Speech Therapy, and she has developed materials available for purchase on her private practice website. She’s also developed materials for Bjorem Speech Publications, she’s an affiliate of Throat Scope, which will probably be brought up today and sells materials on Teachers Pay Teachers. And so any, or all of these products might be mentioned during this pod course. And then Amy also receives med bridge revenue shares. So no non-financial relationships to disclose, but here’s what we’re really looking to do with today’s episode is to talk about oral motor exams, which is really, you know, one of those things that sometimes you do it sometimes you don’t know why you do it. Sometimes you don’t do it. So we’re going to get into the nitty gritty and do some discussions on what are those different aspects of an oral motor exam. What can we do virtually and what can we not do virtually?

Amy 03:41 Use a throat scope.

Lisa 03:41 Exactly. I don’t think we can do that. We are going to talk about some tips to make virtual oral motor examinations easier. And then also explain how we can use this information during– that we received during the exam to make differential diagnosis of speech sound disorders. So that’s it. Let’s get to it.

Sarah 04:02 Let’s get to it and let’s introduce our guest. And there is a very good reason why we have Amy Graham with us today. First and foremost, we just love her. We’ve known her for a while now and had the privilege of actually hanging out with her in person. And she is just is one– if you follow her and you know anything about her, she’s really that amazing in real life and we consider her to be a really good friend of ours. And then we also had her on here because this is not our area of expertise. I mean, I don’t wanna speak for you, Lisa, but I don’t know if you’re like a professional when it comes to oral mechs.

Lisa 04:33 Absolutely.

Sarah 04:34 Sure. So we brought Amy in because this is one of those conversations that needs to be had. I need it. And we want somebody who knows what they’re talking about to help us discuss it. So Amy, welcome.

Amy 04:45 Thank you. Sarah, Lisa, it’s so good to be here. Thanks for having me on.

Sarah 04:50 Oh this is so fun– and will you do, just in case– I mean, I’m sure everyone knows who you are, but if they don’t, will you please introduce yourself and tell us a little bit about your background?

Amy 04:59 Absolutely. So I have been an SLP for over 20 years. I am in Colorado and I have a very small boutique style private practice, which is like, I always say just a fancy word for small. It’s just me. So I’m a sole practitioner. I began doing this private practice thing about a little over four years ago. And I have always loved speech sound disorders, but haven’t had the opportunity to only focus on that always. And so the private practice was my opportunity to kind of have my little niche practice and focus primarily on speech sound disorders. So I see kids primarily with articulation delays and deficits, those kids with phonological disorders and children with apraxia of speech. So that is my primary caseload. And so I have loved doing that. And so in doing speech sound disorders for the last–I would say I’ve been primarily SSDs for maybe three years. And so in doing those, I’ve always done an oral mech exam. It kind of goes into what we’re going to talk about today. But I never had a really good way to organize the information or make sure I had, you know, was hitting all, everything that I really wanted to look at as far as oral mechs go. And so that’s why– I know you mentioned earlier, but that’s why I created an oral mech exam, my oral facial exam that I sell, but I actually created it for myself just cause I wanted something that’s kind of easy, checklist style going down the list. And then the more I talked to other SLPs because I also have a pretty big social media platform on Instagram and my Facebook is growing, but primarily Instagram. So I post a lot of my therapy videos there, and even videos of demonstrations on how I do oral mech exams, how I do my assessments, why I include my oral mech exam in my assessments. And I started to find out that a lot of SLPs were not comfortable doing it. Didn’t really know why they were doing it. And so I decided that in addition to my little awesome checklist style assessment, I would actually go ahead and do a really thorough guideline section so that anybody that has this oral mech exam or my oral facial exam is what I call it, can kind of look in the back under the guidelines and say, okay, I see that they’re, you know, maybe their tongue strength or the range of movement is a little off, but what does that mean? And so that’s why I kind of went in a little bit more in depth in my exam, but anyway, that’s kind of a basis of what I do. I have this small private practice. I only do speech sound disorders and I absolutely love training other SLPs on how to really do effective assessments for differential diagnosis.

Sarah 07:47 I am so excited that we’re having you discuss this very thing because Lisa and I agree, we love a checklist. We love something that guides our critical thinking, but at the same time we need that rationale. And so before we get into the rationale, I want to just take one step back and talk about kind of the current climate, because we’re going to get into why we should be doing the oral mech. But before we even do that, let’s talk for a minute about how this is impacted by– I’m assuming you’re doing teletherapy right now with a lot of your clients.

Amy 08:17 I’m doing teletherapy with a lot of my clients. And actually back in March, I switched everybody to teletherapy for a couple of months. I’ve gradually been seeing you know, with some COVID guidelines in place, seeing people in person again, but there are those families that–and granted I’m private practice. I know a lot of SLPs do not have that option. You know, if you’re in some school districts, you’re doing teletherapy period. And so, yeah, it’s been super challenging to figure out, especially with speech sound disorders, how to do assessments over teletherapy tele-health and even therapy as well. So, yeah, I’m doing both right now, but it has been a huge learning curve.

Sarah 08:59 So you did pick up some new evaluations where you got to do oral motor exams in the context of teletherapy?

Amy 09:05 Yes, absolutely. You know– and I know we’ll talk about it probably later, cause there are some things that are just hard to do with an oral mech exam over teletherapy but there are a lot of things that you can– a lot of information that you can gain from an oral mech over teletherapy and I’ve had the opportunity to do that and kind of learn from some mistakes I made and learn from things that actually worked really well.

Sarah 09:34 Okay. One of the things that, you know, I know the focus really of this course is oral mechs, but it’s a part of the assessment.

Amy 09:42 Absolutely.

Sarah 09:43 And so can you talk a little bit about what does your typical assessment look like when you’re considering whether or not there’s a speech sound disorder?

Amy 09:52 Yeah. So first and foremost, I get a very thorough case history from my families. And I know, you know, we’ll talk a little bit about the oral mech and you know, what some of that stuff means, some of that information, but if you have a really thorough case history, which I have my own too, because some of these case histories that I was using were not really specific to speech sound disorders, and I was kind of wanting to ask so many more questions of the parents as far as, okay, well, is there something– maybe I’m seeing red flags for myofunctional disorders, maybe the child is having difficulty sleeping, maybe they’re snoring at night. Maybe they were– they had– there was pain during when the mother was nursing. Maybe they weren’t able to nurse. So there’s some kind of red flags like that, that can pop up in the case history that can make me kind of guide and direct what I really do want to look for in the oral mech exam, just in and of itself. So I think case history is absolutely– if you can, I know we’re not always able to do that in the settings. I worked in the schools for a number of years and I was not always– sometimes I never even met the parents ever. And I worked with these kids for years, so it’s not always possible, but whenever you can, if you can talk to a caregiver about this case, you know, get their case history, a really thorough one. For me that’s first thing.

