Marisha: Hey there. And welcome to the SLP Now Podcast. I am so incredibly excited to have Liliana with us here today. We are going to be talking about all things bilingual therapy. It is definitely going to be a crash course. We were just talking about this before we started recording. And all of the questions that I have for her, like each individual line, could be a massive course. Liliana has done a ton of work to kind of distill the most relevant details, and give us just a good starting point. But, this is definitely, like I said, crash course.
But, a little bit about Liliana before we dive in. She is a certified, licensed bilingual speech language pathologist currently practicing in Chicago, Illinois. She obtained her bachelor's degree in communication disorders in 2012 and her master's degree in speech language pathology at St. Xavier University in 2014. She has extensive experience serving with the bilingual population, which is why she's here today. She currently works full-time in a public school setting as a lead bilingual SLP for her district. She also works part-time in early intervention with bilingual families. She runs an amazing SLP blog geared towards providing bilingual resources for SLPs and parents. She also creates bilingual resources and activities on her Teachers Pay Teachers store. So without further ado, welcome, Liliana.

Liliana: Hi. Thank you so much for having me here. It's a pleasure chatting with you today.

Marisha: I am so grateful you are willing to share your time with us. I've been getting a lot of questions from the SLP Now Podcast listeners about bilingual therapy, so I am super excited that you get to share your wisdom with us here.

Liliana: Oh, thank you. I'm glad to be able to answer any question that you have today.

Marisha: Before we dive into all of the nitty-gritty details, I'm really curious about kind of what led you to specialize in bilingual therapy and how you got to where you are today.

Liliana: Well, it's definitely been a long journey. I would say it really just started early on when I was trying to choose or pick a career to study, which can be a difficult task for most 18-year-olds growing up. At the time, I just remember I wanted to major in forensic sciences, but I wasn't sure. I also thought about psychology. I think my mom played a really huge role in my just decision-making and just her influence. She always urged me to pursue a career either in the medical or healthcare industry where I can utilize my Spanish-speaking skills in hopes that I can make a difference in the Latinx community.
Then, I mean, for this reason, growing up in a household where Spanish is the language predominantly spoken, that meant trips to the doctor with my grandmother or making phone calls for my dad in order to interpret for them. So, my mother always stressed kind of the importance of being able to find someone who's proficient in Spanish when going to a hospital or any type of facility. But most importantly, she often stressed that the quality of parent communication improves greatly when you have someone that relates to you on a cultural level. Then, I feel like that statement stuck with me forever.
So since the beginning, I knew I wanted to work with the Latinx population, with the bilingual population. At the time, I was actually at the University of Illinois studying psychology. I just kind of realized that that wasn't the career for me. So once I got my mom kind of urged me, she's like, "Oh, you should look into speech therapy. It sounds like a really great career." Then, I did my research and switched majors, switched schools. And like I said, from the beginning, I had let my professors know that I really wanted to kind of have a bilingual emphasis with my clinical placement. So, that's kind of how I gained experience working with the bilingual population.
Then, I guess fast forward to once I graduated and once I did all my clinical work, I was super excited to finally be on my own and start my career. I was placed in two schools in the Back of the Yard neighborhood here in Chicago where 70% of the community are Latinx, and about 70% of the student population are English language learners. So, I was really trying to find resources. I was honestly a really complete nervous wreck my first year. I was trying to learn a ton, ask a ton of questions, make materials, and just overall try not to panic just because that's when I really realized that resources and activities were very limited in Spanish. So, I started really just creating my own stuff and using my activities in therapy. Then, it just kind of took on from there. I wanted to share my activities and share my resources with other bilingual SLPs that I know are in the same boat as I am trying to find resources and activities for their specific population.

Marisha: I love that story. I feel like I just was a little bit similar in that I started with psychology, too, and eventually switched over to speech therapy, but yeah.

Liliana: I think we made a really great choice.

Marisha: I agree. I think I chose an amazing field. I love how you were able to use your Spanish and just your experience growing up to kind of create a really specialized role for yourself and having an impact in a way that ... a very unique impact. So, that's super inspiring. Thank you for sharing that.

Liliana: Aw, thank you. Thanks.

Marisha: Now, let's get into the nitty-gritty content. I think it'd be helpful to start about just talking about some common myths about bilingualism because I think that's kind of a good starting point in just making sure we're on the same page.

Liliana: Yeah, of course. I will discuss some of the most common myths that I have heard over the years while working with the bilingual population. Most of these myths I have heard from parents or professionals working in our field who may not be necessarily informed about the best current processes in regards to working with linguistically diverse and bilingual populations. And some of the myths that I will discuss have been debunked by a vast amount of research, which I will mention as well.
I would say the first biggest myth is that ... It's on the topic of language confusion. Language confusion is the idea that children are incapable of becoming bilingual without experiencing some sort of confusion. Therefore, it's often believed that exposing infants or toddlers to more than one language will cause delay. Currently, there's no research that shows that bilingualism causes language delays. We can expect children to meet the same developmental trajectory as those who are exposed to one language. This is a quote directly taken from Asch's statement on bilingualism.
Then, of course, there's research. There's a study done by Dr. Barbara T. Conboy, who's an SLP with specialty training in early language and bilingualism. She completed a research study in language differentiation in bilingual infants. Overall, her research indicated that children's cognitive systems as early as infancy can handle more than one language without confusion. So, that myth was debunked by all of the research.
Then, another myth that's often heard as well is it also goes along with the topic of language confusion. And it's that when children mix their languages, it means that they are confused. I have heard this concern from several parents of bilingual children over the years. Often, the parent will state that he or she heard his or her child say a word in one language and then started to combine words of features from the second language in the same sentence. Now the parent is concerned that their child is confused or not learning each language perfectly.
This is actually an amazing behavior that the parent is observing. It's called code mixing, which is the use of elements from two or more languages in the same utterance or conversation. Often, as children are learning both syntactical symptoms from both languages, the child may carry over features from one language while speaking. And if a child is still learning both languages, we might hear what may sound like to us as errors. However, when compared to the mainstream language, however, I like to tell parents and other professionals that these are not errors but instead interesting linguistic patterns which indicated that the child is really starting to understand and manipulate these grammatical rules from both languages.
Parents and educators should not reprimand children for code mixing because code mixing is actually pragmatically strategic and grammatically constrained, meaning that it doesn't occur randomly. We know that it's actually rule governed. And often, people code mix in a way that respects the grammatical rules of both languages, which is really, really cool. It also helps to fill lexical gaps in the child's proficiency in the target language and at times may also reflect the child's cultural and social identity. So, code mixing is perfectly normal.
Then, another big myth that I often hear, too, is speaking two languages to a child with a delay or disorder will make them worse. Therefore, during intervention and at home, the parent and clinician should expose the child to only one language. This is probably, I would think, the most commonly heard myth that I've heard in multiple settings from multiple professionals, including doctors or pediatricians who have recommended that the parent should only expose their child to one language. Often, parents of children who have autism are worried that speaking two languages might delay their child's language development or altogether just stop it.
It is intuitive to think that adding another language may impair their child language learning systems, but there's a growing body of research indicating that children with a wide range of communication disorders are capable of becoming bilingual. There have been several studies on children with Down syndrome, articulation impairments, and autism. And all of these studies have shown that bilingual children's language skills can be comparable to monolingual children with the same impairment. Overall, there's no evidence to support the idea that being bilingual will result in additional language delays for children who have language impairments. We can see this statement supported in research studies completed by Gutierrez-Clellen, Wagnus, Corkman, Pratus, Kreigo. There's several research studies that have also debunked this myth.
A very popular study that was done was done by Hambly and Fombonne in 2011 where they compared the social language abilities of three groups of children with ASD from Quebec and Ontario. In the research study, they had three groups. One was monolingual. One group was simultaneous bilingual, meaning that they acquired both languages at the same time. And another group was sequential bilinguals, meaning that the participants acquired one language first and then later the second language. The researchers examined several language aspects in the study, such as social responsiveness, initiation of and response to pointing, attention to voice, vocabulary size. And overall, they did not find differences between these bilingual groups and their monolingual peers with ASD. We can see similar results in other studies with children who speak English and Chinese.
But overall, these researchers found that children with ASD who were simultaneous bilinguals did not experience additional language development, developmental delay. The findings suggest that children who have autism or Down syndrome are definitely capable of becoming bilingual.
Then, lastly, another big myth is bilingual children will have academic difficulties and the language of intervention should be provided in the classroom language or the language of instruction, which most of the times, here in the US, is English because providing intervention in any other language would not support the student's progress in the classroom. This myth I frequently hear in the school setting, especially during IEP meetings or during any meeting where a special education team is deciding types of academic supports that the child will receive.
I have been in meetings where parents or parent advocates or other professionals will make a case for removing bilingual support or pushing for English-only instruction or intervention because English is the language of instruction. And once again, this idea that exposing the student to another language will cause the student more learning difficulties or lead to not mastering any languages is highly believed. Although this assumption may appear valid, there is no evidence to suggest that children with severe disabilities are unable to successfully become bilingual. This statement comes directly from a researcher by the name of Ohashi. In 2012, he did a research study.
But, overall, restricting language input to one language only may result in negative consequences which can impact the child who comes from a bilingual environment. We need to think that if bilingualism were too cognitively demanding for children with disabilities, it would mean that children with typically developing language skills will perform below their monolingual peers because of the increased cognitive load of bilingualism. But yet, the research, the literature does not suggest that. We have research that shows that bilingual children can have academic advantages of being bilingual, including superior problem-solving skills, multitasking skills, and increased cognitive flexibility.
A study by Barac et al. in 2014 called the Cognitive Developmental of Young Dual Language Learners found that, overall, in the area of nonverbal executive control skill such as memory, typically, bilingual children showed more advanced skills than their monolingual skills. Then, a more recent study that appeared in the Chicago Sun-Times called English Language Learners are Matching, Exceeding Other CPS Students revealed that bilingual ELL students met and sometimes surpassed monolingual students academically.
Overall, I believe that it is our ethical responsibility as professionals, as SLPs to educate others about the facts and the research currently out there. Because myths like these can have an impact on service delivery, an impact on decision-making in the special education process. We really must keep in mind that eliminating a child's home language comes with great consequence. It can result in poor language models at home, difficulty with family cohesion or communication, and prevent families from passing on their cultural values. So, we really must take this into consideration when working with diverse populations. And just ultimately, it's not our decision to make when it comes to which language the child should be exposed to.

Marisha: Oh my goodness. What an amazing overview. I was scrambling away taking notes. There's so much good information there.

Liliana: Thank you.

Marisha: Thank you so much.

Liliana: No, no. Thank you. I could definitely send you the research studies so that you can share with the listeners.

Marisha: No, that's amazing. So helpful. Those are all things that I've heard in meetings and everything, too. So, I think this was a really great starting point in just kind of getting all of us on the same page on where things stand with bilingual therapy. So, let's just dive into some ... And I wish we could talk about this for much longer time. But like I said, we're doing crash course today. Let's start diving into assessment. So, what are some ... Let's say we have a bilingual student on our caseload. We're convinced that we're looking at both languages or maybe even more than two languages if they are speaking more than that. But, what are some of the best practices for the assessment pieces? Where do we want to start with that?

Liliana: I will kind of outline some really important just key features about bilingual assessment. As SLPs who work with culturally and linguistically diverse populations, I would so that foremost, it is extremely important to become familiar with the student's ethnic background, educational background, student's cultural and dialectal differences prior to your evaluation. You definitely want to use your resources and do a thorough review on pragmatic differences that exist within the student's culture. Portland State University has some really great resources. That's the Portland State University website.
Just the last thing you would want to do or to make is a miss- or over-identification of the language disorder because of a cultural difference. So, definitely inform yourself about the student's dialect. For example, there are so many dialects that exist within English and/or the Spanish language, for example. And it's not safe or best practice to assume that your students speak the same dialect as you. I speak Spanish. However, my dialect of Spanish is completely different from a student living in, let's say, the northern part of Mexico. And it is completely different when compared to a student who is from Puerto Rico.
Overall, a point that I really want to stress is that we also need to acknowledge the students' linguistic differences and not judge or hold these differences as less or as the substandard when compared to the mainstream language. Overall, the SLP that is evaluating or working with diverse populations needs to practice culture humility in order to best serve these populations. But overall, we really need to be able to obtain qualitative and quantitative information from our evaluation and ensure that we are using a variety of assessment tools to help guide our decisions when assessing diverse population.
We definitely need to use multiple measures, both informal and formal, in order to really obtain the complete picture. So, you definitely want to do an in-depth family interview. Caregivers can always provide accurate information about a child's communication strengths and weakness, and just being able to understand the family's view, which can give us a lot of insight about the child's cultural values, educational status, language use, and communication deficits.
We also need to complete thorough interviews about the child's language background use. This is completely different than the regular interview. This information, the language background use, is going to help us obtain language of the student's dialect history as well as measuring the amount of exposure and usage of the student's language and the communication partners that the student communicates with on a daily basis. It really gives us a lot of good insight to the student's language preference and information about the student's acquisition of both languages.
So, tools that are very helpful for the part of the evaluation are language history questionnaires. Some assessments such as the BESA already have great questionnaires embedded within the assessment. Or you can always download a questionnaire from ... There's a website from the Cornell University that also has a good questionnaire called The Multilingual Language Use Questionnaire, which is really great. Because once again, it really breaks down all of those questions about language history.
But aside from that, too, we need to use nonstandard speech language assessments, pragmatic tests, language samples, or even criterion reference assessments if formal standardized testing is not available in the child's primary language. These tests will help determine the client's understanding and use of conventional language. And just really keep in mind that most, if not all, assessments are not always normed on the diverse population that we work with. Therefore, using scores to justify our decisions is not enough. I can't stress that enough. The most widely standardized language assessments that SLPs use are biased against most linguistically diverse students.
So even according to Dr. Kate Crowley, who is a well known SLP researcher, most bilingual students perform poorly on a standardized test, not necessarily because they have a disorder but because they do not have the same prior experiences as the mainstream American middle class experiences that form the content of most of these standardized tests. So, definitely keep that in mind. And keep in mind that it is not appropriate to translate standardized assessments to reach a standard score when you are working with these diverse populations. You simply cannot report standard score as when using assessments that are not normed for that specific language.
You start to think, "Oh, well, if I can't use standardized assessments, well, what else can I use?" One of the best tools that you can use is in-depth language sample. Honestly, it's the best tool that you can use when evaluating bilingual students. Language samples prove to be not culturally or racially bias. It's considered the gold standard for assessing children's language skills because it, honestly, is the only assessment measure that captures a speaker's typical and functional language use. This is a quote directly from Heilmann et al., 2010. Clinicians can use tools like salt and sugar to assess the students' morphology and syntax in both languages or even obtain language samples with tools such as the SLAM cards from Dr. Crowley's Leaders Project website. You could download them there. They're free. Also, just check out the website because it contains great information about working with diverse population. But, she has several tools on there that you can use and download so that you can use for your assessment.
Then, lastly, I would say that dynamic assessment can also be very useful when assessing bilingual children. And for those who are unfamiliar with dynamic assessment, it's a method of assessment which uses the test, teach, retest model. It can help us determine difference versus disorder when working with children that speak another language. Dynamic assessment really focused on the child's ability to acquire the skills after being tested and after being exposed to instruction. Children who are able to make significant changes after short-term learning or intervention sessions are very likely to have language differences in that language disorders. Overall, that's kind of my outline of things. So, just keep in mind when you are doing these assessments, language samples, interviews, dynamic assessments, criteria, and reference test.

Marisha: That is another amazing overview. I love how you structured that. It gives us some really nice action items to kind of look at and compare and see what we're currently using in our assessments, and then giving us a jumping-off point to learn a little bit more. So, that is perfect.
I second Dr. Crowley's site is amazing. I love the SLAM cards and all of the resources she has on there. So, that's a really great place to look if SLPs are wondering about language samples.

Liliana: It's a really great resource to just also learn more about dynamic assessment. Because I feel like that's one of the biggest questions that I often receive is how do you do a dynamic assessment or what are the components. So, she has great, great resources, the Leaders Project website.

Marisha: Yes. Yeah, we will definitely link to that in the show notes. Let's say we finish our assessment. We did our interviews. We looked at the language background use. We did a variety of different assessments. And we're only using norms when appropriate, which it sounds like that would be pretty rare in these situations, and we did some dynamic assessment. So, how do you go about starting with goal writing with English language learners? Do you have any rough guidelines or suggestions for getting started there?

Liliana: Yeah. Figuring out where to start in speech language interventions can be tricky, especially when working with bilingual children. Every case is different. And I will keep kind of my recommendations a little general because of this. However, one point to always note according to best practices in bilingual intervention and research by Dr. Goldstein, who is the author of the book Bilingual Language Developmental and Disorders, is that it's always easier to start with therapy goals that consist of shared features of both languages in order to develop a strong foundation and lead to overall gains in the student's language ability in the first language and in the second language.
Basically, what that would look like would be imagine you have a student who speaks, let's just say, English and Spanish. Finding shared features between both languages would be in the example of, let's say, a language goal, would be plurals, for example, because plurals exist with the final S, adding the final S to nouns, exists in both languages. So, that would be a goal that you can address. Let's say for the example of articulation. For example, if you're writing a goal for articulation, you would want to pick target sounds that are also shared amongst both languages. So once again, going to that English, Spanish example. Some shared phonemes would be the S sound, the M sound. You might want to start there when you're writing your goals.
But in addition, targeting shared features in your speech language goals will really help you avoid writing goals that are dialectal differences, which is not best practice. And once again, it's just really important to become informed about what those dialectal differences are. Write goals that consist of shared features of both languages. Then, once the student has mastered those goals, intervention can then later address the non-shared features or language-specific features as deemed appropriate.

Marisha: Awesome. Then, for SLPs who aren't as familiar with the second language, you mentioned that Portland University site ... Here, I'm trying to look back at my notes.

Liliana: Yes, yes. Portland State University.

Marisha: Portland State University. That would be a good place to go for dialectal differences or no?

Liliana: Yeah. The Portland State University website has a variety of languages under ... I believe it's the multilinguistic tab that they have on the website. They list a variety of languages. You could just click on the language that you're looking for, and it gives you an overview of pragmatic differences, just information about the culture, the language. It's very, very informative.
I know ASHA as well has a lot of good information on the website on dialectal differences for some languages. Bilinguistics has a whole book on different languages and their dialectal differences. So, I would highly recommend checking out those resources if you are working with English language learners.

Marisha: Is there an easy ... Are there similar resources to identify the shared features in both languages?

Liliana: Yes. I think, once again, Bilinguistics has the shared features within their book. I can't think of the names right now, but they do list out kind of this diagram where they show what those shared features are and which features aren't shared as well within their resources.

Marisha: Awesome. That leads me to a follow-up question, too. Of these resources that we can use, if we're not familiar with the language ... Or, yeah. So, the follow-up question there is ... So, let's say an SLP is working with a student who speaks Portuguese and she doesn't speak Portuguese. She can do that research and figure out the shared features, the dialectal differences, all of that. But, do you have any other ... I mean, ideally, the student would have a speech therapist who speaks both. But, do you have any tips or suggestions in navigating that?

Liliana: Yes. It can be challenging at times working with or communicating with families who don't speak another language that you know you know. In that specific case, sometimes you might not always find a Portuguese-speaking SLP to help that student. I would highly recommend the use of an interpreter if possible. That is best practice is to provide the student with intervention in the child's language. So, I would reach out to your admin, your school if you do come across a situation like that where you don't speak the language. Because in that case, like I said, you would really need the use of an interpreter.

Marisha: Awesome. Then, that leads me to the next question. In that case, we'd also be working with the parents. Oftentimes, if that's the primary language for the student, then that is also the case ... Or that can be the case for the parent as well. So, do you have any suggestions in providing effective communication when the primary languages don't match up?

Liliana: Yeah. Once again, like I said, it sometimes could be difficult to find those resources or even the use of an interpreter if possible. I know sometimes that's not the case, especially when you want to just be able to send home activities or explain an assignment. Overall, here, I'm going to list some tips in order to help improve communication with parents. I always ask families about their language preference for activities, meetings, and overall communication. I highly suggest that. Don't assume that because English is their second language that they aren't comfortable speaking it. If they prefer to speak in their first language, definitely try to find an interpreter. But, that's definitely a question to always ask families right from the bat is what their language preference is.
Definitely get to know the family and their culture. Once again, this is practicing cultural humility and being able to be culturally competent in order to ensure that any activities or materials you provide are just appropriate culturally and accurate. Let all the students and families know that they are welcome. A welcoming environment that celebrates students' cultures and encourages family leadership creates a strong foundation for relationships in your practice.
Then, use your resources. If a translator is not available to help you translate your materials or instructions on an assignment, you can use Google Translate. It's not perfect. But from experience, parents will tend to appreciate the effort you put into your communication a ton in case you really, really need something translated.
Then, the biggest point, I guess my biggest point of advice, is don't cut corners. It may seem very easy to leave out information or feel frustrated that you cannot get your message across with ELL families, but ELL families are legally entitled to information about their child's schooling. This includes all information about enrollment, parent conference meetings, IEP meetings, and any services that the school provides, such as speech therapy. They have the right to understand this information and have this information in a language that they can understand. ELL parents must have access to the same information as non-ELL parents.
According to the US Department of Education, schools must communicate information to limited English proficient families in the language they can understand. They must provide translation or interpretation from appropriate and competent individuals and may not rely or ask students, siblings, or friends, or untrained school staff to translate. It's just not sufficient enough for the staff to be merely bilingual.
Then, another thing to keep in mind, the IDA 2004 mandates that an interpreter facilitates the communication between individuals who do not share the same language. This includes assessments as well. Really keep in mind that sending information home in English will not always ensure that it is read and understood. I want to say ask yourself, what is your school doing to meet the needs of the current student population within the school? Does the school staff reflect the student population? I know sometimes these factors may seem out of our control, but we need to initiate these conversations with our admin at our schools in case you find yourself in a case where you have some students that need that interpretation or need that ELL support.

Marisha: Wow. So many good tips. I did have a follow-up question, too. I mean, we could talk about all of these points for hours and hours. But, I'm curious if you have any specific suggestions on getting to know the family and their culture. Can you give a couple examples of questions you might ask or just how you might approach that?

Liliana: So if it's a student on your caseload, you would've had to do a background assessment or just a family interview as part of the interview. I do ask these questions. I ask the families where they're from, what language is spoken at home, what information about the dialect. I let them know that it's more so for my assessment so that I can really understand how the child is communicating. So, just kind of making that point really straightforward, just saying that it's for the assessment purposes. But, I'm a pretty straightforward person. I will ask families about their preferences. I will, like I said earlier, ask them what language they prefer communication be in. In the beginning of the school year, I do kind of an activity where we talk about where we're from and just to really get to know one another and get to know my clients and get to know my students so that I can effectively provide them with just the intervention of with the assessments that they need.

Marisha: That's perfect. When you mentioned that, it reminded me of an article that one of the SLPs in my membership sent me. I think it was ... Yeah, it was this week. I just pulled it up real quick. The title is How to Celebrate Multicultural Diversity in Your Classroom. So it's geared at teachers, but it had a lot of similar things that you mentioned. They're activities to do with students, but some of ... I'll just share one or two of the quick ideas. But, they recommend having the students interview a parent or grandparent to learn more about their cultural heritage or just having ... Like you said, just talking about that in the speech room. That's an amazing language activity. So, it could kind of give us that information and also be therapeutic.
There's also sharing information about food. That's part of their cultural heritage. The blog post has ... Or like playing music from their culture. There's just so many different ideas on ... They're great therapy activities also, but they give us some really great information, and I think it's a cool way to celebrate all of the different cultures that we work with.

Liliana: Yeah. Once again, this just ties into how I mentioned earlier, just making sure that your practice, your intervention really celebrates and encourages, like you said, all cultures within the speech therapy room, and you're using materials or tools that are accurate and represent a variety of cultures or represent the student's culture. Because that's really important as well so that the student can also see themselves in the types of intervention that you're giving.

Marisha: Yeah, that's perfect. Then, I'm curious, too. This is backtracking a little bit, but I'm super curious. We talked about assessment, and we talked about selecting goals. Then, I'm curious, too. When it comes to the actual ... When it comes to treatment and diving into intervention, and with your current caseload, I guess might be the easiest way to start talking about it, how much of your intervention is in English versus Spanish? What does that look like? How do you structure that? Just some super ... I know that could be a three-hour course as well, but do you have any ... I'm just curious to get a quick snapshot of what that looks like for you with your caseload.

Liliana: Well, for me, for my specific caseload ... And this, it varies school to school, SLP to SLP based on their caseload's needs. At my school, there are two SLPs, myself and my colleague. The way we have divided our caseload is she takes all of the monolingual students, because she's monolingual, and I take all of the bilingual or predominantly Spanish-speaking students. Currently, on my caseload, I would say 90 or 85% of them, their therapy is in Spanish and Spanish only just simply because I work with a lot of preschoolers. The preschool students often come from environments where Spanish is the predominant language at home. And they come into school only speaking Spanish, and they're acquiring English in the school setting. So, intervention is in Spanish 100% with them.
It really varies. Once again, if you are trying to decide what language intervention should be in, once again, you really have to tie it back to your evaluation and all of the information that you obtain. Like I said, if there's cases where the student's intervention might be in both languages, cases where it might be in one language. So, it's hard to say exactly. But, just always keep in mind that you don't want to discount for the student's home environment. If the student is exposed to another language, then you definitely want to use both languages in intervention.

Marisha: Perfect. Thanks for humoring me with that backtrack there.

Liliana: No, crosstalk.

Marisha: I don't know. I thought that was super interesting to kind of address in terms of what that looks like, too. So now, circling back yet again, we were just talking about improving communication with parents who might not have English as their primary language or who prefer to communicate in another language. One of the things that you mentioned was working with interpreters. I know you have some really amazing tips to share in terms of how to effectively work with an interpreter. So for an SLP who maybe hasn't done that or isn't as comfortable just from the lack of experience, what should we definitely consider when we're working with those?

Liliana: Yeah. So, not necessarily in the school setting. I have worked with interpreters. Because like I said, most of my caseload has been Spanish, predominantly Spanish-speaking, which, I mean, I speak. However, in the early intervention setting, I have worked with interpreters. I have been able to kind of gather all of these tips just from my experience and also from just reading research articles. But, when I was in early intervention, I worked with several families who spoke Arabic. I had to work with interpreters with all of these families.
I'm just kind of going to go over the tips that I think are really, really important that I want to highlight. And the first one being that you really have to make sure you have access to a licensed and certified interpreter. It kind of goes along with the statement, again, that just because you're bilingual doesn't mean that you can translate or interpret. I'm sorry. Interpret everything adequately. So, you want to make sure that the interpreter is licensed, certified. Inadequate interpreting skills can definitely hinder the communication process. So, make sure that your interpreter is proficient in both languages, that they can convey meaning, and understand linguist variations of the particular language that you are working with. Make sure that they are familiar with your field's terminology. That one is super, super important. Also, ensure confidentiality and discuss it with the family as well.
Also, I would highly recommend that your interpreter is also very culturally aware. Once again, it's important. Just because someone speaks the language doesn't always guarantee that they understand the culture. When I was working with these families, there was a lot of things that at first that I didn't know about the family's specific culture, even though I had done my research. I had read several articles, but there was just so many things that I still had to learn, things from taking your shoes off when you enter the family's home. That was a big one for me as well. Just making sure that your interpreter can also help you with these questions and just kind of guide you with their own experiences is really important.
Then, one big point, too, is preparing before the session. That one is a huge one. Back when I was working with an interpreter, I would always meet at least an hour before the session. Or if you can't do it the same day, but definitely plan meetings prior to your session so that you can discuss, once again, the terminology, the process, everything that you're going to be doing that day, what you want him or her to say or how you them to say it is really, really important. So, just preparing before the session. Once you are in your session, I would highly recommend that you talk to the family and describe what the roles are. Describe how you're going to be the one working with the child, and the interpreter really just kind of serves as your voice to communicate with the family.
Always address the parent, that one's a big one, too, and not the interpreter. That one can seem ... I want to say you almost do it unconsciously when you want to communicate and you turn to look at the interpreter, but you really don't want to hinder your relationship with the family. So, looking at the family as you're talking and not the interpreter is a big one. So, making eye contact. And like I said, the interpreter just kind of serves as your voice, and that's it. You're still communicating with that family.
Remember to also take pauses. I also know this from experience just because, like I said earlier, I have interpreted for my family before. And if you're talking too fast, you can miss really important details. So, really take pauses as you are talking to the family, making sure that everything's getting interpreted. Check for questions. Always, I like to ask the families questions, backup questions to make sure that I understand that they understood what I was saying.
Remember to also take note of the nonverbal language. I like to make sure that I'm looking, once again, at the family directly. And if I notice any type of kind of nonverbal language like facial expressions, I kind of like to ask questions just once again to make sure that they understood what I am talking about.
Also, avoid oversimplification of diagnosis or recommendation. I think that's a big one, too. A lot of times you want everything to get interpreted correctly, and you try to word things in a way where you might want to make it more simple so that it gets communicated across more simple. But, don't oversimplify way too much. Be really straightforward as well with your recommendation.
Yeah, I would say those are kind of the big tips that I would recommend. Oh, and I almost forgot. One last one. Debriefing. That's a big one, too. After each of my sessions, I would debrief with the interpreter at the end just to make sure that their observations were the same as my observations and things were interpreted correctly, or if I missed anything, any concerns that the parent said, or a question that the parent might've had. Because when you're in the session, everything can move so fast. Time goes by so fast. So, always just kind of comparing observations at the end, debriefing at the end with the interpreter is key as well.

Marisha: Wow. Lots of great tips there. I so appreciate it. Thank you, Liliana.

Liliana: No problem.

Marisha: That brings us to the end of my content question list. I know we touched on a lot of different topics today. If SLPs want to learn more and kind of hear more about what you do, where can they find you?

Liliana: Well, definitely on social media. They can find me on Instagram, on Facebook. Always feel free to reach out, send me a message. I am currently working on my website. It is up right now, but it's under construction. But, I do have a website called bilingualspeechie.com where I do post several of these resources that I have mentioned, tips on bilingualism. So, definitely there as well. But, yeah, just feel free to reach out to me on social media if anyone has questions.

Marisha: Awesome. Then, any parting words of wisdom or advice or just the one ... If SLPs walk away with one thing today, what would you emphasize?

Liliana: If SLPs could walk out with ... Bilingualism does not cause language delays. And use multiple measures when assessing ELL students. Multiple measures, not just standardized assessments.

Marisha: Yeah, perfect. I definitely have a list of probably a hundred different takeaways, so hopefully people walk away with more than that. But, it's always interesting to hear what stands out to the presenter. That was so incredibly helpful. Thank you. Then, if SLPs are wanting to access any of the links that we mentioned, including Liliana's social media handles, and some of the research articles, and the blog posts, and all of that, you can go to slpnow.com/54. And that's a wrap, so thank you.

Liliana: Thank you.

Marisha: Hello there and welcome to the SLP Now Podcast. I am incredibly excited to have Kristie Knickerbocker on the show today. She is a speech language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center and she also lectures on voice science nationally. So, she is an SLP rockstar and I've been waiting patiently or maybe a little impatiently to get to talk to her about all things voice, because she is such an amazing resource. I am really excited to get a peek at what she does today. But, she will also share some tips and suggestions for those of us who are working in the schools and trying to figure out what we're doing with these students. So without further ado, hello Kristie.

Kristie: Hi Marisha, how are you?

Marisha: Awesome. Super excited to get to learn a little bit about you today and all things voice. I'm super curious, can you tell us a little bit about your journey? How did you get started with voice therapy? We know that you have a private practice and I'm curious what that looks like for you today.

Kristie: That's a really great question. I'm an interesting story. When I was in high school and growing up, I've always been a singer, so I enjoy singing, I'm very musical. I enjoy writing, I enjoy playing instruments. I sat down on the back porch with my parents in high school, when you decide what are you going to do, are you going to go to college? I told them I really, really, really wanted to do music. So, I had auditioned for a music scholarship to go to Texas Christian University for a vocal performance degree, and I got the scholarship. So, we had all decided as a family that I was going to do that.
That same senior year, I was prepping for a competition where I had to sing a song, an art song by myself, and something was going on with my voice. It was nothing I could control. It was the weirdest thing. I just knew the sound wasn't coming out right. It wasn't coming out correctly. I discovered that if I pushed on my throat to the side, it didn't make that weird noise. So, I went to the competition and sang, and performed pushing on the side of my throat. The judge looked at me and asked, "Why are you doing that? What's wrong with you?" I said, "Well, my voice sounds really weird." So, she asked me a couple of questions and basically said what I was afraid she was going to say, which was, "You probably need to go see an ear, nose, throat doctor."
That was the push I needed to go get looked at. There was a bump on my vocal cord and I was devastated, been worried about next steps right away. I was told I needed to go see a voice therapist, a speech therapist is what they called it at the time. I was so concerned that this speech therapist wouldn't know anything about music, would know nothing about singing. I went and I met her. I was pleasantly surprised. She was a singer as well. She knew lots about music, and knew exactly where I was coming from, and that was really comforting because it was a really scary time. But, I ended up having surgery, and had the bump removed, and I was then in rehabilitation. So I had more voice therapy and then went and continued on in college like an injured athlete, where I wasn't really singing very difficult songs, trying to take care of things as I healed.
My voice teacher had a meeting with me and said, "You need to probably think about a different career path, because there's no way you're going to graduate on time with this injury." So, I was again, devastated but then got to thinking, "Well, what can I do?" I had considered doing nurse practitioner or a physician at some point during that backyard conversation with my parents. I said, "Well, what about doing the speech pathology? Doing what my speech pathologist had done for me, being that person that knows about singing, music, voice and then being able to marry that love of healthcare person, patient care with music at the same time."
So, fast forward to graduating graduate school, I had taken a semester, extra class on entrepreneur mindset and things you might need to be thinking about if you ever wanted to start a private practice. I thought that was really neat. I was scared of it though at the same time. I decided that I would incorporate after I got my license. So, my husband helped me. We chose the name O tempo Voice Center, because O tempo is a musical term. It means that you deviate, you have a rhythm, the beat of a song, you start off with that certain timing and that certain rhythm. You may deviate from that throughout the song to a slower part or a faster part, but then, the musical notation, it's like the map, it tells you o tempo, which means go back to the tempo that you started with. So, just like I try and do for my voice patients, and what I knew with my vision, to help them get back to that baseline. I wanted it to be named something healing, something that they could identify with.
It's not the best name when you're trying to talk to insurance companies because and they don't know, they expect an H after it. But, it's been an interesting journey to do that. It just found me, and then I found it and it has become me now.

Marisha: I love that. That is so cool, and very unfortunate that all of those things happened. But, I feel like sometimes things happen for a reason and now you get to help all of these other singers and musicians find their way back too, which is really cool.

Kristie: It's the best feeling. It really is, to be able to work with someone who you know exactly how scared they are for one. They're coming to you, not because it's me, it's like, "Oh, I'm coming to voice therapy." They're freaking out inside. They think that things are over for them. To give them answers, to get them goals to help them get back to what they were doing, is the best feeling.

Marisha: Yeah, that's amazing. So cool. You've lived it, so you're probably... I know you're amazing when it comes to, I don't know, just being there for them and knowing what to say and how to support and all that. So that's amazing.

Kristie: Yeah.

Marisha: Now, let's dive into some of the nitty gritty voice therapy stuff. The first thing that we decided to talk about was just the difference between behavioral and physiological voice therapy. So, can you tell us a little about that?

Kristie: When you think about voice therapy, maybe if you're listening to this, you had a little bit of a class part of a class, maybe half a semester, maybe you got a whole semester or maybe you got more than that in school, maybe you even got an extern placement where voice patients were being seen. But, it was always something that I was confused about. It was usually the way it was presented in class. So, voice therapy was this thing in the corner that nobody wanted to touch, nobody wanted to look at, but I was super excited about it because I knew that's what I wanted to do. But for everybody else, it was very visible to me that it was challenging. It was either they didn't know enough about it, so they just didn't care. They said somebody else can do that. But, I got to thinking, "Maybe it's just because the information is presented in a confusing way."
So, I want to talk about this because, I think it's important to help you piece together what these differences are, so that you know the types of voice therapy that you might need to give to very specific patients. Because, not all voice therapy approaches aren't created equal. Sometimes patients need more of those types than others. Sometimes they just need one approach. So, I wanted to dive into talking about the differences between that, so you understand it better.
The most common I think, behavioral voice therapy technique is resonant voice therapy. If you're thinking behavioral, this is the type of voice therapy where we're teaching patients what to do in the middle of their voice production. We're changing the technique of how they're creating sound, how they're using air and the shape of their throat and mouth to project that sound. It's something that's happening in the moment. So, that's what behavioral is. Then, physiological voice therapy is slightly different because, you're completing vocal tasks that might tax the system and overload it muscular-wise breath-wise, trying to get gains in what someone's able to do. An example of physiological voice therapy would be like LSVT, Lee Silverman Voice Therapy. Another example would be Joe Stemple's Vocal Function Exercises, the he, the glide up to glide down, and then there's five different notes that the person's singing. These are programs that are implemented with the idea that the person will make gains with how many times they're doing them per day.
Back to behavioral, the most common is resonant voice therapy. This is where you're humming or you're creating a very buzzy sound at the front of the face, vv or, zz, and most commonly hums, where you're trying to get vibration sensation somewhere in the mouth, somewhere in the nose, your cheekbones, and feeling what happens when you do that. The humming, the vv, zz, those are all types of semi occluded vocal tract exercises. That seems like a really scary long way to describe something, but in layman's terms, it is where your vocal cords are creating sound and then you're doing something to the tube that shapes that sound.
So, the throat is part of that tube, the pharynx is part of that tube, the mouth, the oral cavity is part of that tube. If you're putting something in the way of that tube being open for an ah, like you're closing your lips or you're bringing your tongue to your teeth, or you're completely shutting your mouth and having something come only out of your nose, your nostrils, that is a type of semi-occlusion, you're putting something in the way of that tube. That humming is one thing.
The benefits of semi-occlusion are that, it helps the vocal folds come together and not vibrate where they're colliding so hard. This is helpful for our patients who may have lesions, where we're not wanting the vocal cords to slap together so many times a second or so hard. It's helpful for patients who may have excess tension, and we're having them re-coordinate those behaviors. If they're straining because of that excess tension, or if they have pain from that excess tension, resonant voice therapy's a really great option. You may have heard of straw phonation, that is another type of semi-occluded vocal tract exercise, lip trills, tongue trills. There's even a new one. I was at a fall voice conference last year in 2019, and the guy was presenting research, and it was humming, but he was closing the nostril slightly with both fingers, so it was a muffled hum. That provided even more semi-occlusion, with the fingers almost sticking up the nose, sticking up the nostrils. So, I'm looking forward to reading research on that as well.
Then, another type of behavioral voice therapy is stretch and flow. This is where a person may be exhibiting breath holding patterns, or again tension or perhaps we want to again, alleviate some lesion by spacing the vocal folds out a little bit further, and not having them come together fully when you're creating sound. Stretch and flow is created by taking... It's the only approach that takes completely vocal cord vibrations away, but it keeps the articulation there. What I mean by that is you may start with just blowing on an U, and then you advance to actual articulation tasks. Some are rote like counting, and then you're able to advance up those counting hierarchies. You can mix and match days in the week, months in a year, just easy on the brain, but all, one, two, where your throat's really open and there's no vocal cord vibration. Then, you bring the vocal cord vibration back in, but you have it very, very minimally. So something like one, and then you can count like that, two, three.
A little bit different from the resident voice where, one, two, three, you're trying to aim for vibration at the front. The stretch and flow is more of how much air is coming out, how open and relaxed is your throat. But again, all of those are techniques that we can try to help shape what a person is doing and then have them continue on into their conversational speech, which is the ultimate goal. The goal shouldn't be they can do straw phonation with 100% accuracy. It should really be, they can use a variety of these tools, of these behavioral voice therapy tools to get the desired outcome, whether that's less pain when they talk, they sound better to themselves, they have better acoustic measures that we can test, that kind of thing.
But then the physiological, like I was saying earlier with the vocal function exercises, those were created by Joe Stemple, and there's a really good MedBridge course that he did where he describes exactly what they are, exactly how to do them. I think there's no better way to describe all those because he's actually teaching a patient in those videos. So, it's a perfect way to learn those. Like I was saying earlier, LSVT is another type of physiological voice therapy. A newer one is a PhoRTE. This is Edie Hapner and Aaron Ziegler, and they are creating again, a protocol the patient does daily. Then, you're taking these measures to see how well they're doing, and then you advance them as they respond to this type of therapy, and then you change it based on the patient's output.
So, there are different types of voice therapy. It's not a crazy amount of different types, but there definitely are considerations for your patient based on what their needs are. If you had somebody with both vocal cords where they are atrophying and not touching all the way, you might not want to put them on stretch and flow and make them breath here. We would potentially want to put them on the physiological type where they're really taxing their system, trying to bring the vocal cords a little closer together. Then if they were rough, we might throw in some resonant voice to help them sound less rough, that kind of thing.

Marisha: That's super helpful. I love that overview. I think this definitely is more of a crash course and a comprehensive of how to do everything. But, I'm definitely interested in learning more like, how do we decide all of those? But, I think this is a great starting point, and it gives us just enough of a foundational knowledge to... Like if we have a student on our caseload who's receiving voice, then we at least have a basic overview of what might be happening depending on the approach, or if we are in a position where we're deciding, we at least have a starting point to figure out which approaches to look into. So, that's super helpful. Then I'm curious too, because I've heard a lot about straw phonation, where does that come in and when would you use that?

Kristie: That's a great question. Straw phonation falls under behavioral voice therapy. It is a type of semi-occluded vocal tract exercise. It was researched very heavily by a man named Ingo Titze. He found out with many studies that what was happening was that, when you're creating sound and air into a straw, you're putting your lips completely around the straw, and you're blowing air and sound through it, that, that creates something called inertive reactance. Again, a fancy word. But, you can just call it back pressure. That back pressure travels from where the straw limits where the air and sound's coming out at your lips, and it forces it back down towards the vocal cord level, the glottic level. It encourages the vocal folds to not vibrate so hard, they don't slam so hard together.
This is a really great tool I think for all ages. I'll tell you why. You can use, we've been calling it Blowfish, but where your lips are slightly parted, your cheeks are puffed up, where you're making the straw shape with your lips. I find that it's not appropriate for every patient. I also find that the straw gives the person something to hold, and when they see it becomes a visual cue. So, they're able to be reminded, "Oh yeah, I need to do my voice work today," or it's almost fun, right? They can grab the straw and say, "I'm doing something really great for my voice because, I have this tool and I'm able to do it," versus just maybe relying on their mouth or their lips. It takes it out of their body. Because, a lot of times if the tension is present, it's hard for us to get out of that mentally. If we can have an external thing, potentially we can help alleviate that.
So you would use straw phonation if you had a patient who has excess tension, or they may have dysphonia, which is just the fancy word for rough voice. But, you would want to test on probe just like we do for speech therapy anyway, to see if they're appropriate, to see if the straw actually does something that's good for them. In my evaluation sessions, I will hand the patient a straw after evaluating, to see if they're a good candidate for it, just because it's usually very easy to explain. Again, with that thing in their hand, they're reminded visually, "Oh yeah, I have to do something." So I'll have them wrap their lips around the straw and make noise. I'll have them pick a pitch and travel up and down in pitch to see where they feel the most vibration at their lips also. Then I'll ask them, "Do you feel if there's strain? Do you feel if you're pushing at the throat level?"
A lot of times you might hear that push or that strain, they might sound something like hoo, because their pattern of how they're creating sound is so tight, it's so uncoordinated and that's all that their body is remembering how to do when you ask them to vibrate their vocal cords. We see this a lot with people who have had an illness like laryngitis, or they have had some cold or upper respiratory infection where they cough a lot, or they're straining to make sound because their vocal cords are so swollen. This a lot of times will help break that habit for them. So, straw phonation is easy to do. You can have them do one to two minutes. You can even put just sounds, single notes. You can have him put it in water and blow bubbles into the water while they're making the sound. Sometimes that adds a little resistance, and it has them use breath in a different way. So I think that that's helpful as well.
But, straw phonation is not for everybody. It could cause more tension than you think it should. So, listen to your gut, right? Follow your instincts with it. Because, while it's good in theory, a lot of times I will try it with a patient because I'm thinking this is going to be perfect for them in the clinic, and then they try it and I completely throw it out the window, and they're walking out the door because I've given them something else by this time, and they will say, "What about that straw thing?" I'm like, "Forget we even did that. I tossed it. We don't need that." So, straw phonation is a good thing to know about. It's good to have in your toolbox, but it's not the end all be all.

Marisha: Okay, perfect. Let's do a quick recap. We talked about three different behavioral approaches. There's resonant voice therapy, stretch and flow and straw phonation. Then for straw phonation, you said that it's ideal for patients who have, or it can be a good approach for patients with excess tension or dysphonia, but we want to abandon that if we find that using the straw actually causes more tension. So who would you say, who would we use resonant voice therapy with? What would we see or what would an ideal patient be for that?

Kristie: Great question, very similar. So, somebody who may like routine and things where they can try a type of voice therapy in multiple occasions. The resonant voice therapy can be used in a hierarchy fashion where you're doing, Katy Verdolini Abbott calls it the Basic Training Gesture, mm-hmm (affirmative), like you're answering a yes question, and single words mention or moon. There's a chant version as well, where they're sustaining sound. My mom mails me money.
But, this will be good for patients who might have just, I mean, straw phonation too, might've just come off of vocal surgery and they need something that's not very taxing on the vocal folds. Any gentle phonation or gentle sound production to start off with might be good for patients again, who have pain when talking. If they come to you and they sound like this, and you need to rebalance how they're using breath and vocal cord vibration and resonance, you can teach them how to make the sound and then create that, take them way over their comfort zone, and naturalness of speech, because I sound really strange doing this right now. Teach them how to do this and then teach them how to draw back from that, where it actually sounds more normal, like natural conversation.
But, if they find themselves going back to that pattern, they can breathe in and then check back in with that resonant voice. So, it's more of something you're going to have a little bit more cognitive load to do that versus, stop do the straw for about a minute and then come back in. So, it's something that can be put within the context of a person's speech in a little bit of a different way. But yeah, it's a great approach. I think it is just like straw phonation, I think patient dependent. Sometimes we'll do really great with a patient with straw phonation during a session. They do it for one week, it's really great. They come back the second week and things have gone really downhill. We'll throw a resonant voice in there and then that helps things. Then, they can rely on both straw phonation and resonant voice to help them reach their target outcome.

Marisha: Awesome. Then, what about stretch and flow? Is that also similar in terms of crosstalk.

Kristie: For stretch and flow, you would want to use that on a patient who has a really difficult... A lot of times patients will have difficult time humming where it's relaxed. You would think that's not that hard, I can hum. But, sometimes their patterns or how they sound doesn't necessarily create smooth quality. They can't break the pattern of the tightness or the dysphonia with the humming alone, because it's too similar to their everyday speech. So, for those patients, and there's actually a study it was a non-inferiority study, meaning one wasn't worse than the other, and it looked at comparing resonant voice therapy to stretch and flow, finding that both were able to make an impact positively for patients. So, this would be if your patient can't do resonant voice therapy really well or if you think they're holding their breath and you want to go ahead and start there, you can.
But, because it takes away the vocal cord vibration and it focuses on airflow and output of air, I think it's a really good one, if your patient's personality or their presentation is one where their shoulders are really tight, they're holding their breath, they're talking really fast like this, absolutely it is like that, you really need to break down the systems so that you can build them back up again.
So you can say, "Hey patient, let's talk about breath. I want to teach you how to really focus and slow down on your articulation, how you're forming words. Breath happens the whole time." You're able to teach them utterances on one breath and how that feels. Then, you throw the voice back in. Because, sometimes it's too much to think about for a patient, because they've been vocalizing one way for so long.

Marisha: That makes a lot of sense. Thank you for that overview. Then, what about the physiological one? We talked about LSVT, then Joe Stemple's vocal exercises and PhoRTE. So, Who would you use LSVT with?

Kristie: Yeah, great question. LSVT was formulated with a specific group of patients in mind, and that's patients with Parkinson's disease. Those patients with Parkinson's lose volume, they lose intelligibility. A lot of times they get, because of their age bode vocal cords. So, we're combating three things all at once. The LSVT is Lorraine Ramig and Cynthia Fox, and they created this where the person is holding out these long ohs. Their tagline is think loud. Speak Out is Samantha Elandary, she's doing something really similar with that as well. These long, loud productions of sound so many times a day, so many times a week, and they're aiming for overall system improvement and overall system change, by just physically completing those exercises. So, getting gains like you would at the gym, okay?

Marisha: Mm-hmm (affirmative), perfect.

Kristie: PhoRTE is really similar. It takes into consideration some vibrant talking, some exuberant voice exercises. It looks a little different from LSVT and Speak Out as well. However, it's different in that it's less sessions. The patient does a lot of work from home. LSVT has a component where you a lot of times will get dementia progressing slowly or rapidly with the Parkinson's. The LSVT requires the patient to complete the session with the therapist four times a week for four weeks. PhoRTE's a little bit different because, you can have these check-in sessions and we expect the patient to have a pretty high ability to be self motivated, cognitively aware enough to do what we ask them to do, because they're measuring their sound as they do it. So, I think PhoRTE's a great option. The patient's able to have more flexibility and not come in as frequently, or not be seen as frequently and getting great gains that last. I think that covered it.
What I didn't mention and I should have, I didn't, for behavioral voice therapy there's a newer one for behavioral as well called Conversation Training Therapy. That's Jackie Gartner-Schmidt and Amanda Gillespie. It's the first therapy, this also has a really great MedBridge course on it. It's great because for speech therapy, for language therapy, for things that you all are doing every day, most of the time you're doing a hierarchy approach, right? You're getting the child to a certain level or maybe even the adult. You're doing something and then they meet that criteria and then you're moving to a higher level. For conversation training therapy, you start with a certain type of cue and then you're able to add these other tenets of the therapy whenever and wherever you want.
So, I think it requires a good understanding of how voice therapy flows. But, I think both women do a great job explaining the how of it during that MedBridge course, where you're able to say, "That makes complete sense. I can always start there and then add these other components in. Then, I probably was doing that already with my other patients and I just didn't realize it." So, what they're finding with that is while traditional voice therapy may have required multiple sessions weekly for months, the CTT is actually creating an ability for patients to not be seen very frequently. They're learning it from the first session, learning how to generalize. Then, the results are lasting as well for quite a long time after. So, it's groundbreaking because why wouldn't you want your patient to advance as fast as possible? Of course, you would want that. But, I think the right type of patient for this training as well, needs to be taken into consideration, and cognitive level, the ability to multitask is one of those components.