Lisa 11:09 Well even in the schools, I think that’s the whole idea of a review of existing data because there is typically a case history form, a very generic one that has been created by the district. But that doesn’t mean you can’t send your own form home specific to communication if you’d like to add that to the paperwork that goes home. And then also when the team meets to review the existing data, that would be a great time to ask questions and record this information. If you didn’t have a chance to get any sort of checklist form.

Amy 11:39 Right. And that’s why I made– I know cause I’m a mom, I have three kids. Whenever I get those case history forms, you know, at the doctor’s office or a particular specialist. Oh my gosh, they’re crazy long that, you know, they’re wanting all this information that takes me like, you know, an hour to fill the whole thing out. So I have my own too, where it’s just really checklist friendly for the family, but it touches on everything; family history, birth history, you know, pregnancy history, delivery– was that an issue? Medical history, cause there’s lots of things that can pop up even in the medical history. Nasal congestion, frequent colds, chronic ear infections, you know, that kind of thing that can really kind of guide your assessment as well. And then I always ask about feeding and eating history, thumb finger sucking, pacifier use, you know, were they messy eaters? Was drooling observed? Cause all of those things too– some of those things can be red flags for myofunctional disorders or even maybe sensory issues where the child might need a referral to an OT. So, and then we look at, I look at developmental history. Are there any, you know, delays in their gross motor skills, fine motor skills, educational and academic history, speech and language history? So there’s a lot of things that, you know, you can– for SSDs, for speech sound disorders that I look a lot deeper into that can inform the rest of my assessment.

Sarah 13:01 I love this because I think like Lisa said, I’ve always just used the generic form I’m given. And I collect the information because I know it’s something that we’re supposed to do as part of the assessment. And then I just kind of put it to the side and move on. And so one, I need the right questions, but then two, I need to know why I’m asking them and what that information is telling me–

Lisa 13:20 What is clinically significant from that information.

Sarah 13:21 Exactly, right. And we’ll include resources in this episode, in the resource section. And so this is definitely something that I want to share with everybody because I have a feeling it looks really different than the generic form I used, and again did not offer that much help for me.

Amy 13:39 Yeah, yeah, for sure it does. And then going down through the rest of my assessment checklist I have, which, by the way, I’ll let you know too, it’s a free downloadable checklist. I love checklists, on my website. So it’s an assessment checklist and I just go down, I get my case history, I make sure the hearing has been screened. I get an intelligibility scale, in context scale completed. And then I do my articulation assessment, those single word tests, right, that you use. And then, I always look at phonological awareness too for kids because we know research shows that those kids with any type of speech sound disorders are at more risk for difficulty learning to read. So it’s always something that I kind of add in there too. And then I get a connected speech sample. Then I do my oral facial exam, which I usually do last because you’re kind of, up all in that kid’s business doing those oral facial exams. So I want to make sure they’re really comfortable with me if, you know, if they’re in person, especially.

Lisa 14:34 You don’t want to do a gag reflex right out the gate?

Amy 14:39 Not first thing.

Sarah 14:44 You’re like hi I’m Amy, it’s nice to meet you.

Lisa 14:45 I’m gonna test your uvula with this tongue depressor and let’s see what happens. It’ll be crazy.

Amy 14:52 Exactly.

Sarah 14:53 It’s so true. And these are the things we have to consider and think about if you’re just meeting this child for the first time, the oral mech is so invasive and it’s not something I would start with. I agree. Now that doesn’t mean we don’t do it at all, which I’ve been very guilty of skipping that part of the process and then finding out months into treatment. This is a true story. I qualified a student for speech sound disorders and probably a couple of months in, I was looking– for some reason I was real close to their mouth probably for some tongue shaping or something and realized the child had a bifid uvula.

Lisa 15:28 But what does that mean?

Sarah 15:30 Well, I hope we’re going to talk about what that means and when we get into the structural reasons and what we should be looking for, but it was that moment of, oh, well, if I had done that two months ago– and then what is so awkward about it is how am I supposed to bring it up now? I didn’t do this in the first assessment, but we’ve got something that we need to talk about.

Lisa 15:49 So maybe that’s what we need to talk about. You said it was kind of optional in your practice, as to whether you did that or not. So let’s talk a little bit more about that aspect of your evaluation, where you’re doing that oral motor examination. What do we have to be doing other than– I mean, I think of, I used to be like, okay, smile, pucker your lips, say ahh.

Sarah 16:12 move your tongue left and right.

Lisa 16:14 Right.

Amy 16:14 Yeah. Right. Well right. And we’re looking at all those things. Right? But then what I do, I want to look a little bit more in depth. So when I’m looking at just the face, I’m looking to see if there’s symmetry and I’m also looking to see if there’s– what their tone is at rest. Like if they’re hypotonic, if they’re hypertonic. I’m looking for mouth breathing too, because if a child is mouth breathing, that is not a good thing. Mouth breathing is not typical, and so that’s one of those red flags for those myofunctional deficits as well. But I always look at these, each of these aspects in the context of what their speech errors are. So if you find something like, oh my gosh, this kid’s tone is just, you know, really low. But if the issue is not necessarily dysarthria, then it’s something to note, but it may not necessarily inform the type of therapy you do because it may not be the thing that’s actually impacting the child’s speech. But it’s always something that I kind of want to know. So I look at that face. I look at the jaw, I look at their range of motion. Have you ever had a kid that comes to you and their lips don’t hardly move and their jaw doesn’t hardly move. And you’re like I can’t hear you. Your jaw is not moving up and down. So I’m looking at whether or not there’s good range of motion with that jaw, and then dentition too, is another thing that I look at because those– it doesn’t necessarily mean like, oh, this kid has an overbite. We can’t work on this sound. But like I said, it’s one of those red flags for, oh, I see an open bite. I see an overbite. Is there thumb sucking going on? Probably so, so we probably need to either address that or bring it up to the parents. I know it’s not something– all of these things that I address here you don’t always address in the schools, but it’s at least information that you can provide the parents and say, you know, I’ve noticed these things. I know that maybe the child’s bite is off. It’s just one of those red flags that I noticed. And then orthodontia, please check to see if your child has any kind of palatal device, because I have had some kids that come to me and like there’s speech is so slushy, oh, you have a palate expander. Your tongue can not get to where it needs to be in order to say some of these sounds. And so of course your speech is going to be off. So I think looking inside the mouth just to know what’s going on is super helpful. I look at the pharynx too. I want to know if you have a child who’s hypo nasal. So they kind of sound stuffed up, are their tonsils big? You’re only gonna know that if you look in their mouth. And then I look at the palette. And so if you have a child who’s hypernasal, who sounds kinda like they’re talking through their nose and you see something like, ooh, maybe a bifid uvula?

Sarah 18:57 Yes Amy, what does that mean?

Amy 18:58 Well, it can be a sign. Often it can go hand in hand with a submucosal cleft, which means that soft palate may not be working well enough to close off during those non nasal sounds. And so you’re going to have a child that sounds really nasal. And so that definitely is if the child– now not all bifid uvulas warrant this, but it’s one of those things to say, okay, if you are also hearing some hyper nasality and a bifid uvula, that child needs a referral to a craniofacial team, because they’re the ones who can rule in or rule out velopharyngeal dysfunction and tell you whether or not therapy is even going to help, because it may not, depending on what’s going on. And then you’re not working with this poor kid trying to fix something that isn’t fixable outside of, you know, surgery. So–

Sarah 19:44 In my defense, I do want to say it didn’t impact him.

Amy 19:48 There you go.

Lisa 19:48 That she knows of

Sarah 19:52 There was no hyper nasality.

Lisa 19:58 I will say one of the things I used to see a lot in oral motor exams too is that whole idea of being unable to– like, if I had them stick out their tongue and they couldn’t disassociate, they just kind of rest it on their lips and their teeth. And I think of like a sound like R which they have to be able to disassociate movements to get that sound in.

Amy 20:13 Absolutely.

Lisa 20:17 Look at me. I do know something.

Sarah 20:17 You do.

Amy 20:17 Absolutely. No, it’s so true. You’re very welcome. No, it’s true. Cause when I, when I assess the tongue, you’re not just looking at, okay, can you stick it out? You don’t have a, you know, a tongue tie, you’re good. You’re looking at whether or not they can move that tongue independent from the jaw because you’re absolutely right. If you’re going to work on R, that child has to be able to move the tongue independent of the jaw. So you may have to kind of back up for a session or two and teach them how to do that, but you’re not going to know unless you do this oral facial exam. And so I’m always looking at– sometimes too the size of the tongue. I’ve had kids with really large tongues and small little oral cavities. And so you’re going to have to try to figure a way to help this child use compensatory strategies maybe for particular phonemes and then like I’m looking also at the strength of the tongue, I will say the strength, I’m looking more at agility of the movements because we don’t, we know we don’t need a ton of strength in order to produce speech well. But the child needs to be able to move that tongue with agility. So that’s what I’m looking for, but I am still looking at strength as well, because if I notice, if I look back at the child’s speech and they’re kind of, you know, imprecise articulatory contacts, if they’re a little breathy and then all of their muscles are a little bit weak there’s dysarthria. So all of these things can kind of– we need to know these, this information in the context of, you know, their speech and their oral motor oral mech function so that we know what kind of appropriate therapies to use. So definitely I look for all those things in the tongue and then lips too, you’re right. You want to know, okay, can this child’s— is there weakness in the lips? Because if you’re working on bilabials and they’re just having a really hard time building up that intraoral pressure for B and P that’s something to know that you’re going to have to really teach that child how to do so there’s–

Sarah 22:18 Or lack of lip closure.

Amy 22:20 Yeah, totally. Exactly. Or, and sometimes this will help you too– figure out what kinds of cues and prompts are going to help that child. Maybe they really do need some tactile prompting. And so, you know, you need to have somebody there–hard over teletherapy, but if you ever get that kid back in person, you know, I use my fingers to kind of close those lips for them while we practice our whatever sound or whatever word we’re working on. So yeah, there’s so much information than just okay, pucker your lips, stick your tongue out.

Lisa 22:49 Well. And I think it’s interesting that you brought up that idea of type of cueing too, because I read this brilliant article by this lady named Amy Graham, but I had never thought of this. You had mentioned in this blog post that you had written for Tandem Speech that this idea of if you have a kid with a really hyper gag reflex, then that might not be a kid that you want to be putting your hands around his mouth because it might initiate that. So you know it informs the type of cueing that may or may not be successful with that kid too. So I thought that was super cool.

Amy 23:23 Absolutely.

Lisa 23:23 That was a new bit of knowledge I learned

Amy 23:25 Yeah. Well, good.

Sarah 23:28 Amy’s a wealth of it.

Lisa 23:28 I know.

Sarah 23:30 While we’re still talking about kind of the rationale of why this is absolutely something we should be doing, you’ve convinced me of that. I promise I got that part. I need to do this every time I am going to be considering speech sound disorders. And now when we talk about when people just hear the word oral motor, there’s so much controversy around the treatment or a motor treatment, I’m not going to get into that. But the point being that a lot of maybe what’s controversial about it is the oral motor treatment approaches that aren’t actually necessary for speech. So when I hear that, then I think, well, when I’m doing an oral motor exam, should I be doing blowing? And, you know, non speech, motor movements or should everything I’ll be doing in my oral motor exam, be related to how we produce a speech sound?

Amy 24:23 Oh, that’s such a good question. I’m so glad you asked it. Cause you’re right. I mean, there’s still kind of a lot of controversy over, you know, what we call those n-s-m-o-e’s right? Non speech oral motor exercises, which is different from oral motor skills. Right? But I still look at those non speech oral motor skills especially for my kids with whom I suspect apraxia, because that’s the only way you’re going to know if there is any non speech oral apraxia is if you have them volitionally do those movements. Pucker your lips, smile really big, pretend like you’re blowing out a candle. What do you do when you’re going to kiss mom on the cheek? And if they can’t do those things, and then you come to find out, you do a dynamic motor speech assessment, and yes, they do have a apraxia of speech. They probably–those red flags were already there because you know that they could not do those volitional non speech movements. So you have to check that. That’s why we look at that. It’s not because–

Lisa 25:21 So would you do that though if you had a kid that came to you for an evaluation, because the parents were concerned with like a single sound speech error? Would you go into that as well?