Marisha: That's super helpful. Again, thank you. We've got a quick overview of the different types of therapy that we might use. Then, what do you do if you're one or multiple approaches and the child just isn't responding? What would you recommend then?

Kristie: That's a really, really great question. The type of therapy, you always want to start with what the child is stimulatable for. So, you may go through multiple, you may have them lip trill, you may have them hum, you may have them yawn and sigh on that yawn, you may have them blow bubbles in the cup with a straw, you may have them get louder, right? Whatever makes the best sound, you should go with. But, that may change the next time you see the child because maybe that isn't something they're responding to. So, you can always switch mid session. You can switch the next day, next time you see that child if they're not responding, and jumped around those techniques all while trying to attain where the child is going goal-wise.
You find this by discussing not only with the child, but the teacher and the family to determine why the child is in voice therapy in the first place. What are you trying to improve? What is out of the range of normal? But, maybe the child isn't responding to therapy at all, right? You're doing these indirect voice therapy things, and indirect is the component of voice therapy where we talk about hygiene or vocal wellness. We talk about preventing phonotrauma, so avoiding the throat clears, avoiding the yelling, that kind of thing, drinking the water, how well are you hydrated. These are all important things. Are you resting your voice after? Do you have a routine for your voice? Is there a warm up that you do? Those indirect things? Limiting the time you're on the playground because maybe you're helping to limit the yelling, as the child just can't stop yelling on the playground. Or changing what recess looks like for that child for a little while.
But, if they're not responding at all, meaning they haven't been able to carry over, maybe that's what that means to me, they're not responding. Meaning they may not, meaning carry over, I would want to know and talk with the family. I might make a couple of phone calls. How is Johnny doing his practice at home with you? What does that look like? Do you do the cards that we send home? Do you do the worksheets? Oh, that's boring, okay. What do you do at dinner? What does talking look like? Can you incorporate some of these techniques when you guys are talking at a meal? What does bath time routine look like? Or if the child's older, what are you doing when you drive Johnny to soccer practice? Is there a conversation going on in the car? I would really probe how the family is involved.
Also, there is a really great article, let me see here. I think it's Barbara Weinrich, it's Lisa Kelchner and some other person, Susan Baker Brehm. I was like, "If I can't remember it, I'm going to be..." I thought of it. But, their article looking at how voice therapy really impacts or how it's impacted by the family involvement, the therapy techniques may do very little to impact what we look at as the outcome. But, a huge component of that is how the family views voice therapy, what importance the family gives to doing the practice, carrying it over. So, I think if the response isn't there, I want to know what's happening at home.
Then, the other phone call would be to the teacher, or maybe trying to hop in and chat with him or her after the class one time, to see what's going on in the classroom, how the teacher is able to help facilitate the new voicing, phonotrauma prevention, the hydration, that kind of thing. See if there's something you can do to help troubleshoot. That's the first thing I would do.
Then, if you do that for a while and there's still no response to the therapy, I would really suggest potentially getting a reevaluation by the doctor. That might include getting visualized again. So, another video stroboscopy or at the very least a nasal endoscopy where they're going through the nose. Maybe they don't have the light to look at it in so much, but maybe they can look with the nose scope, to see if it's really what we thought it was to begin with. Sometimes you get the kid scoped and you think, "Oh, it looks like vocal nodules. These will go away if we do therapy and vocal rest." Then, if nothing's improving, you may go back in and then discover maybe with a more specific test, like a video stroboscopy you say, "Oh, this wasn't nodules at all. This looks like a cyst on one side and it's swollen on the other side, because the cyst has been hitting that other vocal cord every time they talk, and it's going to require surgical removal."
In that case, it's great because there's a reason the child wasn't responding to therapy, right? The child was doing everything, the family was doing everything, teacher, they were all superstars, but it was something that needed to be fixed surgically. So, had you not visualized, had you gone and continue to do what you do, Johnny will get better, year two goes by, nothing changes, you have frustrated parents, frustrated teacher. Johnny thinks he is the worst child ever because they can't fix his voice, when the easy answer was let's get another visualization here, and really see what's the problem.

Marisha: That makes a lot of sense. I remember from my voice classes that it was really important to have that exam before starting therapy. So, is that the truth? Why would that be the case?

Kristie: Yeah. I think most definitely it's the truth. We need to visualize what's going on, just like eating habits. I was talking about this at Sin City Laryngology in February, making a case for visualization before treatment, just like a doctor would not do any recommendations before an X Ray, for a broken arm or a broken leg. You wouldn't want to have any surgery on something unless you had done a scan, a CT scan or an MRI. We do these scans so we can have a better idea of what we're looking at. I think that's absolutely the same for voice therapy because, if you're not looking and you're creating a treatment plan you are saying, here's what I believe the problem to be based on what you hear, what you see the patient doing from the outside, and you're missing that inside component, you may be setting yourself up for harm in the way that what you do is futile. Everything you're doing is not going to fix the problem because the problem really needed to be fixed with surgery.
That doesn't mean that the surgery... Like you wouldn't do voice therapy if the person had had surgery, right? It's always a better outcome when there's a combination there. But, the expectation I think is the most important part. You have to be real and truthful with your patients about what they can expect. If they just expect voice therapy to fix the problem and it's not fixing the problem, there becomes a trust issue with you as the provider. You're no longer trustworthy because what you said was going to help is not helping. What are they supposed to do now?
I think having that video stroboscopy completed before implementing any treatment plan, helps you help them, it helps everybody. You get a lot of pushback because, if you see patients in the school and you're saying, "Hey, this kiddo needs an exam," the school doesn't necessarily want to pay for that. But, I think it's really important. A lot of times the parents may be scared. They may not want to have their child get examined. So, if they're very adamant that they don't want that exam, you can't force them to get that exam. But, I think you have to have these conversations about not... Limited knowledge on your part resulting in limited improvement potentially, you may not be able to have the whole picture. So, you may not be able to give them the outcome that they desire.

Marisha: Okay. Perfect. Thank you for that overview. I think that's a good reminder and refresh too. So, what other recommendations do you have for school-based SLPs? Maybe we can start with students who are seeing a voice therapist and who have gotten all of the visualizations like video stroboscopy, like there's the voice expert working with them. What do you recommend for SLPs in that situation?

Kristie: Well, a good behavioral voice exam. If you've had the doctor do the exam or an SLP in your area who does video stroboscopy, you have that done and that comes back to you, you still need to know what the child does well, where you're going to head with therapy. So, a good ability for behavioral probing, I would start there. I would gather acoustics, acoustic measures if I could, meaning fundamental frequency. So, the average pitch that the patient talks at, you could run acoustic measures, something like the Acoustic Voice Quality Index that gives you a number that indicates if dysphonia is present or not. So dysphonia again, messed up sound like hoarseness. The Acoustic Voice Quality Index supersedes jitter and shimmer. Those are maybe words that you look back in your brain and you think, "Oh yeah, that was something we learned in school. I can't remember what that means."
But, something has come out in recent years called Cepstral Peak Prominence. It is a much more sensitive indicator. It contains the ability to measure connected speech. So, the child talking in a sentence as well as sustained bell, where you may have only used jitter and shimmer to measure ah, and maybe the child sounds really great doing ah. But then, they start talking like this. So, how can you measure something that is really representative of what the child's output is? So, enter the Acoustic Voice Quality Index because that contains part of that Cepstral Peak Prominence and some other measures as well. You can gather some aerodynamic measurements as well. You can get vital capacity for the child to find out phonation quotient or estimated mean flow rate, to determine if the child's using air adequately.
All of those... I've put together a guideline on how to obtain those measures with a really concise measurement tool in Excel that I have in my online store. To walk you through and guide you with how to administer a behavioral acoustic or a dynamic evaluation. I added cards so that the child can hold the cards and then flip to the next one, where you have the target what they're about to do, they can read it out loud and then they have an idea of where they're headed. It's tangible. They can flip through the cards so they're not distracted.
Then, you would start determining goals. You would decide what they sounded best at, what made them sound better. Then, you would discuss with the child. I think it's super important to see where he or she has any opinion on the situation. That's going to help with motivation. I think that's really important as well as the family and the teacher, just discussing what support system they have at home, how they're going to practice, what that's going to look like. You can explain what it'll look like at school, and then how your check-ins are going to be, how the odds are going to look for the voice goals for that child.

Marisha: Awesome. I love that you have that voice assessment guide, because I know that could... If it's something that we don't do a lot of, I know that can be intimidating to dig up all of the notes, but that's an amazing resource.

Kristie: It was super intimidating to make Marisha because, I've been worried to make it for such a long time because, I was thinking, "How am I ever going to throw all the knowledge I have about what you do in an evaluation into something that can be replicated? That can be recreated and utilized?" But, the more I talked to people who really were just using S/Z Ratio and calling it a voice evaluation, I was like, "I can make something that can give them so much more information, and the ability to help mark progress in such a better way." So I made it. I had it tested. I had lots of people try it and give me feedback on it. I changed a lot of things about it as it was being made.
But, I had been making these other resources for my store for like resonant voice therapy games, stretch and flow games, straw phonation games, breathing training, that kind of thing, for pediatric patients because, why should speech and language kids have all the fun? You're looking for things for mixed groups and it's like, "I have nothing for this child with a voice disorder that's on my caseload." So I said, "There's nothing, so I'm going to make it."
But then, I kept getting these questions about, well, how do I know when to use resonant voice? How do I know when to implement straw phonation? So, part of the reason that guide was made as well is because it has suggestions and probing in it, like the no prep voice workbook that's in the store as well, the one that has... It's like, I want to say 120, or 128 pages I think, maybe it's more. But, that goes through again, probing what the child sounds like and then activities where you can bounce back and forth. If they're doing great with straw phonation one day and you need stretch and flow the next day, and then you have activities on that to work with your mixed groups.
So, out of that came... Out of making these came the need for guidance on how to implement them as well. So, that's why the guide I think is so important and great to use because, it includes a video demonstration of how to implement all of the measures, the testing, and shows you exactly what to do. So, you don't have to just do S/Z Ratio, you have a lot more at your disposal.

Marisha: That is so cool. Then, I will put the link to the voice assessment and then the voice therapy workbook in the show notes. So, those will be at slpnow.com/51. There's even more resources that you've made that are amazing. So, I'll just put the link to your story there too. Then, what recommendations would you have for a student who, like we get a referral from the teacher, we find that they have, like their voice, they're having some dysphonia or whatever it may be. I assume that we still want to have that good behavioral voice exam. Then, we talked about trying to get a physician to look at the vocal folds before starting anything. But, do you have any other suggestions on how to navigate that?

Kristie: Yeah. That brings up a good point. I have a lot in the past in our clinic, been able to do video stroboscopy for SLPs who send their children, and then the child gets treated in the school. So, we can do the exam at our clinic and then collaborate with that SLP to say, here's what the child was really good at and here's your starting points, and then collaborate. You can collaborate with the SLP who may do voice all the time in your area, so that you know what to do and where to go with that child. So, I think that we're better together regarding our experiences because, if you don't know much about voice and you're trying to treat that child and you're thinking, "Well, I know enough where I can probably not harm the child," but I think it's really important to get the opinion of the specialist SLP because, you can still make a difference in the school. Maybe you need a little guidance, need a little collaboration with that person.
So, I would suggest in your area, getting an exam or at least giving a call to the SLP to say, "Hey, what would you do with this child? I have this child in my caseload. Here's what I'm thinking. What are your thoughts on that?" A mentor situation where you're going to benefit as the school SLP because you'll know what to do with the next child with a voice disorder. But then, that child's going to benefit too because, you're going to be a lot more equipped with better knowledge after that consult. Because, the thing you find, I find, is that if you didn't have a placement opportunity where you could go and watch voice therapy be done, it's scary or strange or odd.
Leah Helou actually talked at Sin City Laryngology in February also, about the Meta Therapy. What she describes is our dialogue, the things that we're saying, how we're saying it, the schemas that we build in our mind, the routines. It's how we as clinicians do these things methodically, to get the result we want in a session. It's our attempt at programming a framework that we use in each session. It may not look the same in every session, but if you're watching it go down, you know what that speech pathologist is doing.
So, this type of thing, and trying to let somebody know how that's happening, maybe by having that SLP come and observe, maybe the school says you can go observe at this voice clinic so you can learn how to treat our students better, I think that that's helpful as well. Because, then they get to see the Meta Therapy and they're not so bogged down with, "Okay, great. They did their hum in a hum level, now we can do an M word level." They have the idea of you don't have to have 50 M word sounds really resonant to move on. The repetitions are important, yes, but you need to be able to have that skill of stepping back and looking at the framework that you're using to conduct a session.
You all have frameworks so you use all the time with your speech and language arctic children. It looks the same with voice, but there's a little bit different considerations for that. So, I think if you're an SLP in a school and you have a student that needs an exam, maybe you can go and watch that exam, right? That's how you're going to learn, or potentially you can go and observe the SLP do the scope or the SLP do the eval, who maybe does voice more frequently or you can at least give a consult phone call to somebody who can mentor you and support you as you're supporting that student.

Marisha: Yeah, that's perfect. I love those ideas, and just getting really strategic with the resources that we have available. Yeah, definitely that mentorship, collaboration approach seems like it would benefit everyone involved.

Kristie: Yeah, most definitely. I really do feel like we're better if we can collaborate, but it's not always intuitive, right? Because you have so many students on your caseload, you're crammed with stuff to do until the day is over, you probably take work home with you and then it's time to hang out with your family because they need you too. But, I think it's important to collaborate nonetheless, to try to do better for your patients. Because, that's why we do this in the first place. We don't we don't go into speech language pathology without big hearts and loving what we do. We do that because we love our patients and we want them to succeed.

Marisha: Yes, I couldn't agree more. I mean, I wish... I feel like we could talk about all of this stuff for hours and hours, but we're almost at the end of our time. So, if SLPs want to find out more about you, where can they connect with you? I'll definitely be linking to your Teachers Pay Teachers store and your website, but where do you hang out and where can SLPs find out more?

Kristie: I do hang out on Instagram pretty frequently. My handle is @Kristie_voice. That's K-R-I-S-T-I-E_voice.

Marisha: Well, thank you so much, Kristie. This was an absolute treat. I so appreciate your time, and thank you for sharing your time with us.

Kristie: Thanks so much for having me, Marisha. I really appreciated it.

Marisha: Hi there, and welcome to The SLP Now Podcast. I cannot wait to chat with Jessi Andricks today about all things stress management. And before we dive in, just a little bit about Jessi. She earned her master's degree in speech therapy from the Medical University of South Carolina. And she has worked in many settings including teletherapy, which is especially exciting in this time. But she's also a trained integrative coach and yoga teacher. And she also runs a site jessiandricks.com. She's presented at multiple conferences and conventions, and she focuses on helping SLPs reduce burnout and stress through evidence-based stress management tools and techniques. So I cannot wait to learn from her because I could definitely use some of this myself. But before we dive into kind of all the evidence based strategies and good stuff, Jessi, first of all, welcome to the podcast.

Jessi: Thanks. Thanks for having me on today.

Marisha: Yeah. And I'm just really curious to hear about your, because your bio kind of tells a little bit of your story. But I'm curious what that path looked like for you. Where you started out as an SLP and then how you got to the roles that you're playing today. And doing all of these amazing presentations, and courses, and education. I'd love to hear a little bit of how that all evolved and came together.

Jessi: Yeah. It's nowhere that I ever thought that I would be in grad school or undergrad, because I went and got my degree in communication sciences and disorders for undergrad too. So this is never where I imagined, even the teletherapy part because that was not a thing. At least not the way it is now back when I graduated.
So I started out. After I graduated in 2008, which seems not that long ago, but I'm realizing that was forever ago. I worked in probably every setting imaginable within, or at least that was available within three years. And some of it was just circumstances like positions being cut or new things opening up. And then some of it was from feeling really stressed and just assuming okay, this might not be the right setting for me to be in. I'll see what else is around.
But I started out in a skilled nursing facility in a really small rural town in South Carolina. And I loved it, but I knew that I wouldn't be there forever. And I had an opportunity come up at a rural hospital in doing inpatient and outpatient with adults. And if they ever, for some reason had pediatric clients, I would see them as well. So it was kind of like everything. And it was somewhere I had done clinicals at. So I jumped on that opportunity because I thought this was my dream job. And it was amazing. And I am so thankful for that. But it was an hour commute every day from my house.
So that started to take a toll. And that's really where the stress started to build for me. And I started to kind of start to question things and think, "Well, maybe this isn't really my dream job." Or, "What do I do?" But there wasn't anything like it closer to where I lived. So I started to just really feel stuck. And I thought one good thing might be pursuing some hobbies or doing some other things that I really loved. So I started to take yoga classes because I thought you hear yoga and you hear about how wonderful it is for stress, and for managing stress. So I started taking classes. And I didn't necessarily feel the big, super peaceful after class or all my stress was gone. But I thought it looked really cool, and they knew so much stuff. And I wanted to learn how to teach that.
So I ended up doing yoga training while I was also commuting in the other direction, an hour from my house. So for about five months, most days of the week I would be on the road for an hour and a half in each direction. 30 minutes to the yoga training, an hour in the other way.
So physically, the stress was starting to build. Mentally the stress was building, and then my position was actually cut. So it wasn't I got to a point where I was like, "Okay, this is too much. I quit." I kind of was going to stick it out. But it was 2009 I think, 2010. The recession had definitely hit, and it was rural. It was small. So my position was unfortunately cut. They decided they only needed one SLP instead of multiple at the hospital.
So I ended up working in the schools after that, contract, because that was the only thing that was available where I lived. And as much as I love the schools. And my mom, my sister both worked in schools in regular ed, in special ed. So as much as I'd kind of grown up around that, that was definitely the position that after being there for two school years, or pieces of two school years, that's kind of the one that led me to say I'm done.
And I ended up quitting being an SLP for four years. And I quit quit. I would think about going back at first, but I eventually quit. And if someone was, "What do you do?" Meaning did you go to school for something? What type of job do you have? I would never mention that I went to school for speech therapy unless they asked something about it. And instead I taught yoga, because it was the thing I had trained in and I loved it so much. And I just assumed that I had chosen the complete wrong career and spent all of this time, all of this money doing the wrong thing. So I decided I'm going to teach yoga, which is definitely not as full time as being an SLP. Which SLP is over 40 hours a week for a lot of us. And teaching yoga was kind of here and there.
But I dove kind of into that side of things. Teaching yoga classes, training in it, mind body fitness, health coaching. Kind of focusing some on what we're eating but also our stress and the wellness aspects that we don't always focus on.
And I did all of this because I thought this was what I was just so passionate about. But looking back, I can tell that it was what was healing and what was managing the stress that I had been feeling for years and years as an SLP.
And there really wasn't anything specific that happened or some really crazy caseload or anything when I was an SLP that caused me to need to quit. It was just the slow and steady buildup of stress and of the daily schedules, things being either really far away or when I worked from home, having to start very early and kind of end a little bit later in the day. And just all of those little things that we all experience building, and building, and building, and building, until I didn't know what to do except assume that it was the wrong career.
So that's what I ended up doing for four years was ignoring that I had ever been an SLP. And if people ask me what I did, it was just, "I'm a yoga teacher." And that was it. And the only time I'd really ever mentioned that I was an SLP was when people would ask me or they'd kind of say, "You seem smart, why didn't you go to college?" And I would say, "Well, I actually a master's degree. I was a speech therapist for about three years. And then I decided not to do it. It was just the wrong career for me."
I think you can imagine the kind of funny looks I would get from that type of response. It was kind of a, "Oh my gosh, you did that and now you teach yoga." But to me it just made total sense at the time. Yeah, this is what I meant to do.
And then eventually I came back to the field. Things just shifted. I had a baby. The studio was helping run, the owner moved and it was closing. So I just wanted some stability, and I decided I'll give this speech therapy thing a try. And I've been in it ever since in some form, in some way.
And it's been a different perspective for sure. Having taken that time off and trained in these different things. And that has definitely helped me come at it with a different attitude, a different take on it. And also just knowing what I need each day or recognizing that when the stress is building, what is kind of off balance for me or what have I not been doing that is usually really helpful. So it's been kind of a crazy ride since graduating way back in 2008 and getting to where we are now.

Marisha: Wow. What a cool story of. I love that progression. And I think that it's a pretty unique set of experiences I think. Well I don't know, who knows how many SLPs become yoga teachers instead and then come back to the field and do all of the amazing work that you're doing. But that's super interesting. And I think that gives you a really, because you've gotten all of that additional training and just different experience too, that I think is super helpful when helping us figure out how to manage our stress without having to explore all these different career opportunities.
Because I think we choose, there could be a case that speech therapy isn't the ideal career for someone who's listening. But I think a lot of us really love what we do. It's just the stress of all of the different elements that break us down over time. So I'm really excited to dive into those areas with you today.

Jessi: Yeah. And it's so true. When I was going through it, I had decided that I just didn't love it anymore. And I loved, when I decided that this was going to be when I was an undergrad, I actually switched from early childhood education to CSD major. And I didn't know a lot about it, but I was like, "Yeah, want to work at the schools, but I want to do something a little bit different." And then when I found out all that we could do, I was just so excited and just wanted to go to class every day, which is not the case for a lot of people in college. A lot of the time it's like what class can I skip out on? And I was just so excited to learn and loved it.
And then when I was going through it, it was like a total shift in my the way I was thinking about it. I don't have any interest in this. It's just totally the wrong thing. And when you're chronically stressed and eventually it leads to burnout. One of the big kind of hallmark signs of that is kind of apathetic or cynical attitude. And it's exactly what happens a lot of the time when we start to think that way. "Oh, this isn't even working or it's not doing anything. Nobody even knows who we are anyway. We're just the SLP that no one cares about." We kind of get stuck in that spiral of cynicism, that I think it's really easy to get stuck in and then keep feeling that way. And then eventually, if that's all that we can connect to with our career choice and with being an SLP, it's really hard to pull out of that and to not just appreciate what we can do in the field, but find that passion that we used to have or even just the interest that we used to have in it.
And I do think that's why a lot of people feel like, "I must've made the wrong choice or I need to get out of this field." Even though, really somewhere that love of it is still there. It's just been taken over by the stress. So yeah, I think so too. I think that once in a while, you could find someone that really chose the wrong career totally. But a lot of times it's just that stress becoming so overwhelming.

Marisha: That is so fascinating. I love that. And that makes so much sense. If we're in that stressed, burned out place, then we are more apathetic and cynical. And it's easy to convince ourselves that we never loved it in the first place, or that we'll never be able to love it again.

Jessi: Yeah.

Marisha: Yeah. Wow. Okay. So if we're in that stressed out space, where do we even start. How do we start navigating that and what can we do as SLPs to manage that stress?

Jessi: The things that we can do are not anything, I always feel bad at this part. They're not anything all that crazy or mind blowing, or secret. Like here's the secret magic thing to do. It's like the things that we can do are pretty routine, and things that you may already have tried to do.
I went to a course one time that talked about this. It's like knowing something and then actually doing something are two totally different things. We can know how to do something and tell someone all the things to do, all the steps to do, everything about it. But actually doing it, we can't always do.
And it's kind of like we see that sometimes with our students, or patients, or clients we work with. There are times where you may be working on something with a student. Like maybe you're working on a sound and they can tell you all the things that they're supposed to do to make the sound. But then actually doing it and carrying it over into conversation, they get stuck on. So it's like that but with our stress.
So the things that we can do are simple things like mindfulness and awareness. And awareness is really the first, kind of the first step. Just recognizing that you are stressed or recognizing that something is not working for you in your daily routine or in your work. And being aware of how you're moving through your day, or how your day is kind of affecting you, or certain things that might be triggering you. Even if you don't do anything about them, but you're just aware that it's happening, that can help you start to make that shift to manage the stress.
So really, awareness is the first thing. Just kind of thinking about your day or thinking about what's going on, why am I so stressed? When do I get stressed during the day? And trying to pinpoint some of the things that might be, and sometimes it's really easy. It might be the pile of paperwork that you have or the crazy caseload. But being able to kind of see okay, how is this affecting me? How am I reacting when it's time to figure out when to do my paperwork? Or how am I feeling when I have more patients or students added to my caseload, and what is that triggering?
And then when we go to actually manage it and do something about it, it's using the tools of mindfulness and stress management. So taking time. A lot of it is just taking time for yourself. So organizing things and planning things are awesome. And I mean they definitely help. Because if you're completely, things are just unmanageable with the paperwork that you're doing, with the billing you're doing, with the caseload you're doing, then of course you're going to be stressed. So having things to help with that absolutely helps. But then having things that just help you personally. Like noticing what your energy levels are during the day, and if you need some time between sessions to kind of regroup. Or if you need to switch around the students that you're seeing to meet if you have high energy students maybe, and you're seeing them in the afternoon when you're feeling really drained. That might not work out so well. Or just knowing do you need something to help you transition from work to home so that you can get your head more clear where you're not thinking about work all the time when you're at home.
I find that happens to me a lot. I was not someone that would bring work, physically bring it home ever. Some of that, it sounds really good. That makes it sound like I was super organized. But I think it was more that burnout. "I'm not going to take this home. No way. I'm going to ignore it. I'll deal with it another time." But in my head mentally, I was still thinking about, "What am I going to do with this person? Oh my gosh, I have this thing to do tomorrow. I don't know what activity to do." It was just thinking about it or if I had a really hard meeting, just kind of replaying things all the time where I didn't get that head space.
So having something that you can do to help you say, "Okay, work is done. Let me shift shift my mind into being at home and letting work go so I could be present while I'm at home." And sometimes it's just having a buffer at the beginning of your day or at the end of your day. And I think this is really important when you're working from home, which a lot of us are right now, are doing teletherapy. Because if your space is in your home, then it's really hard to leave work sometimes. And you kind of feel like you can work right up to the end of the day and just step out of your office and into your home. But without having those little buffers that give you some downtime to yourself to regroup and to just check in and see how you're doing, it can make that stress grow.
And those things sound really simple. But I think when we look at our day, we usually aren't doing them. Those are the things that we cut when we're feeling stressed and overwhelmed. Those are the things that we're like, "Okay, I don't need these. I can just get rid of that and just focus on the work instead." And I think that does happen a lot. I know that happened for me a lot. If someone asked me to take on more students, even if I knew I could say no, I'd just say yes. But then my extra time during my day would get cut, and then I'd feel stressed. So it's that kind of cycle we get stuck in a lot.