Amy 25:30 I always go into it because for one thing, sometimes I will get a child that– in fact, I have two on my caseload right now with a history of apraxia. But those apraxic motor planning issues are resolving. And so they don’t necessarily sound or look apraxic right off the bat, but there’s a history of it and I’ve done my case history. So I know that. And so I still want to know if there are any issues in that area that that child really has a hard time with. It’s also informative as to prognosis. So if a child has apraxia and you find that they don’t have those– a non speech apraxia, that’s better for prognosis. So if they do though, you know that the prognosis is a little bit worse if they do have non speech apraxia, if that makes sense.

Sarah 26:17 Yeah, it does. And this was pretty eye opening. We worked with our mutual friend, Jenny Bjorem.

Amy 26:24 Yes, love Jenny.

Sarah 26:24 to talk about an informal assessment for apraxia about what? a year ago. And it was really eye opening for us because that was one of the first things that she said we needed to include was the non speech oral motor exam. And, you know, that was one of the things when we created our oral mech checklist in Toolkit, it was very, very focused on the speech. Now, there’s a component for structural looking too at the jaw and the tongue and things like that inside the mouth. But then it was all very focused around speech. And so I loved when she talked about why that is important for apraxia and something we need to consider and because the impact on treatment and I think we talk about this more later, but what this looks like when we’re getting this information directly impacts how we’re going to treat that child. And so that was really eye opening, I think, for both Lisa and I.

Amy 27:15 Absolutely completely. And I think too, it just, it’s so quick to do those things. It’s like, okay, pucker your lips. I mean, it takes 10 seconds, so why not do it? So it’s on my checklist. Yup, did it. No problem there. Nope. The child– I’ll mark that no, the child did need a model. And even with the model, it was difficult. So it’s so easy and so quick to do, you might as well do it.

Lisa 27:36 So we’ve talked a lot about the oral motor examination, but I’d really love to dig further into what do you have to, you know, what components of this exam can you do virtually? And what do you have–

Sarah 27:49 maybe say both, maybe start with, what do you do if you’re in person and then– so like what tools do I need? and then how then do I do that virtually?

Amy 27:58 Okay. So this is where I mention throat scope because it is– I will say I have so many SLPs who are like, well, how do you get an oral mech on a three year old? Or even from some four year olds? And the throat scope is like, we call it either a magic fairy wand or a lightsaber. And it is amazing.

Lisa 28:18 You know what’s so funny? They sent us one early on. And so we went to the streets where our office is located in Mesa, Arizona, which is part of Phoenix, Arizona.

Sarah 28:25 And we were downtown.

Lisa 28:27 We were downtown on the streets, just walking up to people and asking them to identify what they thought it was. What does it do? So we heard lightsaber, mini lightsaber, we heard pregnancy test. Some of the craziest answers it was the funniest.

Amy 28:43 Awesome.

Lisa 28:43 Do you have that video?

Sarah 28:43 I have that video somewhere, maybe I’ll add it as a repost

Amy 28:49 You need to repost that one.

Lisa 28:49 So funny.

Sarah 28:49 but it is, it’s magical. So much better than a big giant popsicle stick.

Amy 28:53 it is.

Lisa 28:53 but I did get the flavored ones. When I couldn’t have a throat scope, I always made sure I had the super duper and I let them pick, do you want grape? do you want cherry? They loved it.

Amy 29:02 However, because I used to use those too. However, I would have some kids who were just totally averse to any kind of–

Lisa 29:13 It’s still wood, it’s flavored wood.

Amy 29:13 Or they didn’t even like the flavor. They’re like, ew that’s gross. I’m like, oh shoot, dang it.

Sarah 29:18 Now what? Now I’m using my finger.

Amy 29:21 I know.

Sarah 29:22 Ok, so throat scope is a must.

Amy 29:23 Absolutely. I think it is. I mean, you can use a little, you know, a wooden tongue depressor, but if you’re– especially if you’re looking and assessing small kids, younger kids and you got to look in their mouth, a throat scope, for one thing, it makes them less afraid. It’s less like the doctor’s office right? Where they do actually gag. And then secondly, it absolutely lights up the oral cavity like nothing else. So, usually I’ve got my little flashlight or I’m turning my phone light on so I can kind of see in the back of their throat and you know, it’s kind of clunky. With a throat scope it just totally lights it up so I can really get quickly– that’s the other key too, with little ones you want to quickly get in and out of there because they’re, you know, they’re kind of wiggly and squirmy. So I would say that’s my first tip is that’s the tool that I use. I use my throat scope.

Lisa 30:15 And it has a replaceable cap then that you use for different students?

Amy 30:17 So it is basically it’s the clear blade clicks on when it clicks on to the base, it lights up the blade and then it’s disposable. So you toss it when you’re done. So it’s– I love it. I use it all– I actually use it in therapy too. So you do toss it, don’t clean it. I know some people are like, oh, we just clean it. Especially in the day of COVID let’s not clean those blades anymore. Just toss them. They’re disposable. They’re recyclable. Just toss them. But so that’s what I use first. So in my typical practice, I guess maybe the easiest way is I’ll just go through each one and talk about what I look at and the fact that you can, whether or not you can do it in telepractice and in person too. So like we talked about the face, right? I’m looking at symmetry, I’m looking for their tone at rest and I’m looking to see if there’s any mouth breathing. You can do that over teletherapy, you can do that in person. That’s easy to do. It’s a quick check. Boom, boom. I look at jaw range of movement, open your mouth, close your mouth. How is the jaw range of movement? And then is there symmetry of movement? Is there any groping during when you ask them to do some of these tasks and that we can do over teletherapy and in person. Dentition is a little bit trickier ‘cause I think the further you get inside the mouth, the harder it is to do over teletherapy. It’s just not great. Even with the throat scope. However, the couple that I have done via teletherapy–I’ve had a family– one family that was not super close, but they actually purchased their own throat scope. And so they had one on their side of the camera. I had one on my side of the camera and if that’s a possibility at all, it makes them so much smoother because the child can have it. And you can tell, okay, now look up a little bit, okay, open wide. And they’re holding it themselves. Or even the parent is holding it. And I was able to get a really good look inside their mouth over telehealth–over teletherapy using it when they had it on their side, isn’t always–

Sarah 32:21 Now is their mouth like wide open at their webcam?