Marisha: Yeah. Those are such great tips. So many good things that we can do. Okay. So a couple of things that were really interesting. I love that you mentioned the energy levels. And then just being strategic with how we set up our sessions and our schedule. And I know we sometimes, we feel like we don't have a lot of space to make that happen. But I think just one shift can change your whole day, I feel like that's super powerful.
I love what you mentioned about transitioning from work to home, and how we might be bringing our work home mentally and not just physically bringing home reports to write. But if we're replaying the day and just mentally being focused on work even while we're at home and not being present. And I'm curious, because you mentioned having a buffer at the beginning or end of the day. But what does that look like? What has worked for you or what have you seen other SLPs do to navigate that?

Jessi: Yeah. So for the buffer, I kind of like to think of it as you can start really small and then you can build it out a little bit. So a little buffer would be just making sure that you have time before you actually have to start work, and you have time after you actually finish to just settle in or to just kind of get ready to head home and kind of have a transition there of some kind. So you could have, and again I think this is really important when you're working from home too.
But let's say that you know you have to be at work at 8:00 AM. Or you have to be at work at, that's when if you're working in the school, that's when your first student's going to walk in, or it's 8:30.
Planning some time before that. And if you can, before your student just to settle in and check in with yourself, and see how you're doing when you arrive. And if you're working from home in teletherapy, one of the things that's really awesome is that there's no commute. So sometimes it's like your first student starts at 8:30, you walk in and turn on your computer at 8:25, and you start.
And that kind of sounds like almost lazy, but it's not lazy. It's kind of just like there can be so many other things going on at home and without that commute where you're having to get out the door. Sometimes you kind of give yourself, "Well I need a few minutes." So it's okay.
But giving yourself time to settle in. And if you're eventually in an office or a classroom somewhere and you physically are just sitting at your desk. Give yourself time to check in. And just do a mental check in. See how you're feeling, notice how your breath is. If it's nice, and calm, and steady. If it feels short, if you feel a lot of tension in your body that's going to build up or letting you know that maybe you're holding onto some stress. But just kind of checking in.
And then at the end of the day, planning time beyond just the end of the day wrap up where you might be finishing your billing or planning and prepping for the next day. But giving yourself time to just kind of regroup. And again, check in and notice if you're really drained, do you just need maybe five minutes extra before you head out the door and before you start work again to just sit and breathe for a few minutes? Or to listen to your favorite song, or to do something that doesn't have to do with work and that gives you a moment. Almost like a little mini break to just shift out of work mode and to give yourself something for you.
And this could extend into a full blown morning or evening routine. If you wanted to really set up your whole morning, you could maybe start the day by giving yourself some time to again, check in right when you wake up.
And one thing I had someone say to me one time was that you don't have to aim for 100% every day. You don't have to show up 100% every day, because it's impossible. So if you check in with yourself, you can see when you wake up, am I feeling 100% percent or am I feeling at 40 today? And I think right now with everything that's going on in the world, we're probably not at 100%. And a lot of times we may be at the lower end. But knowing that okay, if I am not 100% and I expect myself to be, I'm going to be let down, I'm going to be stressed, I'm going to be frustrated. But if I know that this is where I am today and I'm going to do the best with that, then you kind of set your day up from there. And know that you may have some struggles, and that's okay.
And you could even do some movement of some kind to start your day just to kind of feel like you've done something good for yourself. You could do meditation, which is really great for your brain, but also really great for reducing the stress response that gets triggered in our brain and in our body. And you can even do some kind of journaling like setting your intention for the day or setting goals for the day. And those could be woven into a bigger morning routine. And of course a cup of coffee if you need it.
And then in the evening, you could do things that kind of help you wind down. So it could be right at the end of your workday. Maybe instead of just that little buffer, maybe you have something like you go outside for a walk if you're able to. Or you get up and move a little bit if you've been sitting at your desk all day. But you can take a little more time if you have it.
And then if you wanted some kind of end of the evening routine to help you wind down, you could again, kind of stretch out a little bit. If you've been sitting at a desk all day, you might feel kind of tense in your shoulders, your back, your neck. Or you could do a meditation that just kind of helps you to unwind so that you sleep better.
Or even a journaling practice. There's two that are really good in the evening. One is called a brain dump where you just, any thoughts that might be stuck in your head replaying from the day, you just put them down on paper so that they can live somewhere else instead of just being in your thoughts. And then a gratitude journal, which helps you end your day on a positive note, remembering three things from your day that you are grateful for or that went well. Or that you can just kind of highlight as little positive moments from your day. And that can help you end your day or your work day on a positive note.
So again, they're not huge. Oh my gosh, this is the big thing I've been waiting to hear. This big secret about managing stress or about setting up my day. But there are things that we may not actually be doing. Like we've heard of doing or we've kind of played with here and there. But to actually get into a routine of doing them and creating your day around those can really start to make some big shifts.

Marisha: Yeah. And I couldn't agree more and I feel it's easy to be like, "Well, I've tried it or that sounds silly. That's not going to change anything for me. I have all of these big issues that I'm dealing with."
But just a personal experience share. I think everyone has struggled with a little bit during, or is still struggling with just the recent changes. And I don't know, just quarantining, and social distancing, and all of that. And I feel like my morning routine especially was, I would wake up and just feel, I don't know. I did not feel very good. But I had a morning routine. And I've been working on it for a long time. But I feel like that's what kept me sane and saved me. I was very intentional with what I added to the routine. And there are things that I know set me up for success and helped me feel good. I do the meditation, the journal, coffee. I did add exercise and stuff. But I feel like after going through that routine, and you can make it as short as long as you want. But after going through that, I felt like a whole new person which allowed me to show up and do all the things that I do during my day and have fun doing it. So yeah, I think it's incredibly powerful.

Jessi: Yeah. I feel the same with the morning routine. With everything, mine kind of got thrown off. And then I have a baby. He's not even a year old yet, so that totally was already thrown off morning routine wise. But it used to be my husband would take my daughter to school in the mornings, and I have time before work to get ready and get kind of settled, and have my morning routine. And even with the baby, that was still kind of the case. And then when all of this happened, everyone's at home.
So at first it was really awesome because it was, "We don't have to have any kind of morning routine, we can just kind of go with it." But then I realized I missed that. The same thing. I missed that start to my day where I felt like I was taking charge of the day, or that I was energizing for the day instead of the day kind of taking charge and overwhelming me right from the spot. So instead of hitting the ground running and running out of steam right away, having that morning routine and slowly easing into my day was something that I really needed. And me personally, I'm still slowly building back into that. and every little bit is definitely helpful.
And I think that's something too. We don't have to make huge shifts right away. But like you said, just those little changes and adding things back in and really tweaking things, or slowly putting them into practice can really, really help. So it doesn't mean that you have to go out and get this huge morning routine now, and then do this big process in the evening. But if you just wake up, give yourself five or 10 minutes in the morning. Or if there's something that you usually do that you don't have to do and you can make a swap, and you sit, and you journal, and you write out your intentions for the day. Not a to do list, but what you want to get from the day or how you want to be from the day, or whatever it might be. Or you sit and you do a meditation, or you just sit and you have a hot cup of coffee with no interruptions for a little bit. Just this kind of moment of Zen and meditation in kind of a totally different way. That can really shift your whole day.
And for me, again personally for me with little ones at home right now. Getting up, and one morning routine thing that definitely has a shift for me is getting dressed before they are up is a huge shift. Because otherwise, it's like that one little action sets up the day totally differently. But if I don't do that, then I feel like I'm behind on doing anything with them and getting anything done throughout the day.
So it can be really small stuff, but these small things can make big shifts or they can slowly build into more and more things that you can do that really help. But yeah, and just kind of figuring out what works for you and knowing it doesn't have to be perfect, and doesn't have to be a huge thing, can help.

Marisha: Yeah. I love that. And that's totally actionable and doable. Just starting with one minute of just even thinking before we get out of bed potentially. Just what's my intention for today? There's little tiny things that we can add on. And I feel like once, if we pick something that's really easy and really doable, it's easy to add on to that over time, which is really cool.

Jessi: Yeah. Little mindful moments throughout the day.

Marisha: Yeah. And then I love the ideas of, just I think setting ourselves up for success with kind of more of the routine based things. And I think that helps us manage when the crazy things come up. But do you have any? Because I feel like sometimes we're just kind of in crisis mode. Do you have any suggestions for when we're, if something really crazy happens. If we, I don't know. Progress reports are due for example. Or we just find out that they're adding 15 kids to our caseload or whatever. When those really stressful things come up, do you have any strategies for that in the moment?

Jessi: Yeah, absolutely. And it is true that some of the things would not be, if you have a crazy IEP meeting whether you're at home or it's something that you've experienced when you were able to go to the schools. Or if next year if your school is going back and you're in a meeting. There are some things that would be really, you're not going to just stand up and start walking around in a meeting and being, "Oh well I'm trying to reduce my stress." That would not be okay. And slipping into a full blown meditation. Closing your eyes in the middle of a meeting does not always work. So there are definitely things that you would do outside.
But there are things you can do. Like if you know that something stressful is coming up like a meeting or progress report time. You can build in some, really it's self care. What it boils down to, that word is so trendy and sometimes almost kind of overused. But being mindful of what you need. So really focusing on your self-care at those times. If you know that something's going to be really stressful like progress report time, make sure that you have in your calendar or maybe set a reminder or something, some things that you can do for yourself that are not related to work. Something that you can do that's going to help you check in with yourself, that's going to help you see how you're doing and then will help you feel better in the long run.
And those are the things that we tend to cut a lot of the times when we're so stressed. We have so much work we need to do. I'm just not going to go for a walk today. Or I'm just not going to take a lunch break today and eat my lunch. I'm just going to totally cut that out of my day and just scarf something down really quick and keep going.
But giving yourself breaks and giving yourself time to get up and move, time to check in. Those are all even more important during those times that are kind of crazy.
And if it's something like a meeting. If you have one where you just know that it's going to be one of those really, really stressful meetings. Preparing yourself beforehand. So not just giving yourself time before, but maybe taking, doing a meditation where you do some deep breaths and you try and kind of find that little bit of calm before you go in. So you're more grounded, you're more steady, and you're not feeling as anxious or stressed where you're able to really think more clearly and process things more clearly. That can help in that.
And then when it's those times where you go into work and you think you know how the day's going to be. And then you get an email that's like, "Hey, you have five more students. And I know you're already full and you have no room for these, but schedule them." When it's something like that where it's just you don't even know what to do. Taking time to just be aware and just say, "Okay, how am I feeling?" Of course I'm feeling this way. It's okay for this to be stressful. And then remember that it's not going to be this way forever. That this in this moment is stressful. But not just that it'll pass, but that there are things you can do for the stress. So yes, this is stressful. But I can take a few deep breaths. I can try and problem solve through this. But before I problem solve, I've got to get that stress managed so that I can fully focus on it and I can fully think through it.
Because one of the things that stress does is not only, sometimes when it's leaning towards burnout gives us that cynical attitude. But when we have the stress response triggered in our brain, it kind of takes over. And the parts of our brain that like to process things, and problem solve, and think things through, and give us these really clear steps on what to do our overwritten. And that's why when you're really stressed, it's so hard to think and to figure out what to do next. So when we're in that state for so long, that's why we feel like we just can't figure out what to do.
So when you have things, knowing that it's stressful but then taking a few deep breaths or going out for, taking a break. Maybe getting up and getting some fresh air or doing some stretches next to your desk or whatever it might be, to give you a moment. So that when you're ready to dive into it and figure out what to do, you can do it. And again, knowing that it doesn't have to be perfect and it might be really messy. But that's okay and it's not always going to be that way.
So when we manage our stress, it doesn't mean that stress will be gone or that we won't ever be affected by it. It's that we are a little bit more resilient to it. Or when we realize that we are not resilient to it and we are totally weighed down. We can figure out, and we know we have tools of what to do or how to check in and see what is not going right for me right now and what can I do to better manage this?

Marisha: Yeah. I love that distinction though. Because I don't know, I think life in general is just, there are going to be hard things. And then especially at SLPs, there will be hard things.
Because I think that perspective is really helpful. Because if we're expecting perfection, if we're expecting to love every minute and just be completely stress-free and zen, and just totally loving it all the time. Then when those things come up, I think that's even more stressful. But if we kind of expect, like sometimes it will be stressful and that's okay.

Jessi: Yeah.

Marisha: It's really helpful.

Jessi: And I think it's really hard for us as SLPs because we tend to be perfectionists. Whether it's a good thing or not. It's just how, and I always wonder if that's why we get into the field or if the process of going through grad school kind of turns us into perfectionists. But it happens. So we want to do everything. We want to do a great job. We want to be the best that we can be. We want to get everything done, and do it well, and be productive, and then that can cause so much stress.
But just knowing that it doesn't have to be perfect. It doesn't mean it's going to be bad if it's not perfect. And knowing that handling our stress that life, all of that is not going to be perfect. That there will be ups and downs, but that we can do things about it even when it is really hard. Or that if it is really hard, it doesn't have to stay that way forever.
And when I talk about balance, there's always this debate about work life balance and how, does it really exist? Is it really even possible? And I kind of like to think about it as more it doesn't mean that it has to be perfect all the time. There'll be times when work takes over and is kind of more of what you're doing. But there'll also be times when life takes over and you're more focused on that. And it's kind of just letting it swing from each side, but knowing that you're not going to be stuck in one forever. And that when you need to, there'll be times when we really do need to focus on work and let that be a bigger part of our life. But knowing what to do to get back to bringing in the other aspects as well. And then when life takes over. And things from home, we start to kind of let those take over and focus less on work, knowing how to bring it back to the center from there too. I kind of think that's kind of where all that balance with our stress and just with all of it comes to. If that made any sense at all.

Marisha: No, that makes a lot of sense. And it's just like it's okay if it's a little bit more towards one or the other sometimes. We'll figure it out. Yeah. No, that's great.
And then I was curious too. You mentioned when we're managing those really stressful events, you talked about finding things that help you feel better in the long run. Which I think is really important. So you mentioned going for a walk, taking a lunch break. What would be on your list of things that, just some other brainstorming for things that might help us feel better in the long run.

Jessi: Yeah. So anything that really helps you tune in or check into how you're doing. So there is definitely when we think of self-care, there's definitely kind of the joke, but it's also because we're actually doing it of binge watching things. Binging Netflix, or really just binging. Drinking a whole bottle of wine every night just to get through. You like to process the day to make it to the next day. Or watching an entire season of something in one day.
So knowing that that is not going to be what gets you through for the long run. That is definitely what's going to get you through in short term. Because that makes you check out. It gives you a break where you don't have to think about anything. You don't have to think about any of the stress you've experienced or any of the work that you feel like you should be doing, or any of it. It's a total checkout where you just sit on your couch, turn on Netflix, and that's what you've got. And that's it for the evening.
And that is totally okay sometimes. Because we have those days where you're just so mentally exhausted that you cannot process or think about anything. And it's just like you have no energy to do anything else.
But you don't want to be that way every day. It's not sustainable. I don't think anybody would want to feel that way that drained at the end of every single day. So checking in and doing something that helps you feel good.
So for me, I know that if I don't get up and move, and have some sort of not necessarily exercise. I mean it is exercise, but some sort of a movement practice or mindful movement throughout my day. Whether I go on a walk outside, we've been doing that a lot just because there's not a lot else to do. And we're fortunate enough to live in a really quiet neighborhood with a lot of green space. So going out and taking a walk every day is something that if I don't do that, I really miss it. Because it kind of just gives me this, whether it's at the start of the day, it gives me a really nice kind of way to ease into the day. And if it's at the end of our day or after dinner, it's a nice way to close everything out.
I also really enjoy yoga. That is an important type of movement for me because it helps me breathe deeper. I always feel like it kind of resets my stress for me, and I feel better after. But I know that for some people, movement is not, they don't feel good when they do it. Or it's just not the thing that they crave. So it could be journaling, it could be that you'd like to get into the creative process and create something.
A lot of people like to bake for stress. Which I love baking, so I totally get that. But there are people that really like to create something like that. Or a lot of people that do knitting as their kind of mindful thing for the day.
But doing something that you can sit and maybe have some time to yourself, or have somewhere that you can focus on yourself while you're doing it and really see what do I need, how am I actually doing?
And it doesn't mean that it'll always be really easy. Sitting and meditating can be really nice, but it could also be really hard because you may actually notice I'm feeling really stressed today and I don't like the way this feels in my body. I don't like the thoughts that I'm having with it. I really wish I could just ignore this instead.
Getting up and moving can be the same thing. You might start to notice that you just feel really stiff from the day and you really don't like the way that feels. But knowing that sometimes it'll be hard. But overall, it will help you and kind of keep you going and keep you able to really connect to the work you're doing, and stay connected to your day, and not be as overwhelmed by the things that are stressful that happen during the day.

Marisha: Yeah, that's perfect. And I love that distinction between things that help us feel better in the short term versus the long term. And that it's not always easy to do the things that help us feel better in the longterm.

Jessi: Yeah, it's so true. And I never want someone to think that I don't watch Netflix, because I definitely do. I always think that. I never want anyone to think that I'm against it. I totally watch something every night, but it's not my self-care. And then the times where it does become my self-care, then I know just from my own experiences and from everything that I've learned. That's kind of one of the things that for me it's okay, if I've been leaning on this a little bit too much, then it's when I know something's out of balance and I need to get back to the things that are actually going to work and actually help me manage my stress and not hide from it.

Marisha: Love it. Super helpful. And then I think we have time for one last question. But a lot of us, and you touched on this already a little bit. But maybe just recapping some strategies and adding any additional ones if you have them. But a lot of us are working from home. And I'm curious what strategies you have to navigate that. You mentioned having a buffer. But what else do you think would help just in this particular situation?

Jessi: It's crazy working from home when you signed up for it. And you went into teletherapy and you've been kind of trained and ready for it. It's even crazier now when you're thrown into it, and you also have a lot of possibly other people at your house, and family members while you're doing it.
So a few things that are helpful are having those buffers for sure. Giving yourself time to start your day and something, to give yourself time to plan and prep at the end of your day for sure. But then have that transition of sorts, something you do that's just for you, that helps your brain know, "Okay, work is done. I don't need to think about it anymore. I'm physically stepping out of this office, but I'm also mentally stepping out and I'm going to be home now."
But giving yourself breaks. It's really easy when you're working from home to sit at your desk for eight hours. Because we forget to get up a lot of the time, or we try and cram everything in scheduled back to back sessions. But giving yourself time to move.
And it doesn't have to be that you go for an hour long or even 10 minute walk. You could just do a few stretches at your desk in between sessions while you're waiting for someone to log in. Or I've been doing this, but I keep a yoga mat unrolled where no one could see me if I had to get on the computer. It's nowhere near, but it's in my office. And I actually started doing that because the therapist I worked with told me that that was kind of her trick that she would do is she would just have it. And then go and do a few stretches in between sessions while she had two minutes. And that those little two minutes throughout her day really helped her feel better.
And making sure you have time to get up and go grab water, or coffee, or a snack if you need it. And have some sort of a lunch break. That is super important, to give yourself that time to actually eat and reenergize. But also to let your brain have a break, let your body have a break from sitting.
And if you can, if you're starting to create your whole schedule from scratch, batching your day around your energy. So if you know in the morning you're more energized. Maybe that's when you have most of your sessions where you really need to be on and really, really fully, fully engaged. And if you're feeling a little bit more drained towards the afternoons, maybe saving that for some of the time that you do quieter planning prep, or quieter sessions, kind of less energized sessions. Planning your day around that and making sure that you take breaks throughout the morning and throughout the afternoon, not just a lunch break. That can really help.
And of course that's ideal, right? That's ideal stuff. But like we mentioned before, just doing as much as you can or doing a few, planning some small shifts in your day can really, really start to build and help you get to where you need to be, where you can sustain this and keep going with it.

Marisha: Yeah. And I love how you keep reminding us of that because you definitely know who's listening inaudible then it's like okay. Okay so I'm planning this out, but I'm wanting to do all of the things. And I can't do all the things, so I'm not going to do any of it. I love the reminder that just a little shift. So if it's, I don't know, making sure that you have water at your desk. Could even be a start.

Jessi: Yeah.

Marisha: Making sure to take a sip in between sessions.

Jessi: Absolutely. Absolutely. And then you start to feel better. So then you want to keep going with the things that make you feel good. And you end up finding more time for them. Yeah, absolutely.

Marisha: Awesome. Okay, well this was super helpful. I love all of these ideas and strategies. And just realistic, you're very real about it in terms of this would be wonderful to do all the things,. But we can start small and take small steps towards just feeling better. Because I don't think any of us want to feel stressed. So I love just the realistic approach. That's super helpful.

Jessi: Thank you.

Marisha: And if people want to find out more about what you do. They got some good strategies but they're still feeling like they want to learn more or just have additional information. Where can they find out more about what you do, where can they connect with you?

Jessi: Yeah. So you can connect with me definitely on Instagram @jessiandricks. And on my site jessiandricks.com where you can find podcast episodes, blog posts, and the subscriber free resource bank called the SLP toolbox with meditations that you can download. Movement audio you can download, some journal templates, just kind of all the little goodies that help you throughout your day to reduce your stress. And if you're really looking to dive into this, you can also check out the online course SLP Stress Management that you can find at jessiandricks.com

Marisha: Awesome. Well, thank you so much for sharing your time with us. And yeah, definitely walking away with tons of helpful strategies. And yeah if you want to, I'll share links to all of the things that you mentioned today like your Instagram and your site, and the course, all that good stuff in the show notes at slpnow.com/53. Or you can just go, if you're listening, you can go straight to jessiandricks.com. So it's J-E-S-S-I A-N-D-R-I-C-K-S. And yeah, that's all we've got. That's a wrap. Thank you.

Jessi: Thank you.

Marisha: Hi there and welcome to The SLP Now Podcast. I am incredibly excited to bring Rosemary Griffin back onto the podcast. If that name sounds familiar, she joined us on episode 13 and shared tons of tips for success with high school life skills. It was one of my favorite episodes. I was just telling Rose that I walked away wanting to work in a high school because she just shared so many amazing tips and made it feel so incredibly doable. I'm incredibly excited to have her on today to share that same caliber of tips and tricks, except focusing on early learners with autism.
And just a little bit about Rose. If you haven't met her, she is a little bit of a unicorn. She is at CCC-SLP, BCBA. She's ASTRA certified and also a Board Certified Behavior Analyst. She's also the founder of ABA Speech and is also an ASHA approved provider. And she's just an amazing resource Rose has presented at the national state and local level about helping students with autism develop a way to communicate with the world. And she also created some amazing products like the Action Builder Cards, the double up game all geared at helping students with autism increase their language skills. So without further ado, hello Rose.

Rose: Hi, glad to be back. Nice chatting with you today.

Marisha: I am very excited. And before we dive into all of your tips and tricks, because we have quite the agenda. I'm curious if you could just share a little bit about your experience. Last time you told us about working with older students. But I'm curious kind of what your path was and how you kind of built your expertise and all of that with the younger population, the early autism learners.

Rose: Yeah, absolutely. I've always had a passion for working with any age student with autism. That's kind of been always my life mission ever since I learned about what a speech therapist was and does. So I remember working even in my student teaching, that's what we call it here in Ohio with students with autism. And I remember we were working at the lower elementary grades and the speech therapist that I was working with was very seasoned and she had a lot of really great visuals we use with the students. And I just remember having some breakthrough moments, working with those students and thinking, Oh my gosh, this is really amazing. This student wasn't talking before and now they are. And it's just such a great experience to meet students who don't have any way to communicate and to see that growth.
I had one year early in my career. I'm reaching not at the 20 year Mark, but I'm kind of getting there. So one year I just did preschool. It was all preschool. And I really loved that age group as well because it's such a dynamic time for students. I remember meeting students and them not having any way to communicate. And then us working together as a team, myself, the special education teacher at that level, you really have a lot of access to parents. Parents are usually dropping off. And so you see the parents and I had one student in particular who had all these different medical complications from birth and we were working together at the preschool level. And I subsequently have seen this mom in the community. And now this student, many years after all this structured therapy is no longer on an IEP and doesn't even need speech therapy services.
And so that kind of joy of seeing a student who has no way to communicate and maybe is feeling frustrated and then working together collaboratively with a team and definitely keeping the parents in the loop. That is really what has sparked my desire to want to work with students who have autism. Just that kind of growth that you can have when you're working together as a team is really, as corny as it sounds it is why I wake up every single day excited to be a speech therapist. I really love what we do. And I say that we're always in, we're helping people increase their quality of life and being able to do that every day really means a lot to me.