Amy 32:25 Yeah, oh let me tell ya, we get super close to the webcam. Like I want to fill up that screen with my mouth and their mouth ‘cause I’m looking inside. Absolutely. It’s not always possible. I know that. But if, you know, if it’s not possible, then I put it on my list of things to do once I can see that child in person. But that is one thing that has made it a little bit easier. Now, when I’m looking at the tonsils, I can’t always see that. Even with the kid close to the webcam, you’re like, okay, well I can’t tell. But like I said, you’re looking at this in the context of what their speech errors are. So if you have a child who’s not necessarily hypo or hyper nasal or they don’t, you know, they’re not mouth breathing then okay. You can probably skip that for a little bit and come back to it when you can see that kid in person. Another thing that I always try to do in person is to get a good look at the hard and soft palate, because arch height of that hard palate, like if they have a really high and narrow palete, usually that means their tongue is low in the mouth at rest, which is not how we want it to be. We want–

Lisa 33:34 You see that a lot with kids with down syndrome.

Amy 33:36 Yes, exactly. And I will see that a lot too with my single sound error kids who have lisps because their tongue tends to be forward at rest. And so it tends to be forward during speech too. And so sometimes if the child– that’s another red flag for a myofunctional issue, which I don’t want people to confuse that with, you know, non speech oral motor stuff because those are in my mind, those are our two distinct types of therapy. Because if you have a child with a tongue thrust, which is a myofunctional disorder, you have to treat the tongue thrust, you can’t just say, okay, well, keep your tongue back behind your teeth for “s.” And yet they still have this tongue thrust swallow pattern. Often I have to treat that tongue thrust before I’m ever going to have any kind of success treating the lisp.

Sarah 34:22 So and a speech language pathologist can do that treatment, but it needs to be the approach that’s kind of probably been formulated by a myofascial specialist?

Amy 34:36 Yes, you don’t– and so, exactly. So I have taken a couple of online courses, honestly, like I am no myofunctional expert. I know an SLP in town who is, so if I have maybe there’s a lot of red flags going on and I think that, ooh, there’s more stuff here than I think I’m able to treat, I will refer out and say, there’s more stuff going on here. But if it’s like a simple, I can tell, like it’s simple tongue thrust. If you take a course or two even online, it will give you so much more information to start looking for those types of red flags. So definitely–

Lisa 35:09 I think that’s one of the controversies though, with this form of treatment, is that to take the courses in person, they are thousands of dollars.

Amy 35:16 Oh, I know. That’s why I won’t do it.

Lisa 35:18 Right.

Sarah 35:19 So that’s the controversy? Or is the controversy, there’s not enough research to support that it’s effective?

Lisa 35:25 I think both.

Sarah 35:26 Oh

Amy 35:27 And well, yeah, that’s a podcast for another day, I think. But there is a difference between, and really like what I tell SLPs that ask about that, I say, take a course, take it with a grain of salt because I think some of the things– I think there are some things that are obviously still controversial as far as the claims being made about what they’re– who should have this type of therapy.

Lisa 35:54 Basically everyone, that’s part of the problem.

Amy 35:54 Right. And I think that’s the issue, right? Like there are few kids that I come across and I’m like, okay, we need to really work on the myofunctional stuff first. Most of the time I’m able to address the speech. And if there are other issues, you know, we can address it down the road or I might refer out, but I don’t think, you know, every kid with every speech sound disorder. And that’s kind of what drives me nuts is, oh my gosh, it’s a tongue tie check for the tongue tie. That kind of drives me a little bit crazy too. Yes. I know that, you know, function and structure like can impact, but not always, not all kids who have particular structural differences are not going to be able to compensate for speech. And I think sometimes we need to stay in our lane, which is speech, and not kind of overreach a little bit. So I don’t– I try not to come down on one side or the other, because I think there is benefit to that type of training. However–

Sarah 36:51 I love you because you have hit every controversial topic that is literally the focus of debate in many a Facebook groups.

Amy 37:01 I’m pretty good at doing that.

Lisa 37:02 basically direct all comments to Amy (inaudible)

Amy 37:05 Sure, sure. Yeah. Yeah. Just go ahead and give everybody my email address at the end.

Sarah 37:10 No, but I love the way– and this is what it always comes down to. Is first of all, let’s be real. We don’t have enough research for most of the things we do. Plus, one of the tiers is clinical judgment and expertise. So I think what I love– what you’re telling me is you’re very thoughtful about it. And so you look, you acknowledge these things then you think about, is it making an impact? Am I the appropriate person to provide support? Do I need to refer? Do I– now, this gets a little tricky in the school setting, so those of you that are school-based SLP’s out there I know you’re like, okay, but what about me? I have a kid who I know has significant tongue thrust that you know, seems to be out of my area of expertise or maybe even something that shouldn’t qualify for my support in a school setting. What does that look like? I hear you, you know, it’s one of those things. I don’t have an answer for district protocols and guidelines are different everywhere. But we don’t have the opportunity to refer out. And that tongue thrust is dramatic in a lot of our kiddos for speech sound disorders.

Amy 38:13 Now what I used to do, and I don’t– it’s what I advise other SLPs. But when I was in the schools, I would clearly tell parents like, this does not qualify this child for our services based on this, this, this, this, and this. However, I do notice these things. So if you would like to look further into that, these are some specialists that might be able to give you more information. So you can be very diplomatic about it. But what drives me nuts is to just keep parents in the dark about it and not even tell them what you’re seeing. You can very easily say that the child does not qualify for school services based on our particular guidelines. But I am noticing some things that you might want to follow up with your pediatrician about. And then let them know what those things are.

Lisa 38:58 And you can include those in a report.

Amy 38:59 Absolutely. I always did. And I never got in trouble.

Sarah 39:03 Yeah. And speaking of which, and Lisa was the lead SLP in the district where we worked. And so you probably can attest to this too. There’s always this kind of hang up for a lot of SLPs that if we see something during this oral mech that looks structural– so whether or not it’s going to be the velopharyngeal– I had a child who I was convinced there was some weakness back there that was having a huge impact on nasality. Any of those two things where a medical person needs to be involved or the orthodontist, everybody hesitates to do the referral because the school has to pay for it.

Lisa 39:35 Yeah, they think the district’s culpable. And really it’s not about who’s paying for things it’s more about, does the team have the information they need to determine eligibility? So even something like if you have a kid with hyper nasality, you can document everything that you’re hearing, but ultimately you can’t really determine what the impairment is if you don’t have that medical component. So if they go get it during that 60 day evaluation window, we can include that information. Well, actually, I think you could say that there is an impairment, but the part that you could never answer on the eligibility criteria, where is there an impairment? Does it require special education? And is there an adverse educational impact that you could say, yes, there’s hyper nasality. This is not right. That is an impairment. You could say, yes, this is impacting them. But that part about is it only correctable with special education? That’s the part that the team would not be able to answer without that medical component. So that’s why it is okay to say, parents, we are finding this during the evaluation, we still have this window. You can push out that MET meeting until the eligibility determination until the end of that 60 day window. And then worst case scenario, if you don’t get it, you can’t qualify right then. But what you can say is, as soon as you do get that component, submit it to the district and we’ll do a review of data. And we’ll include that information along with all of the other information that we collected. And maybe we can determine eligibility at that time.

Amy 41:01 I am so glad you mentioned that. I think that is such a perfect way to look at it and for, for other SLPs to understand how to address it with parents.

Lisa 41:10 So you talked a lot about checklists and I imagine that definitely makes it more streamlined. Are there any other tips and tricks that you have that you found have really– you talked about doing things quickly and that that is always helpful, but do you have any other tips and tricks for streamlining this whole process?

Amy 41:29 Yeah, so especially with teletherapy, I think I have learned with little ones since you’re just on that screen, you have to move quickly. And so what I have found is, especially during these assessments is to kind of break it up. And so I might do a few words from the artic tests, then I’ll go back and we’ll do another couple tasks from the oral mech exam. And then we’ll go back and do maybe 10 more words, and then we’ll go back and do, you know, five more tasks from the oral mech exam. And so I think breaking it up sometimes. You don’t have to sit down and go through this entire test all at the same time, because I don’t know if you’ve ever, you know, worked with a three-year-old over teletherapy, but it’s tricky. And in order to keep them very engaged and not, you know, walk to the other room because they can do that especially if mommy’s not there.

Sarah 42:13 They’re all deuces! Bye.

Amy 42:18 I’ve had that happen. Like, well, you’re gone now. Okay. I guess I’m done. So I think, I think going back and forth and having that–giving yourself that freedom to just do little bits and pieces of the exam, kind of, you know, you can break it up a little bit. So moving quickly, breaking it up, having that throat scope is a huge benefit because I think too, it keeps the kids engaged, even if they don’t have one on their side. When I have one on my side and I can show– they can actually see inside my mouth, what I’m doing, it helps them understand what I want them to do. And so it kind of gets them to look at my face. They really think it’s the coolest thing, even on my side of the screen. And so I think using that. Just, you know, I post on my Instagram all the time. I just posted maybe, I don’t know, a couple of weeks ago of doing an exam with my throat scope on my side and showing him how I wanted him to move his tongue so I could see if there was dissociation from the tongue and the jaw, and it worked so so well, so that has been really good. And then I think also I’ve already mentioned this, but having your checklist so that you know exactly what you’ve already done and you just can easily check things off as you go through it. So I think those would be my top three tips.

Sarah 43:35 And if it is done, you know, doing this virtually. You know, hopefully there’s an involved parent on the other side of that camera. And so you could be doing some training of what the parent could be doing to help give you what you need during that oral mech exam. But I would imagine the other thing is if there’s, you know, some definite concern you may be referring– like, I guess I’m thinking more for teletherapists where they’re working with somebody who’s not local. You would refer out right? Or wait until you can get that information in person.

Amy 44:04 Absolutely.

Sarah 44:06 From a speech pathologist.

Amy 44:06 Exactly. So again, if you’re noticing some things– and if you do that case history, I’m telling you, it gives you so much information too. If you’re looking at the case history, if you’re looking at what you’re seeing with the oral mech exam, and if you’re looking at what their speech issues are and all of that information combined, you might need to tell them, you know what? I really recommend that you see an SLP in person. So if you could, you know, let’s find somebody that I can refer you to where you live, if you’re not close to them. Or maybe at some point you’ll have a plan in place where, okay, we’ll start to be able to do in person therapy here. But we can maybe try some therapy in the meantime to see what’s going on. But yeah, if you see some red flags for things that that child might need a referral for, like to a cleft palate team, like if you’re seeing some things that are jumping out. Even if there’s some soft neurological signs, that’s sometimes warranted a referral back to the pediatrician so that they can look into the possibility of a neurology referral. So some of these things–sometimes we are the first, you know, when we’re looking in the mouth of these kids, I know you think like pediatricians are on top of this stuff, but sometimes they don’t always look at– they’re looking at structure, but not always function too. So I think sometimes we are on the front lines of actually discovering things that nobody has seen before.

Lisa 45:27 Or they’re looking certain structure. They’re doing like the knee taps and they’re looking into your ears and maybe just having you say, “ah,” and nothing else.

Amy 45:35 They’re looking in the back of your throat to see if it’s red, you know, or they’re looking at your tonsils. I’m looking at how the velum is working. I’m looking at the hard palate, I’m looking at their bite, I’m looking at all those things. So yeah, sometimes we are the first people. We’re kind of on the front lines of discovering things that kids might need to be seen for.

Sarah 45:53 I can tell you, I have been the first to bring to attention to parents enlarged tonsils. Where I’ll call and you know, you’re talking to the child and he’s not sleeping at night and he can’t breathe and the vocal quality is impacted and all of these things are going on. And so I look in the mouth and I’m like, well, hello.

Lisa 46:17 Hi tonsils, what up?

Sarah 46:17 Hey how you doing? And so I call the parents and they’re like, oh, okay we’ll take him to the doctor. So I do, I think that’s where we always joke about, you know, speech, language pathologists. We work from the neck up. And so that mouth, we are the ones who a lot of the times– unless you’re Lisa and I quizzed her yesterday on several of the structural and anatomy parts of the mouth and oral mech.

Lisa 46:41 What are you talking about? It’s like when we do the, what is it called?