Marisha: That's amazing. And your enthusiasm and excitement and all of those qualities definitely shine through and I've definitely been transferred some of those because you're just so awesome in what you do. Let's get into the good stuff then. A lot of us have these students coming up on our case load and we're just like, where in the world do we start? So what would you suggest, how do we know where to start in therapy for a student who's not yet communicating?

Rose: I think what's so very important. I really have these kind of different strategies that I try to use when I'm working with any type of student. But I think the first thing that's so very important when working with students with autism is that we take time to build rapport. I call it a therapeutic rapport. That's really just a term that I've kind of come up with over the years of doing presentations and talking to groups of staff. But I think that we have to take that time to really build rapport with our kids. And I think that, as speech therapists, we're very data driven and we want to make sure that we're getting data on different objectives and things like that.
And what I say when we first meet a new student, even if it's the start of the school year and the student is new to you, or maybe the student is completely new to the therapeutic setting is just taking, at least one session, but it may take a lot more for students who have autism and, or some behavioral problems and just kind of playing with the student and being in their space and sharing things with them and making sure that we don't always have to make every situation a very language enrich time. I think that's something that is hard to not do, but we don't want to bombard the student with a lot of different questions.
When I'm meeting a student who has autism and their younger and really across the board, I may just be talking about some of the things that I have. So if I have a farm toy, I may just say, Oh, I have the cow. And now the cow says moo. I want to try to be really excited and playful and I want to make sure that I'm not asking a whole lot of questions. I think that we tend to have a tendency to do that because we want to make sure that we have some social reciprocity where we talk and the student talks. But I think just being with the student and building rapport with the student is a really good place to start.
And so sometimes, in the behavioral world, we may call that pairing. You may hear that term. So the idea is that we're just pairing ourselves, the materials and the environment with good things. So we want to be the giver of good things. Because even if you're meeting a student and they're preschool age, that might be if they didn't have Help Me Grow or they didn't have home based services, that might be the first time that they're ever really meeting somebody. And that might be a really type of different dynamic for them. And so it's important that we are seen as the person who is the giver of good things and the person who is excited and has all the fun toys.
I have this funny story, I was an autism facilitator down in Austin, Texas, and I love that job so much. It really kind of foreshadowed what I do now with ABA Speech. We're talking on talking to groups of professionals, but I would work with the speech therapist there, they're a group of about 35 amazing speech therapists. And so once a month I would give a talk about a certain topic that they wanted to hear about and it always pertained to autism. And then I would go in to their different classes and campuses throughout the week. And I would help with students that were new or students that were not communicating. And I really love doing that. And so the one student that I met I had brought some toys because he was preschool. So you always have to have, no matter what the age, you have to have a lot of fun things. And so I had this little cat toy, I don't even know where I got this thing and it just, you press the top of it and it would move and it would make little noises.
And this student was essentially nonverbal at the time. And so he really didn't say much that day, but we interacted just what I'm telling you, you know what, I'm talking about, things that are going on, but not asking a lot of questions, kind of just in his space. And then I go back to my main office and I come out maybe a week or two later. And when he saw me, he didn't say hi and that's okay because I don't always work on greetings first, but he looked at me and he said cat. And so I thought, Oh wow, that's so exciting. He had this learning history of me being somebody who had something he loved and enjoyed. And that's really where it has to start. You have to build that rapport and you have to find out what your student really loves and enjoys. That's where you need to start.

Marisha: Oh, that is such a cool story. I love that.

Rose: Yeah. Definitely.

Marisha: It's definitely great illustration of that concept too. Awesome. We spend some time establishing rapport, we're really focusing on finding what the student is interested in doing and what they'll enjoy, kind of just pairing in that way. Do you have any suggestions, especially as a newer clinician, I would be preparing for these sessions, I'd be like, what in the world do I prepare? So do you have a strategy? Do you have a ton of different toys? How do you organize the room and kind of select things to set yourself up for success to establish that rapport and do that pairing?

Rose: Yeah, that's a great question. I think the one of the first things too, and after we kind of build rapport, we definitely need to discuss assessment. I know that assessment is something that's very, very important. And usually if you're a school based therapist, the kids might be coming in from a home program or they might already be, they may be coming in from home for an evaluation. And so it is a really delicate balance when you're first meeting students of wanting to be this person who has all the really wonderful things, but you also need to probably do an assessment. Especially when students are younger, you may be part of an assessment team and you may be looking at, does this student really qualify for services? And so oftentimes it can be really difficult to test students with autism or more complex needs because they may not get a standard score on the PLS or they may not be able to sit through the testing.
And so I think it's good to have some things that are readily available, just like you would with younger students, maybe you have different play sets like a kitchen set up and some of those more traditional type things. But you also want to make sure that you have some reinforcers that might be really special that you kind of keep in your own possession as the speech therapist, because you can kind of use those things if the student like bubbles. Let's just say, because I don't know if I've met a child even with severe autism that did not like bubbles and it's kind of a fun toy. So making sure that you kind of have those in your possession. Maybe if you're doing an assessment you're able to have the student do some of the different test items, and then you're able to do some type of reinforcement that you have in your possession so that you could do a little bit of play. And then you could try to go back to testing.
And that's kind of a delicate balance. It's going to be hard for kids. And a lot of times when you're working with somebody who's really little, it really depends on your kind of methodology and also where you're working, but you may have the parent come back. If the student isn't able to answer all the questions, you're going to get a lot of good talk time with the parent, with the family. And you really want to know how the student is talking right then or communicating right then, is that really across the board? How they're communicating in the home environment. I think that's important too. That assessment piece is really important. So obviously if you have students who are younger, you may be able to use the PLS, which is a really, really nice assessment because it looks at all the different pieces and parts, is the student able to request things they want, can they receptively Id things? Are they able to label, what types of words can they say? Those are all really important.
Also, the functional communication profile, is really nice for assessment as well, because it's more open ended. And so it looks at different pieces and parts as far as can they take turns? That social kind of pragmatic pieces on there as well. And so I think those are the types of things that when we're first meeting a student, we want to make sure that we're building that rapport, that therapeutic rapport, and then really the next step is to really get a good assessment because that assessment is really going to help us have a scope and sequence of what we should work on an intervention. And I think when I was starting to work with students with autism, it was hard for me because I was working with younger students in a more year-round kind of ABA type school. And I just remember thinking these students are not getting a standardized score on the tests that I'm giving them.
There's just so many things that these learners could not do. That was really hard for me to know, what are my next steps? And so another test that I've talked a little bit about probably before too it's called the VB-MAPP. And so that test is really nice if you have access to it, if you're working in more of a specialized program, if you're not working a specialized programming, you've never heard of it. It's good just to kind of hear a little bit about it, because you might be getting outside evaluations where somebody has given the VB-MAPP. And so really what that looks at is different parts of communication. It looks at why is a student communicating? It looks at, is the student requesting, are they able to do that independently? Is the student labeling? What can they label, is the student playing with others? Is the student able to be in a group setting which is really, really important information at that age as well, because oftentimes when a student, every student is different.
I've had worked with students before who were essentially nonverbal, but I would tell the parent, your child is very social. They want to be around other people. But it's really good for us to get that complete snapshot of a learner because then we can say, okay, these are the exact goals that really need to be addressed for your student. And I'm a big proponent of making sure that communication is embedded across a student's day two. So rarely am I working on something that the team is not working on as well. I definitely take time to train everybody on how to embed communication opportunities during the day that are meaningful because we can't do it alone. You know what I mean? It's really important for these students that they have that type of intervention across their entire day.

Marisha: Yeah, that's perfect. I actually got to use the VB-MAPP a little bit. I worked in an autism program for a couple of years and it was super helpful.

Rose: Oh, that's great. I think it really breaks things down. Don't you think that we wouldn't necessarily be able to do on a standardized speech therapy test, so that's great.

Marisha: Yeah. And it was a nice way because the special education teacher used it too. And so it helped us have a common language and a common lens around what we were looking at, which is super interesting. I'm curious, we're pulling these pieces from the different assessments that you mentioned, we're observing, the students were getting feedback from the parents and the teachers, we're putting that all together. When we're piecing all of these things together and we have our whole list of things that we could focus on, do you have any strategies for navigating through that or do you have some kind of insight on maybe the most important areas to focus on in therapy? How do you know how do that?

Rose: That's a really good question. I actually have this gosh, it's been so popular. It has been downloaded by just thousands of people. It's called an autism IEP goal bank, which you can find at abcspeech.org, but what I've tried to do with that goal bank, and really what I try to do with any student who's not communicating. I'll have some main skills and really these main skills, you would obviously base them on each individual student in your assessment. But they're kind of, when I first started working with students I used to work at the Cleveland Clinic Center for Autism. And we were a separate program for students that was their least restrictive environment. So it was oftentimes students who had problem behavior that was a barrier to their learning. And I just remember working with these students and thinking just like you said, where do I even begin?
Sometimes it's hard to see that path that we need to take to help the student, have a response form, have a way to communicate. It's hard to know how do I help this student have spontaneous communication? I think that's just really hard sometimes when you're first working with these students. And there's a lot of noise out there too, everyone's going to have a different way that they approach this type of learner. Right. Some people may say, well, I always work on these types of words and I always work on these types of words and what I would say to you. If you're just beginning or there's a lot of noise out there on what you should do is whatever approach you end up taking. And however you're going to set your goals is that you take data and you analyze that data. Because oftentimes we might be on a team where, you said you worked in autism program, you may not always have the same philosophical idea about what you should work on with students.
And so I say, we don't always have to agree on everything, but I'll tell you what, when we take data and we analyze data on our goals and how we're doing things, that really takes a lot of the anxand the kind of upset that we may have when we kind of disagree with people. I would just let you know that going ahead. But there are absolutely different skills that I always try to make sure that we're incorporating and they really come from things like the PLS, from the VB-MAPP. And it's just kind of a culmination of what is appropriate for your learner. But I always kind of talk about these skills as learning readiness skills.
I don't know if you've worked with students in preschool, I'm sure that you have, but oftentimes it's hard for them to sit at a table or it's hard for them to attend so we might use more play-based therapy, which is definitely fine if we're able to teach things directly. But some of the things that I think are so very important for students are gross motor imitation skills. Gross motor imitation skills are going to teach the students. An example of that would be if I said, okay, do this one and I clap, and then I have the student clap after me. So we're teaching them how to learn. We're teaching them how to attend. So there's so many different pieces and parts just in that one little exercise that we're doing with gross motor imitation. Gross motor imitation too, can also be generalized to things like GoNoodle. I love GoNoodle, actually Koo Koo Kangaroo, which is one of my favorite groups from GoNoodle, which gonoodle.com is a free website.
If you've never been to it, it's absolutely amazing. And there's lots of different songs and dances. And what's really cool at that age is you can show students those videos and they have a lot of different imitation skills. So they may have people that are doing dances and the students can try to do the dances too. And so it's really working on that student's ability to attend. If they're with a group, it's working on their ability to engage with others. And it's a really nice kind of play-based way, maybe you're working on that gross motor imitation with the student directly and the teacher's also working on it, but then maybe you do a circle time. And part of it is to watch a song from GoNoodle. And so then you're embedding that ability to generalize into a classroom setting with other peers and things like that. I'd say gross motor imitation is definitely one of those.
Another thing that's really, really important for students is to work on matching. So matching picture to picture or object to object, we have that whole hierarchy that we learn about in graduate school. And so wherever the learner is at with that, I think that's really important. And really that matching is so very key to also work on engaging. You can definitely work on... I had a student who, Oh gosh, they were just not attending. They were at the picture level, okay. We were not using objects. They were able to do pictures, but they really were not having consistent success with some of the pictures that we were using. I was kind of using what I had in my therapy room as far as some picture cards and kind of repurposing some artic cards for that purpose. And the student really was not loving it.
I knew the student really loved and enjoyed watching Daniel the tiger. And so what I did is, we have a copy center. I work three days a week at a public school. And so we can get color copies, but we have to send away for them, which is fine. I'm just happy to get them. And so what I did is I sent a copy center. I went on Google images and I created these picture cards. They were all the same size. So the student wasn't matching based on size. And they were all of Daniel the tiger. Daniel the tiger birthday cake, Daniel the tiger with friends, Daniel the tiger on the show, Daniel the tiger by himself.
And so we worked on matching and something I think so important about that is that, if you're working in something that's more of a structured program, we might put out three different pictures. And so two of those pictures might be distractor pictures, not the targeted picture that we're working on. And one might be that picture we want them to match. We give the student the picture we want them to match. And then we say, match Daniel or match Daniel and his friends. And then the student has to scan, which is such a great skill to work on. And then they have to place it down on the correct picture. And so you're teaching the student, okay, these are the things, these are the foundational skills that are going to help you learn more in a least restrictive environment. If you have some direct instruction and then we go to morning circle, you will be able to attend better in that setting. We're trying to set that student to have a learning history of attending, working on academic tasks for a little bit longer and things like that.
And then the other one that I always like to start with is following one step directions. And I can tell you as a mom of three, my kids have trouble with one step directions on the daily. But that is really important for parents who are autism parents who are affected as a family by autism, just the things that we take for granted, for our kids. I may tell my kids, okay, get your shoes on or get your shoes. My kids may just be delaying because they're watching the iPad or doing whatever and not attending. But for our learners who have autism and are iddy biddies, those types of things are going to be really important because I always talk about the fact that our therapy, it's not just us and the student. We can get really kind of in this almost like, some days I feel like I'm really helping other people. And then other days you might have a therapy session and feel like, what am I even doing here?
But knowing that the work that you do every single day with that student, you might be working on a one step direction, like get your shoes right before they got out to play or whatever. And you may think like, Oh my gosh, this is so hard, or this is so repetitive. But you have to think about the big picture, how it's a ripple effect. So it's like, okay, I'm going to work on these early learning skills like this one step direction, get your shoes. And that, maybe it's going to take this student who has severe needs three or four weeks to learn that one step direction without any prompting, but me I'm when they learn it and you can share that with the parent and they can then embed that into their home environment.
You have to think about what effect that's going to have on that family. That family could say, okay Tom, get your shoes. And he gets his shoes and he's ready to go out for the day. And I just know that when we're working day to day, we can kind of get in this. You know, it's hard to see really what the big picture is, but it's always really important to know that you can embed those things into the home environment and how much our therapy, our daily therapy and what we do everyday for our kids is going to have an effect on their home life and how they're communicating in the home environment. Those are definitely some things I love to start with.

Marisha: Perfect. That's super helpful. And then, so let's say we've established the rapport, we have our assessment. We figured out which areas we want to focus on in therapy. So what would the actual session look like once we dive into therapy?

Rose: Oh yeah. Okay. That's a great question too. I think that's really important. I definitely always love to start working on requesting. I think that's just so very important oftentimes when we're working with students who are younger, they may not have any way to tell us that they want the things that they love and enjoy. I always start my sessions with requesting. In the behavioral world, you might hear that term as manding. And so that's kind of a jargon type term, but a lot of people oftentimes a speech therapist, myself included as a school based therapist, even though I'm a BCBA, when I'm working in a school, I'm employed as the speech therapist I'm definitely doing speech therapy kind of through a behavioral lens, but I'm absolutely 100% collaborating with other BCBAs.
And so even if we're never going to use those terms, I think it's really important to understand what they mean so that... you talked about Marisha, how you used the VB-MAPP and you felt you were able to get on kind of the same working level with the teacher. And I think sometimes those words that we kind of talk about when we don't understand a term, I know that sometimes I get defensive. I've been with other people before, and they've said a term and I act like I'd completely understand that term. And then after I leave the meeting or sign off the Zoom call I'm googling it and whatever. I always start with manding or requesting, I kind of use those interchangeably because that's kind of telling the student, these are the things you love and enjoy, and this is what we're going to start with today. And so that's really, what's going to help our students find a way to communicate with the world.
And something that I think is so important is, oftentimes our students might have really limited things they love and enjoy. So as part of that assessment, or when we start kind of getting in the groove of therapy is doing a preference assessment. And so a preference assessment is something that, I don't like to send them home. I know sometimes teachers do that kind of at the start of the school year. And I think that's fine, but you can just Google preference assessment. I definitely have one at ABA Speech. And so it's really just a list of potential reinforcers. And so that's going to be really powerful information because we want to make sure that our sessions are embedded with things that our student really loves and enjoys.
So no matter the age of the student, but especially for our little ones, we want to make sure that we're starting our sessions with them requesting their very favorite things. I went back to the cat story, the kid who really loved the cat. So when we worked with him, we made sure that we had the cat toy. And we made sure that we had all those really fun toys because we want to spend, let's say that we have a 30 minute session and that's the thing to talk about too, is that the things I'm talking about today might be the very gold standard. I absolutely understand that a lot of speech therapists are not able to see kids individually. I don't want people to think, Oh my gosh, everything she's saying is only if you're working with students individually. I realized that that is not always the case.
Just know that the things I'm talking about, if you're not able to see students individually, things to kind of think about can you have a paraprofessional come to offer some help? Because students may leave the teaching area, get into something different, have trouble attending. And it's really important to kind of have that support when you're doing your sessions. And what's really amazing about building a rapport with paraprofessionals as well, or one on one assistance or whatever you're calling them in your workplace is that when you're working with a student with more complex needs or autism and you have team members present you're really modeling. You're really modeling like this is how we embed communication. This is how we should respond to maybe a behavior that kind of gets in the way of instruction.
And so I think that's important to talk about because sometimes when I'm talking, I do talk about seeing students kind of individually. And I know that that's really not always the case. So just know that there are ways to get around that creative scheduling. Sometimes I've seen students where I'll see them for 15 minutes on one day and 15 minutes on another day, or maybe I'll see students in a dyad, meaning it's just me and I have two students or it's just me and I have two students, but there's one assistant. And then when I'm working with the one student on a skill than the other student, maybe he's engaged in a puzzle or some type of task that the student can do with minimal prompts.
I just want to talk about that because I realized that we don't always have the luxury to be able to see the students in a one on one setting before I get too entrenched here. Okay. So requesting, I think requesting is super important because that's how our student's going to find their voice. I often say that's kind of my personal mission is to make sure that every single student that I come into contact with and hopefully every single student that anybody who kind of listens to ABA Speech will come into contact, we'll have a way to communicate with the world. And so I think that is really, really important. And so during that manding time or that requesting time, you're going to have things that the student really loves and enjoys. And you're going to work on them requesting those things.
I think what's so important about that too, is to remember that we want to work on them requesting very specific things. Let's say that your student really loves puzzles and really loves bubbles and really loves Pete the cat. You're going to have those things present and then you're going to help the student. And if they need help, I'm requesting those things. You're going to help them request those things. And once they do, then you're going to give them that item and they're going to play with it. And then we don't take that item away because we don't want to take things away. That can cause problem behavior, because I don't know about you, but I don't like when people touch my things. And then I'm going to show them something else they might really love and enjoy. I'm going to show them the Pete the cat book, and maybe they see the book and they say, Pete, and then I read the book to them or however we interact with the book.
I call it a rotating array of reinforcement. So that's really how I like to start the session because I'm starting with this things that the student really loves and enjoys. I'm making sure that I have those really amazing things in my possession. And I'm helping the student when needed if they need help requesting those things. And then I'm taking data on that. I want to know, it's kind of like this idea of what are you into today? I'm a creature of habit. I just recently changed my Starbucks order. For the past year, I've had this crazy order. I got a mocha, but it was more complicated than that. I'm not going to get into it because I'm kind of a coffee nerd. And then one day I tried something new.
I go back the next day and the lady goes, Oh, so you liked that drink. I'm like, Oh my gosh, is this good? This lady knows my drink. I think I have a Starbucks problem, but it's kind of like, that's what we're saying to our kids. We're not really saying, what are you into today? What do you want to play with today? You might say that because they're little, but we're kind of analyzing and we're kind of the behavioral detectives. We're thinking like, Oh, when I saw him last week, he really loved that puzzle. I'm going to make sure I have that zoo puzzle that makes the sounds. Or maybe you see him the next week and he really doesn't love that anymore. So you have to have a lot of different things ready to go.
And so I think that working on requesting is the most important thing. And then that's going to kind of give us that behavioral momentum, where the student sees that you have the things they love and enjoy. They're working on requesting them with whatever response form they use. If they're using pictures or their voice. And so that's going to build this history of, Oh, I love going to Miss Rose's room because she has, the bubbles and the cat toy and all the things I really love and enjoy. Sure, it's speech time. I'm ready. And so that's really what we want to start with. And then we want to have a running list. I kind of every year kind of change and modify the way I'm taking data a little bit here and there. And so I always have for each of my students a data sheet that would have, in essence, it's kind of my therapy plan. I'd have the different things we were going to work on.
And so then let's say we do requesting, and I write down the student really wanted to request puzzles and bubbles. They did that on their own, maybe 10 times, and then they wanted the iPad, but I had to prompt them to request that. I make sure that I note all of that information on my data sheet and then I might move into something like working on the gross motor imitation. So I might say, okay, do this one. And maybe I jump. And I think that's important too. You don't have to just work on one target within these different skill areas, but it is important to note exactly what target you're working on.
Let's say that we're working on gross motor imitation and I'm going to do a jump and I want the student to do that after me. I definitely want to make sure that I write that down on my data sheet. And then I know, did the student need prompting to do the skill? Did the student do the skill on their own? And then we obviously want to make sure, especially with our little guys that we're taking time to do play-based things. So maybe we do work for five minutes and then the student takes a little break. Maybe we do some part of our session at the table and some part of the session is maybe in their classroom or it's in a play area, in your clinic, wherever you're servicing the child. I think that's very important because we want to make sure that we're kind of analyzing too, especially with really little kids.
Number one, is it appropriate for them to even come to the table? That's important to think about is the student going to work better on the floor? Where is the student going to work best that's important. And I think too, especially when I'm working with little students gosh, and even my students who are older, I get bored sitting in the same place for 30 minutes. I always try to kind of vary, like okay, first we're going to work at the table and we're going to do requesting and then we're going to do a little labeling and then maybe we're going to go for a walk. And maybe when I was doing just preschool, we had a little gym right across the hall from the therapy room. So we would go over there and shoot a couple of baskets and then we would come back. We had a kitchen area right in our little therapy room, so we would work at the table and then we would go in the kitchen.
And make sure it's kind of this fluid kind of dance that I feel like once you get more accustomed to working with students with more complex needs, it just kind of becomes easier as time goes. And so those are some important things. I might also work on the one step directions like we talked about, intersperse some work on matching. One skill that we haven't talked about yet is labeling. I think labeling for students, if that's what your assessment says to work on is very important. And I think what's so important when we work on labeling. I had a student who I met him in, was he, he was preschool. I met him, I was working in a specialized program with housed within a public school. And I met this little guy who came to us and they said, he's not talking, he has a device. But it was the cutest thing.
I would work really closely with the teacher and I worked on his goals and we would use his device. He didn't really like to use his device and he was trying to talk and he would say little things. And then when he started talking, we just worked really collaboratively. Me and the teacher on all these early learner things, he started talking and you could understand everything he said. And that's one of the things that's so amazing about working with younger students is that level of growth in such a short time which you don't always get that kind of success with older students. It was amazing. He started talking.
For that student, he was requesting, he was talking and one of the things we worked on him with is labeling. And so it was really important that we started work on labeling things that were preferred. So basically just working on things that the student loves and enjoys. If the student really loves the iPad, we're going to work on iPad. Oftentimes that's one of the first labeling targets I work on because a lot of kids love their iPad. Or maybe it's a movie, maybe they really love that, or maybe they really love going to grandma's house. And so we label grandma. So making sure that we're going to start work on labeling things thing that are preferred. Because labeling can be so very hard for our students with more complex needs. We want to make sure that it's not a program or it's not a skill that they don't like working on. And so I always make sure that I'm picking targets that the student really loves and enjoys.
And then I always tend to start working with some nouns, start working on labeling some nouns and then phasing in some preferred actions as well. And then another thing to really think about is making sure that we're showing the student multiple pictures of whatever it is that we're labeling. Let's say that we're labeling horse, and so we have maybe a real life picture of a horse. Maybe we have the object of a horse and maybe we have a picture book that has the horse. Or maybe we just have three pictures of horse. Whatever's going to work for your setup, for your student. And that really, when we show a student three different examples, we're helping plan for that generalization piece, which I've talked about before. And we have to make sure that we're thinking about that when we're planning our intervention. That's so very important for our scope and sequence.
Another thing that's super important is play, which obviously for our little ones, but even for older students, play is so very important. A skill that I really love to use and strategy that has so much research behind it is video modeling. And so I had a student, this is actually the coolest thing. So when I was down in Austin, I heard this lady talk about this language program she kind of had developed. And so loosely based on this talk I heard, I wrote a grant for our teachers and speech therapists and we got all this money, which was awesome. And so what it bought us were some toys and it bought us color copiers. And it was a really cool program, we had it a little, one of the kids, they were in kindergarten and so it was a gas station toy. And so you get the gas, the car pulls up, there's so much language that goes into that.
So what the speech therapist and I was kind of supporting as an administrator, I would go, she would take this toy to a regular kindergarten classroom with typical peers and she would take a very loose kind of language sample about how the kids were, what were they saying when they played with the toy. Then our speech therapist would create a story with real pictures about the toy and the words that the kids were using. And then she would read this story with her kids with autism, pretty severe autism. And then she would also show them a video model of typical peers playing with the toy. And then she would have all kids with more complex needs play with the toy as well.
And we took data on it, we presented about it in the district, but it was really amazing to see when we have that direct instruction with play. A lot of times our students may just have really limited play skills because, maybe number one, they don't really love and enjoy a whole lot of things. Or number two, maybe they would love and enjoy things, but they're just not sure how to interact with them. These video models really show them like, okay, the one we did for the car, it was like, Oh, here comes the car and the car goes vroom and now I'm going to put gas in the car. It was really cool to be able to show them that video, then have them play with it and then reinforce them for using those different types of words. Obviously play is so important.
And then, cooperative play with others. I do a lot of talk about modified leisure skills. And so something that I love, love, love for students at that age is to do modified. Simon says. It's just always, Simon says, so it's kind of like we're working on engagement, we're working on gross motor imitation, we're working on attending. Simon says touch your head, Simon says touch your knees, Simon says do a twist. And those types of things can be really, really fun for the students. So making sure to embed those opportunities. What's so cool about something like Simon says or another game I've done with my students is modified musical chairs, really iddy-biddy.
What's fun about that is you put the chairs out. Let's say we have three students, we put out three chairs and then the only rules are when the music's on you walk and when the music is done, you sit down and that's how you modify it. You don't ever take a chair away because I don't know who came up with that anyway. It's kind of torturous. And so that's how you modify it. You can use whatever songs the kids love and enjoy. You can use whatever is like the hot movie at the time. And then what's nice is if you do have a para pro or two to help you with that, that's cool because then they can help generalize that potentially to the classroom. So let's say here in Ohio, we might have indoor recess more than maybe where you guys live in Arizona. And so during that time the kids may play games in the classroom and so it gives them a time to kind of practice those skills outside of the speech session.
Then the only other thing that I try to think about, especially at this age range too, is we call them intraverbals in the behavioral world, but it would just be kind of like filling in the blank. Filling in the blank for common phrases, is often a kind of a prerequisite to being able to answer some more complex WH- questions. And so I might say ready, set and the student says go. Or one, two, and the student says three. And it's really working on social reciprocity. I say something, you say something and we're engaging together. So that kind of in a nutshell, if you were to kind of take a camera crew and kind of come and see how I do therapy, that would be what you would kind of see.