Sarah 46:45 You just need to brush up again.

Lisa 46:46 at our state convention when they do the–

Sarah 46:48 Praxis.

Lisa 46:50 I know all of those answers.

Sarah 46:50 You answered veleculae every single time.

Lisa 46:53 No, vocal fold.

Sarah 46:53 Oh vocal fold. Ok. We just need to brush up on our anatomy a little bit.

Amy 46:57 But don’t we all though? I tell you that I sometimes, I mean, I wrote this exam and sometimes I even have to go back and read what my guidelines were like, wait, what was that? What does that mean again? It’s true, but it’s good to have those guidelines in front of you because sometimes you’re like, wait, I haven’t seen this in like three years. I need, you know, cause we don’t always see all the structural things in every child. So, you know, you have to kind of brush up on it from time to time.

Lisa 47:21 Well then I love that you not just do the checklist, but like you said, you have all the rationale there for what could it be clinically relevant. And that’s the kind of stuff that you just need to copy and paste right into that evaluation. Because you don’t want to get to the MET meeting and they’re like so what does that mean?

Sarah 47:38 And you’re like “I don’t know.”

Lisa 47:43 And you’re like well…

Sarah 47:43 It’s a problem.

Lisa 47:46 Neurological problem.

Sarah 47:46 Right? A lot of times I go just answer, when in doubt, just answer, it could be neurological. We’re joking people, I promise.

Amy 47:57 That’s one way to go.

Lisa 47:58 Ish, ish.

Sarah 48:01 We’re joking-ish. No. So this is perfect though. I want– let’s talk about those guidelines because here’s where this matters I think more than anything is for the differential diagnosis of speech sound disorders and how we use the oral mech to guide treatment.

Amy 48:13 Yes, absolutely. So it can tell you so much information. I think we’ve already– I think everybody kind of knows like if there is some weakness, then you’re gonna want to have your ears perked to a dysarthria, but dysarthria is the speech disorder. So if there’s some weakness there, but that’s not the nature of the child’s speech issue, note that. Note that there is some weakness, but you’re not going to necessarily need to increase that weakness because like I’ve said, like I think we’ve already addressed, non speech oral motor exercises to increase strength of the articulators do not have a direct correlation to improved speech. So it’s not something you have to necessarily work on directly. You need to work on speech to improve speech.

Lisa 48:52 but it can impact progress. Right?

Amy 48:55 Absolutely. Absolutely. You’ve got to know it, right? Know that that’s, what’s going on and know that okay, well, so this child, if this is dysarthria, then we’re really going to have to work on breath support. We’re going to have to work on over articulating. We’re going to probably have to work on the rate of speech as well, because those are things that are going to help that child with those particular deficits improve their speech.

Lisa 49:16 And to correct the parents with this too, we’re going back to that whole idea of impacting progress over time. You could take longer to establish these speech sounds. And so you don’t want to like have a parent just see this progress report that is not making tons of progress when you’re working on a lot of different foundational skills and it’s just going to take a little bit longer and that’s okay.

Amy 49:37 Absolutely. And I think as well, you know, and it’s kind of the same realm, if you’re doing all of these things that you’re noticing that the child is really having some difficulty with those volitional non speech tasks, like, you know, okay, open your mouth, pucker your lips, stick your tongue out. If you’re noticing that they’re having significant difficulty and then go– and I have the diadochokinetic syllable rate chart on my exam too, because that’s super important. Go and look into–

Sarah 50:02 Can you tell us why?

Amy 50:05 I will

Sarah 50:06 That’s another one I do, but I’m not sure really why.

Amy 50:08 So to me, I think the most valid, the most important thing that I get from that is, you know, I get the “p-p-p-p-p” we’re going to do that 20 times, I’m going to see how fast you can do it. If you have a child with dysarthria– see, I even have to look back kind of at some of my papers, even to remind myself, but if you–

Sarah 50:27 Don’t pull out your guidelines.

Amy 50:31 I know, I’m pulling out my guidelines. But if you have a child who once you get to that two or three syllable, that “ptk, ptk, ptk,” I’ve had kids who do great on “p-p-p-p,” no problem there, right? Like what do they– they do 20 reps in five seconds. That’s perfect. That’s just right on target. But then you get to the multiple “ptk” or the “pt-pt-pt” and they just totally break down and absolutely cannot coordinate those at all. I just had a child I assessed last week. Did beautifully, there were no other big red flags for apraxia, but once we got to “ptk” and this was a school aged child, you should be able to do that “ptk-ptk-ptk-ptk” 10 times. And then I look and see how many seconds does it take that child to get to 10 times. She could not coordinate it to do it once. And so it was a total, like, p-p–I wish you could see my face. I look really good doing this.

Lisa 51:26 Well what does it mean when somebody can’t say supercalifragilisticexpialidocious? Sarah 51:27 That’s not the same thing

Amy 51:31 I think that just means you’re not a Disney fan maybe, I’m not sure.

Sarah 51:33 Right.

Lisa 51:36 Well what if they are a said Disney fan–

Sarah 51:36 This is not the same thing. Let’s go back to “p-t-k.” She’s making fun of me because I do actually have some issues with probably motor sequencing.

Amy 51:42 Do you have problems with that? Aw.

Lisa 51:45 Let’s see if Amy can fix you. Say supercalifragilisticexpialidocious

Sarah 51:50 No, no. Focus, this is not about me.

Amy 51:50 we just need, we just need to break it down. I’ll get my Bjorem speech cues and we’ll make it happen Sarah.

Sarah 51:57 I’m glad you, I’m glad you brought that up on why that sequencing is important. And so for your child who had difficulty with that what does that mean?

Amy 52:06 So I missed that last part. What did you ask? Sarah 52:10 About the little girl you said couldn’t even do it once.

Amy 52:11 No, she could not. And so I was looking at rhythmicity, coordination. Was there groping? And yes, there was all of that during the “ptk” portion. Like she could not even coordinate it. And this was prob–and so I did–that is a red flag for, ooh, that’s a big red flag for apraxia. So I switched courses with my assessment and did a dynamic motor speech assessment to look specifically at apraxia. Cause you cannot diagnose apraxia with just an artic test. You have to really dig a little deeper and make it a dynamic assessment. And so–

Sarah 52:40 Can you tell us why we learned this from Jenny Bjorem? But can you tell the listeners why this is true?

Amy 52:46 You need to really dig deeper and find out where and why that child is breaking down at different syllable levels. And you need to– basically what that will tell– and you’re basically providing cues and probes for this child to see if they can become more accurate as you have them repeat words, syllables, phrases, multiple times. And you’re looking for consistencies because as you probe them and you have them produce these target words, and there’s a very, you know, there’s a method for going through the different syllable shapes and having them say these words back to you multiple times. You’re looking for all of these signs of apraxia and that’s how they show up. All those, you know, the Mayo 10 or 11, what it is now, you know, you’re looking for groping, you’re looking for difficulty with prosody, with, you know, how– basically all of the things of apraxia and I don’t have my assessment out in front of me. But so I did that with this little girl and she was the most obviously apraxic child I’ve probably ever diagnosed, but it did not show up necessarily in the oral mech exam until I went to the “ptk” portion. So super, super important to include those.

Lisa 53:58 You had talked about dysarthria and how oral mechs can help identify that and apraxia. What about, is there– are there anything that, or anything that you can gain from this exam for phonological versus articulation or not so much?

Amy 54:12 Yeah, for sure. Like for my single sound errored kids, I want to know are there any restrictions? Because I know there’s a lot of controversy about a tongue tie, but if you have a child who has been in therapy for five, six, seven years, we’re still working on R and you’re noticing a significant tongue tie. Most kids can produce speech well, and they can compensate well with a tongue tie and it’s not an issue. But if you have a child and they are just not able to, then that might be something to consider, like this really might be impacting speech. So for my single sound errored kids I’m looking at structure and function too. So like we said earlier, can they dissociate their tongue from their jaw? If they can’t, you might need to back up and work on that for a session or two to make sure that they know that skill on how to do that and then work on that in the context of speech. So that’s how I use it for my single sound error kids. And for phonology it’s for ruling out any issues for me. That’s why I look at it. Like I’m looking at–because it helps in that differential diagnosis, if you have a child with these consistent phonological error patterns, or if they consistently have phoneme collapse, I’m like, well, okay, let’s go through this oral mech and see maybe if there’s anything that could be a red flag for, you know, that it’s not phonological– it’s not just phonological. Because it’s always, it’s often not just phonological. Sometimes there are motor components. I’ve had kids and I call, we call them, you know, mixed speech sound disorders, where there is a motor planning component and there’s a phonological component. So I might treat this child as if they have, you know, as, maybe from a phonological perspective, maybe I’ll do multiple oppositions, but I’m going to want to know to incorporate those principles of motor learning into that therapy as well, because maybe both things are going on.

Sarah 56:01 I love this so much. This– what was so powerful for me is I always look back and reflect on my practice and I’m embarrassed. I think I felt like I wasted time with the wrong treatment approach for some of the students that I have had on my case load in the past. And it was because I don’t think that was ever explained so clearly to me that differential diagnosis and how critical that is for determining your treatment approach.

Lisa 56:27 Well, and how complex these speech disorders are. I mean, it’s not just artic. You know

Amy 56:31 Oh my gosh.

Lisa 56:32 there’s so many different things and even–

Amy 56:34 How often have you heard that? It’s just, oh, this is just an artic kid? And then I get them and you do an oral mech exam and you’re like, ooh, maybe it’s not, maybe it’s not just artic. There’s some other underlying issues we need to address. So you’re so right. It’s so much– even just SSDs. It’s so much more complicated than I think most of us realize.

Sarah 56:54 So I think the moral of the story is do the oral mech.

Lisa 56:59 and follow Amy Graham.

Sarah 57:01 and follow Amy Graham.

Lisa 57:01 I love Amy. And I know we’ve said Jenny’s name like 19 times during this too, but I think why you guys both stand out is not just because you’re in the great state of Colorado, but I love that you share what you’re doing in therapy for these things that, again, that maybe I was not doing well, and then–

Sarah 57:19 to see it modeled.

Lisa 57:19 I can see it, yeah. It’s so powerful.

Amy 57:22 I’m a hands on, I’m a hands on person. I need to see somebody do it. And so I figured that other SLPs felt the same way. So I think if you see somebody do it and you also know the ideas behind it, it just makes it easier, I think, to learn.

Sarah 57:36 Well, thank you for your contributions. I know it’s hard to put yourself out there. And so I appreciate that you’re willing to do that because I do, I think we learned so much from seeing these things in action. And, you know, even this podcast episode was one where I was like, how the hell are we talking about oral mechs for an hour? And this has been fascinating. It’s been so interesting. And I really appreciate you sharing what you have learned. I love again that contribution to the field that you put into this tool that we can use to help guide our clinical judgment, but also not just have us do it, but know why we’re doing it. And there’s so much value there. So we’re going to link to that in the resources as well. But then this just also led me to all of the other conversations I want to have with you. I think we need to do some follow up on treatment approaches and things like that.

Amy 58:26 I would love to.

Sarah 58:27 Anyway, we appreciate you so much, Amy. This has been absolutely fantastic.

Amy 58:33 Thank you, Sarah. Thank you, Lisa.

Sarah 58:36 Okay. Now, for those of you listening, if you’re in the timeframe of SLP connect, which I should know the dates off the top of my head, and I don’t. Listen for this outro, cause it’s going to give you all the details you need to know, but that’s it for us.

Lisa 58:47 Take care guys.

Speaker 4 58:48 Thank you for participating in SLP connect. Remember that listening to this pod course does not automatically guarantee ASHA CEUs. If you want to earn ASHA CEU’s for this conference, there is a small $25 administration fee to process and submit your paperwork. You can pay this administration fee and find more details at Once your purchase is made, you will be able to access the course evaluation, quiz and earn your certificate. Please submit these materials by October 7th, 2020 at 8:00 PM Eastern standard time. SLP connect would like to thank its sponsors for offering products, services, and discounts as giveaways to attendees at no charge. You can see a list of these sponsors and enter to win on the SLP connect web page. SLP connect would also like to thank the presenter of this course who has provided her speaking services at no charge. Ready to fill your digital swag bag? You can enter to win a giveaway of your choice by taking a screenshot of this course and sharing it on social media. Use the hashtag SLP connect 2020. So we can find you the winner will be announced by midnight, October 10th, 2020. Thanks for listening. And we hope you enjoyed this second annual podcon.