Marisha: That's amazing. I love all of the examples and ideas and just a really nice overview of all the things. That's awesome. Just a couple of followup questions. In terms of managing the materials, especially with more of the initial phases where we're really working on what the students are interested in, because I know I definitely had pretty poor management of that in the beginning. I would just try and have all of these things ready to go and I don't know. I'm curious what you agree with them. Do you leave your materials all around the therapy room so the student can move around? Or do you kind of put them in the cabinet and grab them as you need them? How do you maintain control of the session and manage those pieces while still kind of keeping the student engaged? Because sometimes they'll have such short attention spans where they quickly go off from one thing to the other. I'm just super curious.

Rose: Yeah, that's a great question. I always kind of talk about that too is that, these aren't the type of students that I'm kind of talking about today where you can just say, Oh, hold on one second, I have to grab that particular flashcard it's in my cabinet because we might just lose that student. And then we might spend the rest of the session trying to get behaviorally back on track to a level of engagement. So that's a great question. I definitely, when I was working in more of an ABA type program that was a year round program for students with most moderate to severe autism, every single student. And it kind of varied by the year, as the program progressed. That clinic has been around for about 12 years now. But we would just start out where the students would have their own organizers, their own kind of like tub of materials, if you will. And so in there would be like their specific picture cards that they're working on, their specific toys that they like to use for requesting.
And that kind of gets hard because sometimes you might have another student who really loves and enjoys that and that's okay too. I don't think you have to have everything together, but you are absolutely right in the fact that you need to be on your A+ game with organization when you're working with students who have trouble engaging because we know what it's like to have good working rapport with a student. And then if you have to grab something or somebody comes into your therapy room to talk to you or something, that you could just lose them. And then you feel like the session is kind of, then you're just kind of getting back to a level of engagement. So really what I would suggest just as a starter is if you could just have a bin for that student and maybe in that bin you would put the different cards they're working on, different maybe you just have like a data sheet in there too that's kind of like that all in one place.
Every place is going to kind of have their own way that they're taking data and things like that. And oftentimes I actually really take data in the classroom binders because the classroom staff is really working on communication goals when I'm not present or when I don't see the kids for therapy. But I think it's a really nice way to start. I would just say one little bin. And then you would put in exactly what you need for that student in their data sheets. So it's all right there and it's ready to go.

Marisha: I love that idea. And I think that even if we don't have the ability to create a tub or a bin for each student, there's going to be a lot of overlap in the types of materials and in between sessions we could switch things out or whatever. That makes a lot of sense. I love that. And then it's kind of nice too, because a tub is something that typically only we can open. So it still gives us that control. And if it's like kind of, I don't know we could see, what students respond best to, whether it's transparent or not. But if it is, that could be a good opportunity to work on some requesting in.

Rose: True. They might see something that they really like in that bin and they might say open or they might say the name of the toy, that's a good way to work on student motivation. We kind of talk about those communicative temptations and that would just be one that inherently, if the student cared enough, to look and see what's in there. And if you're picking out things they might love and enjoy, that would absolutely be another way to kind of incidentally work on communication, which is great.

Marisha: Awesome. And then another followup question. We don't have time to dive into a ton of detail, but any quick tips on data collection because this type of therapy looks very different than our articulation therapy or just anything. I don't know, in the beginning it can feel less structured I think. So do you have any tips on kind of wrapping our heads around that and coming up with a good strategy for data?

Rose: I think data is very important. I think that on abaspeech.org if you just put data sheets in, I think last school year I put together the data sheets that I used for my binder. And really what I like to do is just list each skill that we're working on for the student. And then I list the specific target. So if it's gross motor imitation and we're working on jumping, I list that if it's a one-step direction and it's get shoes, I list that whatever we're working on labeling, I have all that there. And then really what I've been doing is more sometimes we call it cold probe or first trial data.
I just take and I circle a plus or a minus for the first time that we work on that skill. And so that gives me a running record of how the student is doing. And I try to always make my data functional so it gives me good information, but I try to make it really, really easy for me because I'm a school based therapist, I see a lot of different kids. So I want to make sure that it's a system that's going to work for me, that's easy, that isn't taxing. And I'm always kind of refining. I definitely have some free data sheets on that @abaspeech.org as well.

Marisha: That is super helpful and I love just your quick practical tips on that one and that was brilliant. I think this'll be the last question that we dive into. But I think that, because you mentioned the team being so incredibly important and especially when it comes to parents when we're working with the early learners, this is all very new to them and I bet that it's pretty scary and overwhelming for a lot of them. What advice do you give to your parents and how can SLPs effectively communicate in this particular stage of things?

Rose: Yeah, I just try to let parents know that I'm there to support them. I think ongoing communication for all parents is very, very important. Parents want to know what's going on. Parents usually want to know what can they do at home to help supplement what's going on in therapy. I try to be very specific on progress reports and if I'm working in a place where I can talk to parents when they pick up their child, I try to always be really specific about what we worked on. And I try to just not overwhelm parents. I am a parent of three and so I know what it's like to be completely overwhelmed and to feel you're not doing enough ever for any child, especially a child who has significant needs. And I think it's just important for them to know, Hey, I really love working with your child. I'm here to support them.
Because a lot of the times parents who have kids with autism, they may not have those warm fuzzy feelings from being in IEP meetings. That's scary. I've definitely seen parents at the preschool level cry when their child is diagnosed with a disability. It's hard for everybody. And just knowing that you can be there to support them, you can be a sounding board and just trying to be really positive. And to relay really specific information so that they know exactly what's going on in therapy, I think is key.

Marisha: That's perfect. Because I feel like especially in the IEP meetings, there's so much information being shared and do you ever have any handouts or visuals or anything that you like to share? Do you have any go tos for that or do you find that just like the specific progress reports and little verbal communication here and there?

Rose: Yeah, I think that that ongoing communication is really what's so important. And definitely just with our IEPs, we meet together as a team. We send a draft home. I think sending a draft home with ample time so that parents can ask questions, get feedback. Oftentimes with your students with autism, they might already have a whole team of people working with the student in the home environment. If you're a school based therapist, they might want to show it to their home team and get input. And I think I try to really take all that in. And then I just try to always kind of think about the parent's perspective. And sometimes it's hard. We might have parents that might seem difficult to work with. But I think those parents really challenge us and I always just think they want what's best for their child. I think that's what's important to remember too, because sometimes we can get into these meetings that are contentious and that's just kind of the nature of special education, unfortunately.
But I just always want parents to know that I'm here to support your child's communication. This is my main focus and my professional career. And that I think when you kind of show that kind of positivity and optimism even if you kind of have those trials and tribulations with advocates and 20 people in IEP meeting we always just have to be really focused and this is their baby. We need to do what's best for the child because sometimes we have those meetings that they make everybody a little nervous. So just kind of remembering where this parents is coming from I think is really, really important.

Marisha: Yeah, that was definitely a huge takeaway for me after my first couple challenging meetings because ultimately, everyone just wants what they think is best for the child. If we can communicate with that as the focus, I feel it becomes much less contentious and we can just really focus on the child, which is the goal. And I think the tips that you gave and I love some of the phrases you use, like I'm here to support your child. And I think backing that up by sharing when you do see the parent, giving them updates and just being present in whichever way we can, even if it's just in the IEP meeting. Sharing specific examples or specific stories I think just really helps illustrate that point. I'm supporting your child, I am here for them, I'm showing up. And all of that I think is huge. And I loved your other phrases of I'm here to support, I'm a sounding board. Those are all really great. Yeah, really great tips. Okay, awesome. So any closing words of advice or just maybe your biggest takeaway. If you could take one thing from the top what do you think would help the most.

Rose: Yes. I would just say when you're working with students with autism, try to find out what they really love and enjoy. When you first meet them, just be in their space and find out what they love if they're not able to communicate on their own to make sure that you do work on direct instruction with requesting that that's a goal on the IEP and that the things that you're working on are very specific to what they love. Bubbles, puzzle, jump run, things like that. That's really what's going to help our students understand that their communication is powerful and it's going to help really strengthen their overall communication skills.

Marisha: Okay. That's perfect. If we can take away one thing, just really focusing on our students' interests and what they love and leveraging that for some awesome therapy sessions.

Rose: Sounds great.

Marisha: Love it. Well, thank you again for sharing your amazing experience and I just loved your stories and really specific tips and strategies. Thank you again. I super appreciate it.

Rose: Yeah, great to be here.

Marisha: And then you also shared a bunch of different links. For the listeners, if you want to go to slpnow.com/52, I'll share the links to all of the autism goal bank and the data sheets and all of that good stuff so you can easily access that as well.

Rose: Great. Perfect.

Marisha: Thank you.

Marisha: Hi there and welcome to the SLP Now Podcast. I am extremely honored and excited to have Kristin Bowers back on the podcast today. And if you're not familiar with her, she is an ASHA-Certified Speech Language Pathologist who graduated from the University of Pittsburgh in 2007, with her B.A. in Communication Science and Disorders and then in 2010, with her master's in Speech Language Pathology.
She has experience in early intervention as well as private practice and she currently works in the school setting servicing children from kindergarten through fifth grade. She's also the owner of Kiwi Speech, and she creates amazing and absolutely beautiful therapy materials for speech and language services. Most of which are available on Teachers Pay Teachers and I brought her on the podcast today because she is passionate about finding effective ways to have kids practice their sounds, and also supporting other skills like problem solving and growth mindset. And I've been getting a lot of questions about growth mindset, and I think this is something that I've been able to incorporate into my therapy. But I'm super excited to learn even more about it from Kristin today.

Kristin: Hi, how are you?

Marisha: Awesome. So, thank you so much for joining the podcast today. I am really excited to learn from you, and I'm curious, how did you first start learning about growth mindset?

Kristin: I'm a pretty avid reader, and I usually try to read in addition to one fiction book. I'm usually reading a nonfiction book, and I think one of the first times I really came across growth mindset was in the book Grit by Angela Duckworth and although she doesn't directly talk about growth mindset, she talks a lot about grit and how successful people one, may not be more intelligent than the other or more successful people rather and almost no matter how you're going to measure that success, it's not that they're necessarily more intelligent, it's that they have this thing called grit, which she, excuse me, what she sort of defines is this ability to stick through something, stick to something over a longer period of time or to stick with something when it gets hard and that's really closely related to growth mindset.
And then I think the term growth mindset is coming up just so much more in the educational world. Just as philosophies on education change over time, it's just something I started really seeing in the general education world and I really loved that book, Grit, and so just seeing how they fit together and how they could really apply to some of our students, as much as or almost more than just your average kid, right?
So some of our kids are coming to us for the sole purpose of something is hard for them, right? That's why they're in speech. So having an approach to that not just targets their sound or the vocabulary they're using, but also just the way they think about learning in their ability to improve was really important. So I think they just kind of really settled with me, and it was just something I gave a lot of thought to, and started really kind of developing ways to support my students not just in their speech and language skills, but also just the way they thought about learning and their ability to grow.

Marisha: Yeah, I couldn't agree more, and I feel like I had a similar experience around that as well. It just started with a different book for me. I read The Growth Mindset book, I believe it was Carol Dweck.

Kristin: Yeah, exactly.

Marisha: But it really resonated with me because a lot of the students on my caseload, they had obviously multiple disabilities, and they were being seen by resource room, or other special education services, and they were really struggling in the classroom. And I just noticed that some of my students just kept persevering. They kept working towards it, even though I knew it was so incredibly hard for them. Whereas other students, especially as they got older, more and more of them started to shut down, and so I really wanted a way to continue supporting them and making sure that they, just trying to prevent that shut down.
But Kristin, you and I have talked about this before, because you see a slightly different caseload.

Kristin: Yeah, it's funny. I think I know what you're getting at, and I was just going to add that. So yeah, I mean, I think in the nature of our role, we have a lot of kids who really struggle, maybe globally with lots of stuff. But I also have found this to be so applicable to the other end of the spectrum, which is some of the kids I see are actually in gifted programs. And I have a pretty large portion of my caseload that are really high achievers in many areas, and in some ways, I find that they are the ideal candidate for this growth mindset approach, and that's because they're good at everything they do, or they always have been, right?
They're perhaps really good at math, and they were early readers and they just in general have experience in school thus far being really successful with everything and then all of a sudden, they're not that great at speech, right? It maybe for some of the kids I see. I think speech may be the first thing that they've ever come across that has been difficult for them, and they don't know how to look around a classroom and see themselves as maybe the one person struggling. They're used to being successful and they're used to seeing themselves in that light, and I find that sometimes those kids are the ones that struggle the most to hear feedback and speech, right?
They don't like being told that they're not doing something right. Sometimes they're the ones that I say, oh, I heard you say, sue, can you fix that and say, shoe, and they'll say, that's what I said the first time. They kind of sometimes they argue with me a little bit, and I think they just are really having a hard time accepting or knowing what to do with this newfound knowledge that they have something that's a little tricky for them. So yeah, I mean, definitely the kids who have a lot going on, can benefit from this. But I think it's also too important to remember that some of these highly intelligent kids that are successful in other areas can really benefit from it just as much, if not more.
So yeah, I think, it's helpful for everyone, and I've also seen it be really helpful for some of my kids that struggle with a little anxiety. I don't know if you have kids, they're really afraid of making mistakes, and they often won't try, they won't push themselves because they're afraid of that and it's been really helpful for some of those kids who may also be seeing a school counselor for some anxiety issues or kind of perfectionism sort of tendencies, so yeah.

Marisha: Yeah, absolutely. And yeah, I think that's just a good like a nice little summary that it can benefit of a wide range of students, if not all students, because we're all going to be, or they all will face adversity throughout their academic careers, and then I think it's helpful for us too. Especially given recent circumstances, we all get to implement some growth mindset but we'll definitely talk about that a little bit more further into the interview. But I'm curious, can you just give us a breakdown of what growth mindset is?

Kristin: Yeah, of course. So, growth mindset is typically talked about sort of in this dichotomy between a fixed mindset versus a growth mindset, for example. So in a growth mindset, we know that we are capable of change and we're capable of growing. So this can be, I think, when it comes to speech, we talk about it a lot in relation to specific skills. But it can also be things that you might consider personality traits. So someone with a strong growth mindset knows that with work, they can become maybe a different type of person.
Someone with a growth mindset likes a challenge, right? They like to see what they are capable of doing, and they don't really get stuck in this. Well, I'm not a math person, right? That's not something you would hear from someone with a growth mindset or you would hear things like well, if I work at this, I can learn this new skill. So yeah, they have a really strong sense of effort, being a way to change something about yourself and they know that putting an effort and putting in work, that those things are possible.
In contrast, as someone with a fixed mindset, might be more likely to say, oh, I'm not a math person. I'll never be good at that. Just if you could do that for me, that would be great or getting a little bit more frustrated or bogged down in the mistakes. Those things are really negative to someone with a fixed mindset whereas someone with a growth mindset knows that, we only make mistakes when we're challenging ourselves, and we challenge ourselves as a way to learn new things. So mistakes are a good thing, right? It means we're at that level where we're learning, and I think that point of the growth mindset in particular is just so relevant to speech therapy, and what we're doing in our role in that.
So yeah, so a growth mindset is the belief that we can grow and we can change if we put in effort and work, to put really simply.

Marisha: That is perfect, and I love what you said about mistakes helping us grow because if we have a fixed mindset, and our belief is that, I am a math person, but if we for some reason fail some tests, then suddenly that belief is just shattered. But if we have that growth mindset of I'm capable of change, of growing. So like, yeah, I think I like math and just those challenges that come up don't break us quite as much as they would if that was our identity, and it's just evidence for against that.

Kristin: Absolutely. I think that's the trait I see a lot in some of my gifted students, right? Is they hold their identity so strongly in being the best or being the brightest. And yeah, when that one thing that comes along, that kind of breaks that, they really struggle, and they do, they can take it really personally. I don't want to generalize, obviously, but yeah, I see some students take it really personally when they're corrected, right? Or when they make a mistake, and yeah, having a growth mindset or starting to nurture our growth mindset in them is sort of a way to help that.

Marisha: Yeah, and I think we started talking about this a little bit already. But why do you think it's important, and why did you spend so much time learning about it and creating resources? Yeah.

Kristin: Yeah, I don't know, I think for me, it was just really applicable to my caseload. I think it's also really applicable as a parent, you think about the things that we say as parents and maybe the things we don't. And I have a daughter who has very, she has many strengths, obviously, but she really struggles with her speech, and I think my biggest concern for her is more when we thought about kindergarten, right? She's a June birthday. So she was kind of in that age where we thought, she's going to kindergarten, right? Or should we keep her back and we had this conversation, but my biggest concern was less the academics and more of the confidence, right?
I was really concerned that she would go to kindergarten and she would get kind of beaten down with the things that she couldn't do or maybe her lack of ability to communicate effectively, and I was really worried about her confidence and at the end of day, that's all a growth mindset issue, right? That's not an academic thing, that's not going to come from me drilling her with her sight words. That's all about just nurturing an approach to learning, and just yeah, I think as a parent, it became really relevant to me. And again, it was applicable to just so many of my students.
I thought, man, if they just had a more open approach to learning or they were more willing to make mistakes, I knew we could make more progress.

Marisha: Yeah, that makes a lot of sense. And then for me, it was interesting too, because I kind of talked about this already, but I was seeing a lot of students who were struggling globally. Every part of school was hard for them and their peers and sometimes even teachers were placing fixed mindset beliefs on them. Like you're not smart, you're not good enough, you're slow, you're I don't know, all of these different things, whether it was said explicitly or more implied. So that's what got me super interested in figuring it out because I saw what happens over time as the students get older, they just shut down more and more. And of course, that's not always the case but after I learned about this, I thought it could be a really cool way to give these students some extra skills to kind of combat that a little bit and to celebrate their mistakes and celebrate the effort because they likely put in more effort than anyone in the class-

Kristin: Absolutely.

Marisha: ... Even if they don't get the same results but, yeah, it was really cool to see how that could impact students.

Kristin: I agree and I think you mentioned something else too, is kind of it's not just about the single child you're working with, but also kind of the system around them, whether it's the teachers or the students, but even when it comes to, whoa, why do they go to speech? Sometimes you've got that question, and I think sometimes equipping the students with an answer to that, why do you come to speech? Well, some people might need a little bit of help with reading, some people might need a little bit of help with this, and you need a little bit of help with speech. It's not a bad thing.
We all have these things we may have to work a little bit harder at but that's not a problem. We've got this. Equipping them and just again, using it in your language with the other people you're around, the other students. They get to come to see me to work on something extra, how great is that, right? They have this opportunity to work extra hard at something and phrasing that as a positive, not a negative.

Marisha: Yes, I love that frame, or just how you framed that. That was perfect. So, now let's get to some of the good stuff. So how do you incorporate? Because I think before we, I don't know, this is kind of my approach, but before I incorporate something with my students, especially when it comes to this kind of thing, how do you feel like you're able to incorporate my growth mindset in navigating your own job as an adult or a professional? Do you feel growth mindset plays a role there?

Kristin: Oh, absolutely. I mean, I think the more you learn about it, and the more you read about it. So you're right. I mean, circling back to the books we we're talking about. I mean, I think my interest first got piqued by Grit but I've read the mindset book by Carol Dweck, and there's also one called The Growth Mindset Coach, it's by Annie Brock and Heather Handley. But I think the more you learn about it, and the more you sort of learn these phrases and you hear them whether it's words you say out loud, or you hear them in your mind, and you think, man, that's not a good way to look at this and just changing the way you approach.
I mean, we're all going through right now learning teletherapy at a faster rate than we ever thought we would need to, and just being like, okay, you know what? I can do this. For some people, maybe they didn't think they were technology people and are now being forced into this. So just having that open mind about I can learn this. It might take a little bit of work but the more effort, the more time I put into it, I am able to achieve the outcomes I want. For me personally, I have been working a lot on just developing more creativity in myself, and I think that that's something people consider a more fixed personality trait, right?
You're either creative or you're not, more so than maybe learning to read but I just have been trying to get myself the time especially now that we have a little bit more of it, of practicing creativity, and knowing that if I practice creativity, I can become a more creative person. So I know that doesn't directly relate to speech, but just thinking about things in those terms.
I also think the more you adopt a growth mindset, you can kind of use it, looking at yourself, but the way you think about your students and their growth is really important. There was a study by Rosenthal and Jacobson in the 1960s, and forgive me for not having the specific citation. But basically, they told teachers that a specific subset of students in their class was bright and was really likely to succeed, and then when they looked back at those students later, that specific subset of students had increased even their IQ points. And of course, those students originally had been completely randomly assigned.
So the whole point was that the teachers perceptions of the child's quote unquote, their ability, so to speak, impacted the way those students were nurtured by teachers and then impacted their outcomes. So making sure that we are maybe not applying these thoughts like, oh, this student is likely to succeed. Let me make sure that I challenge them and bring that out in them, and on the flip side, oh, the student probably doesn't have the capability to grow. So I'm not really going to challenge them too much.
So yeah, I mean, that's a really applicable, I think, example for us about why it's important to incorporate a growth mindset, not just in looking inwardly, but in how we approach our students and their goals.

Marisha: Yeah, that is so fascinating. I remember seeing that study, and that was just, that's incredible, and so even just the things that we say to our students, it can change their IQ. That's just mind boggling.

Kristin: Right. I mean, right, which is something... I totally agree. My whole family knows now. I hear when they say something to my daughter, she does something, and they're, oh, you're so smart and they know immediately because I don't want to say don't allow that but they know that that's not a phrase I want to hear because that's not really a growth mindset phrase. I'd rather than say, wow, I loved how hard you worked on that or I like that you sat there and worked on that for a long time. That must have been hard, rather than just you're so smart. But they know now. They know they're going to get some side eye from me for phrases like that.

Marisha: Oh, that's amazing. But it'll benefit them too. If you're modeling that.

Kristin: Yeah, exactly.

Marisha: It'll trickle down to your dad or and other people.

Kristin: I have faith that they too can improve their ability to use a growth mindset.

Marisha: I love it. Yeah, and I was thinking about this question a little bit too. I think it's, especially us, whenever we're navigating a lot of change, I think growth mindset really helps kind of decrease the stress because we're expected to make mistakes as we're figuring this out. We're not identifying as like, I'm amazing at tech. I'm going to rock this teletherapy. We just look at it as another hurdle that we're going to overcome. We put on our problem solving pants, and we expect some of those mistakes and look at those as evidence that we're growing, and I think that applies to this situation now as we're moving into a more digital therapy, as we, for new therapists who are just starting out, it feels like an insurmountable, we have so many seemingly insurmountable obstacles when we're first starting.
Like your first IEP, writing it, having that first meeting, the first therapy session, the first new type of client. I feel like we're constantly encountering things, and if we have that growth mindset, it just makes it that much easier to tackle.

Kristin: Absolutely, absolutely. Yeah, I feel like this is turning into just a list of book reviews.

Marisha: Let's do it.

Kristin: But I'm currently reading a book called Range by David Epstein, and it's about how having kind of skill. So the subtitle of the book is how generalists triumph in a specialized world, and I actually kind of I don't love the subtitle for what the book ends up being about, but it just talks about how having a really varied range of skills and interests can benefit you in the job market, but just in general it talks about someone, not sure she's the absolute CEO or the highest up in the girl scouts. But she basically got there because she was this person who had this very broad range of experience.
It wasn't a person that was on the direct track to that position but I guess it reinforces this idea that right? Trying new things, even if in the beginning, you may fail, or even if they're hard or even if when you start, you're not the best, that being free and feeling open to try new things is a huge aspect of growth mindset, a huge aspect of growth mindset. And as you know, that's a huge aspect of speech, I think but it's talking about it kind of outside of the education world and just having that broad set of skills and interests and things that you've tried really can help you in the long run in many ways.

Marisha: Yeah, and I'm absolutely loving all of the book recommendations too. I haven't read Range...

Kristin: I have a long list of nonfiction book recommendation.

Marisha: Oh, me too. Okay, awesome. So now let's get into the super good stuff about how we can incorporate this with our students and in our therapy sessions, and you have a little bit of a framework that you use in terms of how much you incorporate this, can you give us a little breakdown of what that looks like?

Kristin: Yeah, definitely. So we sort of talked about it, I would say almost the first two ways when we think about applying this to our students, right? A lot of us are like, wait a second, I only have 30 minutes with these kids. How am I going to take time out to work on growth mindset, and I don't think it needs to be quite that concrete.
So first of all, just having a growth mindset yourself, even if you apply this to a specific child, not at all, right? And you just adopt it in your own mindset. I mean, that can be really valuable right there, and it's like we talk about that research or that experiment they did. But when it comes to more a child facing stuff, you can really just change the language you use with students. So this doesn't mean teaching them, oh, let me tell you what a growth mindset is, and I want you to do this and do that. But just the way you deliver therapy, there are ways you can deliver it that are more of growth mindset friendly. So we talked a little bit about being afraid to make mistakes, right?
Maybe I'll circle back to that. So I'll go through these first. So the first one is, yeah, just in the language you were using with your students. So I would consider this pretty passive, right? You're not teaching the students about a growth mindset directly, but you were just using that language, and then the second would be maybe encouraging a little bit more of the language in students. So if you hear them say something like, oh, I can't say my R sound, you might say, oh, you know what? You can't say you're our sound yet. I have a growth mindset bulletin board that I have up in my speech room and it has a whole bunch of different phrases that are specific to speech. So it'll say something like, I know I'm learning my S sound because it feels hard right now, and it's sort of just flipping some of those phrases we often hear on their head and putting them in more of a growth mindset friendly kind of statement. And then the third would be, yeah, taking a few minutes to sit down and directly teach them.
This is what a growth mindset is, this is what a growth mindset sounds like. This is what a fixed mindset is, and this is what a fixed mindset sounds like, and trying to help them monitor themselves for those things and change the way they think about learning. So yeah, you can just use it in your own language, you can sort of more passively encourage your students to use it or then you can directly sit down and teach them what it is.
So I think finding a sweet spot for you and to me, it's very student dependent. I have a few groups that tend to get a little competitive. They're all working on the S sound, but two do lateral and two have frontal lisps but they just tend to go like, oh, I think I did it the best that time or in that group, I've done explicit growth mindset work and I've talked to the teachers about it. It's a struggle they see in their classrooms too with them, kind of maybe arguing with the teachers about what they did or didn't get right and just really not taking to feedback or correction all that well. So, they're ones that I've pulled out growth mindset, actual work for them to do while we're practicing speech, and then others I just try to use it in the way I speak with them.

Marisha: Oh, that's perfect, and then should we dive into some more specific examples for each of the types?

Kristin: Yeah. Here's the thing when we're giving speech, and I'm apologizing in advance for making this very articulation specific, but I always want to have students at this sort of sweet spot, right? And we talked about this a little bit when we talked about data collection, right? I don't necessarily want a child practicing in speech, something they can do 100% of the time, that's not going to help them move to the next level. But on the flip side of that, I don't want them practicing something they can't do at all, and I'm always going to try to scaffold that and give them support.
The by definition, we want those kids making mistakes, and if they're not what we're having them practice is probably too easy. So teaching them that mistakes are fine, and mistakes are okay is a good thing. I sort of joke with them sometimes when they say oh, but this sound is really hard for me, and I say, well, yeah, you know what? Can you say the B sound. Now, first of all, these would be kids that are maybe working on R, T and H, and I'll say, okay, I want you to say these words, ball, bat, whatever, and they're looking at me like okay, ball, bat, and then I give them a big round of applause, and make a great big deal out of it and I say, oh my gosh, you did so wonderful at that. I'm so proud of you and they're just kind of sitting there staring at me because of course, they could say those sounds. They're below where they're working on now, and I sort of say, well, that's the point, right?
You're not here to practice things you already know how to do, you're here to practice something that is hard. That's literally the point of you coming to see me. So no matter what happens, you're always going to come here, and I'm always going to make you do something that's hard for you and once you meet this goal, you know what I'm going to do? I'm going to make it harder again, and I think just laying that out to them so they can see that is always going to be hard and that's not a bad thing is really helpful.
I find very few kids come back after that and kind of complain that it's hard because it's literally the point of our job is to find that thing that's hard and to challenge them. So, yeah, first of all starting to frame things that mistakes are not bad. They're the point of coming to speech. We're going to make mistakes, and that's how we know what we have to fix, and then the other major, major thing, I think, is in how we deliver feedback. So in the same way I don't love when my family tells my daughter, you're so smart, right? I'd much rather them say, wow, you worked for a long time on that, or that must have been really hard for you, and that's the positive statement, right? It must have been hard should be the positive statement not that looked really easy, which I think is what we often sort of try to say as praise, right?
Oh, that was so easy for you. You did that so quickly. Good job. But all we're really telling them is that by continuing to show us something they're already good at, that's a good thing and I don't think that that in a growth mindset, that's not necessarily true, right? The good thing you should be finding something you're not good at and working on that. So giving feedback that is more about their action or their process. So instead of saying, wow, that was a perfect R sound, you might say, wow, I really saw how you bunched that tongue up. That was a great work or the other thing, this is I've seen this a few times in the general education is talking about a good mistake, a great mistake.
Jillian Starr talks about how she takes a group of student maybe math problems that they did and she pulls out one that's wrong, and she praises that as a great mistake and they talk about okay, so yeah, the final answer wasn't right but let's talk about all the things the students showed us they knew. So maybe they added, one plus one is three, just as a really simple example, and they'll say, oh, well, they knew to add, not subtract. So that was some knowledge that that student was showing. So she talks about her favorite mistake or her great mistake, and I do something similar in speech.
When you have a child who's gliding R for example, right? And they're saying wabbit for rabbit I often find that somewhere in the middle of shaping that to the R, it ends up being this really distorted L sound, right? If you're doing maybe retroflex. So they don't say wabbit and they don't say rabbit. It sounds something more labbit, and often they hear that L, and they go, oh, sorry. That was an L sound, and I say, oh my gosh, no, that was such an awesome mistake. It showed me that you were moving your tongue. It showed me that you got your tongue up. That was awesome. So to me, I mean, that is a good mistake, right? It wasn't a W, it's a step in the right direction, and the fact that they made an L shows me that they're learning so much.
So praising that mistake is another really growth mindset way to approach their learning and the scaffolding we do to get them from point A to point B.

Marisha: Yeah, I love those specific examples, and yeah, so just to recap. We want to set up our session so that we are giving students that, they're not perfect all the time, they're not always at 100% but that we're also not making it so hard that they can't even tackle it. Teaching them that mistakes are hard. No, that mistakes are okay and even celebrating them. This was a couple podcast episodes ago, but I actually interviewed a special education teacher on mindfulness and growth mindset kind of came up there and she says that she uses glitter washi tape to celebrate her students if they're doing writing or whatever, they'll put the glitter washi tape over a mistake and I thought that was a really cool visual.

Kristin: Oh I love that. It's such a sweet idea.

Marisha: And it's a little harder to do that with articulation but maybe we could just have it on a piece of paper or something. And yeah, and then I love your suggestions on thinking about how we deliver feedback and really focusing on the actions instead of the traits or qualities, like you're smart and things like that or you're good at this and all of that and focusing on them working hard. Awesome.

Kristin: And then the last thing I'm able to add is, is just yeah, making sure that you've set your sessions up as a really safe space to make mistakes, obviously, but also to look silly. You know how often we look ridiculous. I mean, we know as SLPs we look ridiculous sometimes when we're showing them how to make these sounds, right? Or I have a particular student right now who's working so hard on that R sound and it's hard to watch him, right? Because he's contorting his face so, so much to get this R and just making sure that comments, I mean, obvious things like laughing at people is never okay, but making sure that that is absolutely never okay, and being afraid to kind of laugh at yourself and look silly and make mistakes and if that includes you kind of doing these things too then so be it.
But it absolutely has to be a safe space for them to make mistakes and be wrong and to fail. I mean, that's the only way it can work. And again, by the nature of what we do, kids are going to fail from time to time in our room. I mean, they wouldn't be there if they were doing everything perfectly. So yeah, it's essential to make sure that your sessions are a safe space with you and with all the other students.

Marisha: Perfect, and then what about, what does it look like when you're doing that direct teaching? Do you have a hierarchy of activities that you go through? Or how do you set that up for students?

Kristin: Yeah, so I actually, I have sort of over time I've sort of developed a bit of a curriculum for it which is in my Teachers Pay Teachers store, and it's just a culmination of all the different aspects of the growth mindset that I learned about through all that reading that I felt were really applicable to speech. So each sort of lesson has something I would teach the students and again, depending on how much time you want to spend with the kids, you can pick and choose how you're doing it. So typically I say, hey, I want to talk about whatever the lesson so to speak is today. And in the beginning that might be, I want to talk about what a growth mindset is, but then later we might talk about things like neuroplasticity, and of course, I don't necessarily call it neuroplasticity, but I talk to them about how our brains can grow, and the more we practice something, the more connections our brain makes, and the quicker we can do it. And we use lots of examples of things that they've learned and got better at in other aspects like maybe music lessons.
So typically there's, I talked to them about it in this particular curriculum, there's almost like note taking pages that are scaled for their ages. So there's like a smaller one that's pretty much like a coloring page that has the main keywords that we talked about, and then there's a slightly older one. And then I have an activity that we do in speech. And again, I don't do this with all of my groups, they don't all need this really specific direct instruction but some do, and then there's also a homework activity to send home. Because of course, if they're not getting a growth mindset message at home then it's the same with our speech practice, it can be a little lost so that the homework is interesting, I sort of tried to design it that yes, the child is practicing it, but I also wanted to make it very educational for the parents.
So there's kind of an intro sentence on each one that might kind of summarize what we talked about. Hint, hint, use this language at home is kind of the point. So just as an example, and in the first one, in speech, I have them think about at school, at home, activities and forth in speech, they're going to write down something that feels easy for them in each of those settings and something that feels hard for them in each of those settings. And the point of this is just understand that no matter what, we all have things in any setting that feel easy and things that feel hard, and they're so different by child and then the homework activity is I have a list of R, sorry, a list of speech specific things like using the right words and sentences or speaking all day without my voice getting tired.
Saying the S sound. Understanding what I read and hear. Those kinds of things, and it's like a sorting table, like a T-Chart, feels easy for me or feels hard for me, and the idea is for them to just be honest with themselves and sort those into a chart and see, which of these things are easy and which are hard. I've tried to make a really good mix of articulation, voice, fluency and language to see that they all have kind of strengths and weaknesses, and then of course you're framing this entire thing and it's okay that things feel hard. That's cool. That's interesting, right? Not that's bad.
So that's just kind of an example of how I would do a really introductory lesson in a speech but we also talk about making mistakes, we talk about supporting others, we talk about perseverance and then there's a power of yet which is discussed pretty commonly, which is kind of adding the word, yet, onto a negative statement to change it. So I can't say my R sound yet or I'm not good at math yet which of course just reframes it that with work and effort you can be good at math and you can be good at your R sound, you just haven't got there yet.

Marisha: Oh, you've really thought of everything with the students.

Kristin: It was a long, long process.

Marisha: Yeah, but I love that you have, because I think and this could still be a language activity if the students are working on comprehension or whatever it may be, there could be ways to incorporate their goals into this type of activity potentially.

Kristin: Oh, absolutely, absolutely. In articulation, I mean, you can incorporate articulation into anything. I mean, it's got S blends and that kind of thing. So yeah, I mean, it definitely does not need to be something that is separate from therapy, they can definitely be done at the same time. And I tried to take real care when I created the curriculum to make sure that it was friendly for that.
If you spent your entire 30 minute session doing this, you wouldn't be losing a session if you were smart about it and you used all your good SLP skills which is, right? Making a session out of anything, or you could just spend a few minutes on it, you know?

Marisha: Yeah, and I love all of the different facials that helps break it down for students and just the different interactive activities and then also, the parent piece is huge and I feel like some teachers could use that too.

Kristin: Totally agree. It has, I had written a parent letter in there, and I've thought, oh, I probably need to go back and add a teacher letter as well, yeah.

Marisha: Yeah, and have you ever done because I feel like this is something that could be a nice activity to coordinate with the counselor, potentially, but maybe that would be I got along really well with the counselor at my last school. So we did a bunch of stuff together just because we wanted to, I guess and we had a lot of shared kids. But that could be an option too, if you're not feeling like it's something that is easily incorporated into your session just given the nature of your group. That could be a cool opportunity too.

Kristin: I totally agree. In the setting I'm at, my schools don't all have full time counselors. So I don't have, we're often there on opposing days or whatever. So we don't have that continuity of care so to speak in my settings, but I thousand percent agree that would be a great person to get on your team for implementing this and working with the teachers.

Marisha: Yeah, and have you had conversations with teachers about this too, or do you feel like it's just something that you inaudible?

Kristin: Oh, no, I definitely have and I don't know if it's just the schools I work in, but honestly, I feel like in a lot of situations, I don't know, maybe it's just the schools. I feel a lot of my schools have had, so growth mindset originally came from the book called Mindset by Carol Dweck, which I know you know because you had read it. In a lot of my schools that has been school wide required reading for the teachers. So I think for sure growth mindset is already being implemented in a lot of the schools I work in, which is three currently. And my schools tend to be pretty up-to-date with new philosophies and approaches, and that kind of stuff.
So in a lot of ways, I feel like speeches are behind on this because it's all the stuff you read out there is kind of how it relates to teaching and education but then there's this gap, okay, so I get how it relates to education but how do I incorporate this into speech, right? Because we have such a different service delivery model. We can't obviously be doing lessons in explicitly growth mindset for 30 minutes once a week when that's our only time for speech. So yeah, I actually felt like in my world, at least speech was behind the rest of the curriculum or the schools. It was nice to have a way to catch up and support them.

Marisha: Yeah, and I know there are some schools that incorporate this heavily. So being familiar, it might be that your general education teachers are teaching this to students, and just being aware of it is using all of the different strategies you shared, is a great way to support what they're doing there.

Kristin: Absolutely, absolutely. If you want, I think, if I could recommend one book, I mean, it's hard to not recommend the mindset book by Carol Dweck, because of that's the original one. But The Growth Mindset Coach by Annie Brock and Heather Handley, that one is geared specifically to teachers. And while it's obvious, it's geared to teachers and not SLPs, it is just very applicable to education and I found that one to be the most maybe meaningful to me as far as implementation was concerned.

Marisha: Okay, awesome, and then I'll link to all of the books that we've been talking about, all of your materials and everything in the show notes at slpnow.com/50. But I'm curious before we start wrapping up, do you have any other examples or things that you wanted to share for the different levels of your framework in terms of changing the language we use, flipping student's language and then direct teaching? Are there any other favorite or must have activities or strategy?

Kristin: I don't think so. Yeah, I mean, and it is that's how I think about it from a standpoint of I had a lot of people ask, well, I get what growth mindset is, but I don't at how to incorporate it into speech. I don't have time for it. So I think that that was how I mentally broke it up. There's so many different levels, you can spend your time directly teaching it or you can just use it passively. You can be using a growth mindset with them without them even knowing it, and then again, it's important to not ignore the fact that even if you're not using a growth mindset with them, if you're not thinking in a growth mindset about them, then that can have really big impacts on them as well.
Yeah, I don't know. I think that's probably, yeah, the simplest way I can think of to break it down about the different levels, the different intensity levels, so to speak, that you can implement it.

Marisha: Yeah, that's perfect, and I think that makes it a lot more doable because I read that book, and then they have one about Mindset in the Classroom too, and there's the whole mind up curriculum, and they have these beautiful things. And it's like, I wish I had all the time to implement this. But you're so bright there are, starting with us and that research study is just, yeah, that's amazing how big of an impact. Just how we think about our students can be. So that's a huge step in the right direction and then just kind of modeling that and incorporating that language into our sessions and giving students a little bit of feedback. That doesn't take much time. So, that those are worth totally doable.

Kristin: No, but you're already giving it but if you're just changing, like I said, I mean with my daughter, it doesn't take me any more time to say, wow, that looked really hard, good job than it does, wow, that looks really easy, good job. Just switching what it is your praising. There was another, I tried to look it up, I believe it was discussed in the Grit book, and I tried to look it up before I came on here and I wasn't going to mention it because I can't cite it. But in this study, they looked at kindergarten students, and I believe it was in California where there was a large Asian American population, and they gave kindergarten students some sort of assessment, and then they randomized which ones they told did a good job on it, and which ones, so they split the classic 50/50.
But what they found is that many more of the Asian American students were likely to say that they succeeded because they worked hard or they were told they didn't do all they were likely to say, well, the people who did well must have worked harder than me. Whereas the non Asian American students were more likely, and this is in kindergarten, they were more likely to say, oh, well, that person did well because they're smarter or I did well, because I was smarter. And so there's obviously, there's a big cultural component to it, too.
I mean, that kind of goes back to the family piece. I mean, what we're saying in school, and it's just the way we support students, and it doesn't have to do with intelligence necessarily. It's just the way we support students and the language we use to support them. Anyway, so I need to find the citation for that, obviously, but I just thought that that was worth mentioning too.

Marisha: Yeah, no, and it's just amazing to see how big of an impact, just like what we say to ourselves can have. Yeah, it's so cool. Okay, so let's do a recap of some of the different resources that have come up throughout the podcast. So you mentioned your curriculum, which includes all of the visuals and different materials, like the parent letters and things that we can use if we're wanting to implement the center therapy session, but I also feel like it would be, if you don't have the time to read a whole book, that would be a good kind of crash course-

Kristin: Oh, absolutely.

Marisha: ... In different strategies that you can use. So if you're like, I'm not going to use the worksheets, but I want to learn more from Kristin, I feel like that could be a good option. And then we also mentioned your posters, which that would take a little bit of time to set up, but we decorate our rooms anyway. So might as well get some growth mindset in there, and then...

Kristin: Exactly, and there is actually I have a freebie. I can shoot you the link to it, but I have a freebie too, which is just one, one page poster, and it's just 10 growth mindset statements as well. So, I wouldn't say it's a bulletin board in itself, but it is just kind of a freebie poster that you could hang up to remind yourself and your students. Again, they're speech specific growth mindset phrases.

Marisha: Ooh, that's perfect. Yeah, we will definitely add that into the show notes as well, and then the books that we mentioned were Grit by Angela Duckworth, and then Mindset by Carol Dweck, Mindsets in the Classroom by Mary Cay Ricci, The Growth Mindset Coach by Annie Brock and Heather Handley, and then Range by David Epstein. And do you have any other resources or tools, anything else that helped you or do you feel like inaudible?

Kristin: No, I think when I know about it now has come from such a conglomeration of sources and nonfiction books and that kind of thing. But I think if you read most, or some of all those you'd be pretty set.

Marisha: Yeah, and is there, because I think you mentioned this but if you had one recommendation, if they could only read one book, which one would you choose?

Kristin: It might be The Growth Mindset Coach.

Marisha: Okay.

Kristin: Yeah.

Marisha: Cool.

Kristin: I think I read that before I read Mindset. I mean, I knew I had to read Mindset. I think I was waiting for it from the library to be honest, and I knew I had to read it, especially because I was developing this curriculum, and I obviously didn't feel comfortable doing that unless I had really done my research in my background work, and as we mentioned, that was pretty much the original book on the topic.
It's from, I don't know, the 80s maybe it's not new. But if you were just looking for really practical tips about implementation, and you just wanted to take away from Growth Mindset, what's applicable to you, as an educator, I think The Growth Mindset Coach would be a great place to start. Plus, you can honestly skip through a little bit of it because a lot of it has specific lesson plans for teachers which is geared toward the general curriculum. So I did gloss over some of that because I just knew it wasn't relevant to how I was going to implement it.

Marisha: Okay, perfect, and did we miss anything or do you feel like we covered all the good stuff?

Kristin: I don't think so. Yeah, I think we covered the good stuff. If we did, I have like all my Instagram. I noticed going into this, I was just reviewing a few things. I had a few things that weren't loaded, but I have a highlight on Instagram, they've got those, the circles where you can see things grouped by topics. They're usually old Instagram stories, but I have a highlight specifically on growth mindset there in my story. So if you are on social media, and that is somewhere where you hang out that might be another light resource for you, just little tidbits as I think of them.

Marisha: Oh, that's perfect, and then where can speech therapists find out more about what you do other than that amazing story highlight?

Kristin: Yeah, so social media wise, I'm on Instagram more than anything else. So that's just @kiwispeech, and then my website where my blog and stuff lives is kiwispeech.com.

Marisha: Okay, perfect. Kristin, thank you so much for sharing your time with us today. This was incredibly helpful, and I hope that SLPs walk away with tons of tips to implement this in their therapy sessions, and the cool thing is, it doesn't have to take a ton of time.

Kristin: Not at all.

Marisha: It's just like maybe just download that poster and have a challenge to use some of those words, or some of those phrases in your session. It could really be just as simple as that.

Kristin: Absolutely, and you're right. I mean, sometimes it is. Just the change of a single word. So I agree.

Marisha: Awesome. Well, thank you again.

Kristin: Thank you for having me.

Marisha: And yeah, we'll see you next time.

Kristin: Bye.

Marisha: Hi there. Welcome to the SLP Now Podcast. I am so excited to have a returning podcast guest today. Lauren LaCour Haines is going to be talking about all things prompt and cueing, all the scaffolding. I get quite a few questions about this topic. I saw that Lauren presented at her school and her district on this topic. I reached out to her and she said yes. We're going to be diving into all the things scaffolding.

Marisha: Before we do that, I just want to re-introduce Lauren. She is a graduate of Louisiana State University and has been as school-based speech language pathologist in the Baton Rouge area for over 12 years. She serves as an SLP and lead special education teacher at a local primary school. She is also the author of the website, busybeespeech.com. She sells speech therapy-related resources on Teachers Pay Teachers.

Marisha: Today, like I said, we're going to be focusing on prompts and cues. I'm just super excited to dive into this with you.

Lauren: Yeah. I'm so excited too. Thanks for having me.

Marisha: Yeah. The last episode was episode 14 if any of you are listening and are curious. We talked about fluency. That one was definitely a crowd favorite. Extra, extra excited about this one. Before we dive into prompts and cues, I was really curious about ... because I found out about this when you were sharing about your presentation. Correct me if I'm wrong, but I think this was related to, you were giving this presentation because of your role at your school, right?

Lauren: Yes. I am a lead teacher at my school, so I am over all of the special education teachers and the paraprofessionals. Then, twice a year, we have staff development day. On this particular staff development day, I was in-charge of presenting to the paraprofessionals just at my school level. We talked about prompting and we talked about behavior. It was fun.

Marisha: Yeah, that's awesome. I just love hearing what other SLPs do and the different roles that they end up taking on. Thank you for sharing a little bit about that. I know that it sounds like that role includes a lot more than presenting twice a year though, right?

Lauren: For sure. Okay. As lead teacher, I'm responsible for checking all of my special education teacher's paperwork. I have to make sure their IEPs are good to go before we hold the meetings. If they have any kind of procedural questions, I'm the one they go to. I help them write behavior plans for kids. I step in and model different techniques and different ways to handle those challenging behaviors. I'm extremely busy with that all day long. It's almost like two full time jobs in one.

Lauren: The good thing is I do have only half of a regular SLP caseload. I only have about 20 speech kids that I work with. Then, the rest of my time is helping the teachers and the paras and basically putting out a lot of fires.

Marisha: Wow. That's super interesting. I didn't realize that it was, because at first I was wondering like, how does she do all of that? I still wonder because you have a lot of different things on your plate. That's helpful that at least your time is split a little bit so it's not completely impossible.

Lauren: Right. It's a lot easier to write 20 progress reports than 50 so it does help.

Marisha: Yeah, for sure. That is amazing. Because you said that part of the role includes doing some presentations and teaching and really working on that collaboration. This definitely won't be the focus of our chat today, but I know that a lot of SLPs reach out to me about that too in terms of stepping outside of their comfort zones and giving a presentation to a group of teachers or paraeducators or anything like that. I'm curious if you have any quick tips or things that worked for you the first couple times you did that.

Marisha: I mean, it sounds like you've been at this for over 12 years now, so you're definitely further down the road. Any tips for those starting out?

Lauren: Sure. As a lead teacher, I've only been for three years. This is my third year, so I haven't done that role as long. As an SLP, at first, I mean by nature I'm more introverted, more quiet, which is different for SLP. I think a lot of SLPs are very bubbly and try to talk a lot but not me. It took a while for me to gain that confidence, I guess, in myself and in my skills.

Lauren: I had to get to a point to where I was ready to be able to present to a lot of people. You'd have to push yourself. That's one thing I would say. I didn't just want to do it all the time or anything like that, but whenever I stepped into this lead teacher role, I just had to become this other version of myself because I had to do all the things that I wasn't used to doing.

Lauren: For this position, I was basically voluntold, I guess, to be put into this position because our other lead teacher had moved on to a different role and they have asked me to do it. I also have a hard time saying no. I said yes. When I did that, I had to just I guess, put on my big girl pants and just be brave and tried new things. I think it really benefited me in the long run because it made me a lot more confident because other people were depending on me.

Lauren: I guess to a new person I would just say, just find that confidence in yourself and in your abilities and don't be afraid to ask questions and do your research because you do know more than you think you know.

Marisha: Yeah. That was one of my takeaways too when I was navigating talking to teachers in the beginning. Because I really wanted to do, like I always talk about curriculum based therapy and stuff like that. You really need the teacher buy in to optimize what you're doing with that. I was so scared the first time that I talked to the group.

Marisha: Yeah, you put on those big girl pants and make it happen. What came out of it was amazing in terms of the actual results of having that conversation with all of the teachers. It was also really good for me to continue growing as a professional because I definitely ... you prepare for what you're going to share, which solidifies your knowledge. Then just, yeah, putting yourself out there and showing up as the expert and knowledgeable person that you are is pretty amazing. Highly recommended to all the listeners.

Lauren: Yeah. If you step into that role in small ways first, it builds your credibility too. You can offer a lot of suggestions, just one on one with teachers and then maybe join your leadership team, which is what I did before I became lead teacher, they asked me to be on leadership team. So I did. I could give suggestions there which benefited multiple grade levels. Gradually, I built that credibility.

Lauren: People learned to respect my ideas and my opinions because the things that I would share would definitely benefit the kids because we have that expertise in that language.

Marisha: Yeah. Because we're going to be talking about scaffolding so we can scaffold ourselves and maybe first talk about, like teach something or share a strategy with one teacher. Then, as needed, like share it with the whole group and all that. I like it, step by step. Individual small groups, all the good stuff. All right. Perfect.

Marisha: Thank you for taking that little digression there. Let's get into the topic for today, which is prompting and cueing. Can we start out just by defining both of those?

Lauren: Yes. Prompts and cues are strategies that can help the student, but it still increases their learning. A lot of educators, a lot of teachers in SLPs, they'll do this naturally. We automatically will just ask questions and try to help students come up with the answer or learn a task in basically any way we know how.

Lauren: It does help to define what we're doing and to be more purposeful with our interaction. If we know those terms and the differences, I think it helps us as well as the kids in the long run. There's prompting and then there's cueing. They can be different from each other. Though, sometimes, it might depend on who you ask because those terms can be a little bit interchangeable.

Lauren: From my research, prompting is said to be the little more invasive of the two. Prompts are the ones that lead the student to the correct answer more directly. Then, if you're talking about cueing, that's more like a hint or a clue and that typically doesn't give them the answer directly. It's more indirect. Cueing is the one that's more indirect and prompting is the one that's more direct.

Lauren: If it's okay with you today, I might just use the term prompting as the broader term to refer to just any type of assistance because I don't want to keep saying prompt slash cue.

Marisha: That is okay.

Lauren: I know it might bother a lot of people, no, that's a cue, no, that's a prompt. It's just assistance right now. If we're purposeful in the way that we help students and we prompt when necessary and then we prompt as soon as we can. I mean it can really help. That's why I did want to teach the paras at my school about those different ways to prompt as well as the importance of backing off on the prompts.

Lauren: Because we want our students to be as independent as possible and we don't want to overly assist them. That's why you'd rather give them more indirect cues so they can come up with the answer on their own. In general, prompts themselves are not a bad thing. If you do them right, it will not only help them learn but it will aid them in that learning and it won't give them any kind of a crutch.

Marisha: Yeah. I love that distinction. They're definitely helpful. We want to be careful to not over prompt or over cue because that can also hurt in the long run.

Lauren: Yes.

Marisha: Yeah, super helpful. Then, anything else that you want to talk about in terms of why we want to prompt and cue? Or, are we good to start diving into the different types?

Lauren: Yeah, we can talk about why they're beneficial. Sometimes, it's really the only way that a student can learn a skill. You can't expect a student just to know what to do without some kind of assistance. Honestly, we use prompts ourselves whether we realize it or not. When we're in Target, we look up at the aisle signs to help point us to what we're looking for. Then, if we still can't find the item, we ask someone who works there. Then, we even need them to put the item out to us.

Lauren: Then after that, the next time we go into Target, we probably won't need any prompts to find the item because we already know exactly where it is. We'll just go straight there and find it independently. It helps our kids also when they're learning a new skill. If you do want the student to become fully independent, you have to be able to decrease those prompts. You don't want them to become prompt dependent.

Lauren: I wanted to say that on the front side so that you know that's our goal is for them to be independent. Because if they become dependent on those prompts, that could hinder their progress. Fading those prompts is almost as important as giving the prompts. Things that you can do to prevent prompt dependency might be things like rewarding or reinforcing with the prompts first. Then, as they progress, you only reward when they respond correctly without those prompts.

Lauren: This could help the student learn the skills more quickly as well as prevent them from depending on the prompts. That fading is really important. Then what's really essential though is just to make sure that the whole team is on the same page about the prompt fading schedule and the reinforcement schedule.

Lauren: That's one of the main reasons that I wanted to talk to my SPED staff about it because I wanted everyone to know the prompting hierarchy and the importance of trying to say the prompts quickly. Because I have some paras that love to help the students and they mean well but sometimes it can be a little too much. I want them to know how to back off the assistance appropriately. Then, how to reinforce them correctly, the correct way.

Lauren: The only other hand I have like some of my new paras, they still aren't really sure what to do in how to help. They need some general guidance on the different ways that are available to support the students in the classroom they might not know about. Whenever I met with them, we talked about those things a lot. Then, we also discussed IEP accommodations and different types of support we could give during tests and in the classroom and then learning new skills and all that because it's a lot to remember.

Lauren: Especially even to the most veteran teachers and paras, refreshers are important. We had a really good meeting and I'm really happy that we got a chance to talk about all of it.

Marisha: Yeah, that's super helpful. Then, I'm curious too, because I think for SLPs who ... because this is kind of like a dual presentation, I think it's a good overview for us just to take an inventory of the strategies that we're using in therapy. I think, a lot of us, or pretty much all of us do a lot of this automatically. I think it's really helpful to have the terminology when it comes to writing about what we do. I think, what you're sharing today will be incredibly helpful just to have more of a stronger set of vocabulary around describing all the different things that we do.

Marisha: Because there are some pretty nifty terms that you're going to be sharing. Then, I think it's also helpful because you presented this to your parent educators, so I think it'll be helpful because I'm sure you'll present it in a very similar way. SLPs can use this when they are presenting to their teachers or paraeducators to just to help with that conversation as well. I'm really excited about the dual purpose of this.

Lauren: Yeah. It's important for you to have that good framework in your mind so when you share it with others, you're clear. Your whole team can be on the same page and the kids are ultimately the ones that benefit from it the most.

Marisha: Yeah. I love that. I'm really curious too, because we know that you gave a presentation to the paraeducators, but what is the best way or do you have any tips when it comes to communicating the appropriate level of prompting? Once we have that shared vocabulary, what would you do? How would you communicate that? The level of support that Johnny needs with certain tasks, for example?

Lauren: A lot of things will depend on the student and with the skill that we're working on or whatever. I gave them a hierarchy of the different levels of prompting that we use. Then, we talk about like, okay, what have you tried so far? To try to see what level that they're at. Then, we'll go more in depth, in detail of this a little bit later. Since we've already talked about it, I can reference that visual, that hierarchy that I gave them and say, okay, let's talk about the prompts that you're already giving them. How are you helping?

Lauren: I guess that's one thing that I would do. I would use the terminology that we already went over. If they needed more help with that, like if they weren't sure, I would model for them or explain to them or scaffold for them how I would do it.

Marisha: Yeah. I think if we have the opportunity to go into the classroom that could be a good follow up step. Maybe I might model something and tell them, okay, so this is the level that I'm going for. See what you can identify in me. Then, maybe observing them in an activity and be like, where did you think you were at? It's hard to talk about if we're just hypothetical. I think getting super specific could be helpful too.

Lauren: Yes. Okay. Maybe I didn't understand your question. During my presentation, I had YouTube videos.

Marisha: I love it.

Lauren: Yeah. I showed them the different examples of the prompts. I had videos. There's tons on YouTube by the way. If you all ever do any kind of presentation, there's examples of all the different types of prompts. I showed them an example of each one and then after we went over all of them, I had them practice with each other and divide into groups and did groups of two. Then, they had to come up with a scenario and do their type of prompt that they were supposed to be practicing and then they show the group.

Marisha: So smart. I love those ideas. Yeah. There's definitely like, we can use scaffolding here. We can give them the definition first, like explain what we're doing. Then, we can show a video of it. We can have them practice it with a partner and then we could reinforce it in the classroom then.

Marisha: We're being very strategic with our own prompting and cueing with our colleagues. I love that. Because I think we can apply this to any type of skill that we're trying to share with teachers or paraeducators. I'm really happy with this discussion so far. Okay. Are we ready to start talking about the hierarchy and the different types of prompts and cues?

Lauren: Yes. Okay. The prompting hierarchy I use was from The Autism Helper. I think her name is Sasha and she's at autismhelper.com. She has a really nice visual of the hierarchy that they use. There are a lot of hierarchies out there, especially related to ADA and programs like that. I just thought that this lent itself best to a variety of disorders, not just autism that really, because I had paras teachers from that worked with all levels of students.

Lauren: She has that great visual for the most intrusive prompts, which are like the ones that the student would be the most dependent, all the way to the least intrusive, which would be for the student to be the most independent. Obviously, our goal is for the students to be completely independent, but depending on the student and the skills that we might need to teach, we may have to give a lot of support, especially at first. I wanted them to know the different levels and just depending on the kid where they might need to start.

Lauren: I'm going to go over the different types of prompts and I'm going to start with the least invasive or the most independent level, if that makes sense. That most independent level would be the visual prompt. That is a prompt that is a support in the form of pictures or text, photos or even videos. This one is a great way to give support in a way that's natural and it's really easy to say.

Lauren: Examples can be anything from like a sign on the door to a visual schedule. I've also made visuals for the steps of going to the bathroom or completing morning routines for my students. Then, that's for the classroom. Then in speech, of course I use this one like nobody's interest, like visuals are for everything. I have sentence strips for expanding utterances and using correct grammar. I have pictures for WH questions. I made a product on TPC that's like an influencing product that's leveled. It's scaffolded and leveled based on the visual supports.

Lauren: Pretty much, I use visuals for a lot of language skills. It's my go-to way that I level that support. Then, it's super easy to fade because you can just take away that visual. That is visual prompting.

Lauren: Then, the next level would be verbal prompts. That is spoken instructions or questions that provide the student with direction on completing the task. This one can look a lot of different ways and it's probably the most commonly used. I feel like there's a mini hierarchy within verbal prompting because there's a direct verbal prompt, which is when you plainly give them the answer.

Lauren: Then, there's more indirect, which is just giving them more like a subtle hint, not the exact answer. If you want me to, I can dive a little bit deeper into the verbal cues and talk a little bit about that hierarchy with in them.

Marisha: Let's do it. I love it.

Lauren: Okay, good. I did a little bit of research and I saw a study that showed that kids improve their literacy skills when you follow the hierarchy to where you would comment would be like the least invasive, like using a comment. That would be like when you verbally provide that information about the topic or like you model your thinking. You might just say like, "I think frogs like to swim in ponds."

Lauren: You're just kind of giving them a comment when you're reading a book or whatever. Then, the comment would be that first one and then the question. Then, questions would be like, you could ask a open ended question that might give a variety of possible responses. Then, there'd be a closed question, which is like you want them to say a specific response and then like a yes, no question.

Lauren: Then, there'd be like a direction. Like, tell me this, tell me the frog lives in the pond. That was a little hierarchy in itself. It goes from comment to question to direction. Then, there are lots more other indirect prompts that I use, which is like close procedures. That's when you fill in the blank. The SLP might say the first part of an utterance and the child would finish it.

Lauren: You might say, like if we're, I don't know if we're looking at a picture and I want them to label, I could say, "She's putting on her," and they would say shoes or whatever. That would be close. Then, expansions is whenever the student gives a response and then the SLP would expand upon that response using an appropriate grammar and vocabulary. If the student would say something that might be grammatically incorrect, you would just say it in the correct way.

Lauren: If he said, "Him dirty," you might say, "Yeah, he was very dirty." You would just say it correctly expand it to where it was a little bit of a longer utterance. Then, giving choices is also considered a verbal prompt, binary choice. You would give a child a choice between two responses. Where's the dog? Was he in the yard or in the house? Then, there's also modeling and imitation, which as SLPs, we do all the time. We use that strategy for expanding language utterances as well.

Lauren: You would say, "The dog was in the yard, where's the dog?" Then, they would say, okay, yeah, in the yard because you just modeled the correct response. If you recommended sequencing, you could say, what did the boy do next? That might kind of be a little bit more indirect. Then, you could just make your way and get more direction or direct which where you're just saying, okay, what is this? This is a book. What is this? They would have to say book because you told them exactly.

Lauren: A lot of times, I'll use those more direct prompts when teaching WH question to a student who might be really echolalic because they need a lot more direction. I would say, what is this book? Because I want them to say book and not just repeat my question, which is what happens a lot of times when you're working with kids with echolalia. Honestly, verbal prompts can be done a lot of different ways and the possibilities for that one are as endless as languages. That's probably one that's most commonly used I would say.

Marisha: Yeah. I love that breakdown of the different types of verbal prompts and cues that we can give students. I think it can be just having that menu of options I think can be really helpful if a student isn't quite giving it. We can use this information just to help us problem solve a little bit of like, okay, here's what I did. Here's an inventory of the things I did. Then, here's what else I can try. I appreciate that overview.

Lauren: Yeah, you're welcome. We did visual prompt and then right below that one is verbal prompt. Then, the next one is gesture prompt. Honestly, and this is just Lauren talking, but I think that gesture prompting and verbal prompting can sometimes be interchangeable with the level of support, depending on the type of gesture and the type of verbal prompt.

Lauren: They're equally invasive in my opinion, but with her hierarchy that she has, she has the gesture prompt as underneath the verbal prompt. A gesture is when you just give a gesture like you point or you nod or you move to indicate the correct response as you're giving the instruction. This can even be looking at the student expectedly or looking in the direction of the correct answer as a gesture. I do feel like this one's pretty easy to say it as well since you just kind of gradually back off the gesturing.

Lauren: Of course, as SLPs, we will look at students expectantly a lot, especially with our minimally verbal students to give them that hint that we're waiting for them to respond. Another way that I gesture a lot in therapy is by pointing when I'm teaching WH questions. If there's a picture of a mouse driving a car, I might say, who's driving the car? I'm rippling that question. Who's driving the car while I'm pointing to the mouse over and over again. That's one way that I scaffold that.

Lauren: Gesturing can even be as simple as if it's a student's turn to participate, you might make eye contact and nod in their direction for them to take their turn. I feel like I do this one, I use more of that point prompt in therapy when I'm trying to get that direct response from them. Then, just eye contact and nods are more indirect with the gestures.

Marisha: Yeah, that makes a lot of sense. Are we ready for the next one?

Lauren: Yeah. We have visual and then verbal and then gesture. Then, the fourth one is modeling. That is when you show the student what they are supposed to do before they do it. This is the one that we use a ton as SLPs, right? It's when we just show them what to do. If you tell a student to touch their nose, you would touch your nose. Or, if you are teaching a student a new skill, like sweeping the floor and they watch you do it first and then they would try it.

Lauren: I think a lot of classroom teachers I work with use this in writing. They provide the students with a strong model or an example of what strong writing is supposed to look like so that it gives the kids something to go off of. It better prepares them to what's expected of them. That's what they do in the classroom. In speech, we do this all the time with articulation, right? We model the correct productions of sounds mirror. We even pull out a mirror so they can copy our mouth, copy what our mouths are doing.

Lauren: Then, we use that modeling and imitation when we're doing artic therapy a lot. That's when we use. Then, we also encourage paras to use that modeling as well when kids are learning those new articulation skills. That one is modeling. Then, the next invasive one would be a partial physical prompt. This is when you're going in and you're physically guiding the student through the response with a partial physical gesture like a tap or a nudge.

Lauren: In this one, you're still touching the child, but you are giving them minimal physical guidance. If you want the student to touch a certain object, you might move their elbow in the direction of that object. You aren't completely hand over hand helping them at this point. It's a little more subtle. I use this one when I'm teaching simple signs. If I'm prompting the child to sign more and I've already modeled or I know the child knows it, I might tap under their hands to help them initiate the sign to try to get them to sign more.

Lauren: That was that partial physical. Then our last one, the last one on the hierarchy, the most dependent prompt would be the full physical prompt. That is when you go in and you're physically guiding the student through the response of that full physical gesture. You're completely hand over hand basically doing it for them.

Lauren: It might be doing the hand motions to a song within or getting the student to make a sign or maybe even helping the student do a new action. You're trying to teach them. For example, like if you tell the student to clap his hands, you would then take his hands and make them clap. Yeah, this one's the most invasive. You want to fade this one as soon as you can because you don't want them to be dependent on that because they are not mastering the skill at all if you're completing the task for them.

Lauren: Those are all the different types of prompts. We went over from the least invasive to the most. I'm going to go over them again, it's visual then verbal then gesture then modeling then partial physical prompt and then full physical prompt.

Marisha: Perfect. I love that just short and sweet. Lots of examples and just reminding of that hierarchy. I think just having that model to think about is super helpful. Now, let's talk about application a little bit. How do we know when to use which type? Especially, how do we communicate those to paraeducators who don't have ... I feel like it's like a sixth sense of how we do the prompting and cueing. It just automatically happens. How do we communicate that?

Lauren: Yeah. Okay. There are a couple of different ways that you can approach this when you're teaching a student with a skill. A lot of it will depend on the student as well as the skill you're trying to teach. You and your team might have to make some judgment calls and use your knowledge of the student. I'm going to give you a few rules of thumb that you can use to know when to use which type of prompt.

Lauren: Speaking of you and your team, I think, that's part of the way we can communicate this to our staff. It needs to be like they are part of our team. If we go about it as a team approach, like okay, let's talk to the SLP, the special ed teacher and the paraprofessional who are going to be working with this student day in and day out.

Lauren: If you're all on the same patient, you go into it saying, okay, let's talk about how we're going to address this. You come up with a plan together. They feel like they're more involved and then you can also lend your expertise in that area. It does both. It keeps you on the same page as well as the teachers. Then, the strategies they may have forgotten or might not be familiar with.

Lauren: The first approach is when you would go from the least invasive prompt to the most invasive prompt. You use the least intrusive prompt first, which according to our hierarchy would be the visuals. Then, you would go down the hierarchy, adding more prompts only if you need to. If you go back to our target example, that I gave earlier, like I couldn't find my item by using the store signs, so I asked the store clerk to help me and he gave me the directions to find it, which is a verbal prompt.

Lauren: Then, if I still can't find it, he could walk me over and point to the item on the shelf, which would be the gesture. Hopefully, I don't need him to model taking the item from the shelf. I might need him to physically help me if it's out of reach or something. When it comes to our students, it's really the same way. We try visuals and then we give clues with our words and then we might point or gesture.

Lauren: Then, if they still don't get it, we'll model and then partially prompt them physically and then hand over hand if we need to. This is a good approach if you're trying to assess how much of the skill the child can do independently. You might start off using that if you want to see what the kid can do. Then, another benefit to this one is that if the student gets repeated time to respond to the request and more practice time with that skill since you're asking him to do the same thing over and over again.

Lauren: That's going from the least restrictive to the most restrictive. Then, the second approach would be to do the opposite. In this case, you start with the most invasive and work your way up to the least invasive. Depending on the skill, you might start with the full physical prompt and then continually fade the prompts as they learn that skill. If it's a skill that doesn't require physical prompting, like if you're working on answering questions, for example, you can't physically prompt that.

Lauren: You might start with modeling and then work your way back from there. I'll model the example or the answer and then I'll use the gesture and then I'll use verbal cues and I'll use visuals, so you would go back. If you're teaching a student to sign, like if they're trying to teach them to sign more, you might hand over hand the sign when you're first teaching it. Then, you may tap their hands to remind them to sign.

Lauren: Then, soon you might just model the sign when you expect them to use it. Then, they'll imitate you. Then after that, maybe you don't need to do that anymore. You just need to point to their hands or look at them expectantly. Then, you might just even be able to say, "Hey, what do you want?" Or, "Do you need more?" Then, they'll be able to make that sign on their own.

Lauren: This approach is good to use whenever a student is first learning something new. You just want to make sure that you're fading those prompts when you can. Then, I was reading some research and I think it said that this approach resulted in fewer errors and quicker skill acquisition than the other way. I'm guessing it's probably because as long as you're fading those posts quickly, then that one would work better for those fewer errors.

Lauren: Because you're starting off helping them and then you're backing off, backing off, backing off. They know what to do after you show them.

Marisha: Yeah. How did you explain that fading to your paraeducators too? Because I feel like it's just something that I was just trying to think about, like how would I explain that? Because I feel like it's something that we just naturally do to figure out. Did you come up with kind of more of a systematic way to explain that to them or what did that look like?

Lauren: I use with that visual hierarchy sheet from The Autism Helper and then I show them the different levels. If we're fading then we have to back up. If you're physically prompting them, you have be more hands off like on the next try. Then, we have to constantly assess and see where we're at. If they're hand over hand getting a student to try to cut with scissors, you have to eventually try to see what they can do without that.

Lauren: I gave them that hierarchy but then at the same time, I encourage them to back off a little bit. Then, there are some other tips for using these prompts more effectively that I went over with him as well. That was like the first one would be delay your prompting by decreasing that amount of time before you offer assistance.

Lauren: Basically, you would wait a bit before going to that next level of prompting. If you're going the first way, like you might give them a verbal prompt and then wait three seconds before you give them the gesture prompt. They have that hierarchy sheet, but they know you want to give them a chance between those before you go to the next one. You don't want to just automatically assume that they can't do it. You want to give them some good wait time.

Lauren: Then, if they're getting frustrated or whatever then you would step in. If you can constantly decrease and back off and lengthen the amount of time you wait before giving the next prompt just to give them that more independence or try to get them to respond appropriately, then you would do that.

Lauren: You would decrease the amount of time before you offer assistance. Then, you also want to gradually decrease the intensity of the type of prompt you're getting. Within each of those areas, within each of those types of prompts, there's many degrees of intensity that those prompts can be. It's hard to explain or our show unless you're in the moment and you need to see what a kid needs.

Lauren: For example, like if you're doing the partial physical prompt, you want to fade from the wrist and then maybe to the elbow and then to the shoulder, then maybe stand behind them. Then, you can back away entirely. Just that constant trying to back off as much as possible. Or, in the case of verbal prompts, you could start by giving them direct prompt and then on the next target try close or try an indirect prompt. They are constantly learning how to do those things in. It's going to take time, it's going to be trial and error, especially for the newer ones, the newer paraprofessionals.

Lauren: I feel like the ones that have been doing it for a while, they get to see the special education teacher and the classroom teacher and the SLPs modeling these types of prompts all the time. A lot of it might come with experience, but the more you can show them in, the more you can teach them, the easier it will get.

Lauren: Another tip I tell them is to know how to reinforce appropriately to prevent that prompt dependence. Like I mentioned before, you want to praise a child or give rewards that will help the student become more independent. If they are first learning, reward them for completing that task prompted. Then, after you have backed away from that type of prompt, only reward the student, if you're using a star chart or whatever, you would only give them a star for the level of prompting that they're on currently

Lauren: Then, that will motivate them to become more independent and try harder because you don't want them to depend on that assistance. I tell them that. Then lastly, we talked about it's always important to evaluate the effectiveness of the prompt that you're using. You want to use your observations and any data to make sure that the prompts being used are effective for that student. It will also help you determine when you can fade the prompts. It'll help you in a lot of different ways.

Lauren: You want to remember that each child is, and each new skill even, is different. You want to make sure that you're taking really good data and you want to use that specific data to help you make those decisions. You don't want to only rely on your previous experiences with that child or with that prompt with other children beforehand. You want to maybe even do trial runs with levels of prompting and create a plan of action with your team. It's important to take note in your data or tally sheets on what prompts you use and how invasive they were. I feel like if you're teaching your paras to take that data and then to mark that, then they're identifying the level of the promptings that are used.

Lauren: Even if like you are modeling, they could take the data for you and then they could write the prompts that you were using to get more familiar with those types of prompts. Just talking as a team to make sure that you're all on the same page when it just comes to all this prompting techniques is super important. Our teams aren't perfect but we try. I felt like the little presentation that I gave helped them and they had some good things to say about it afterwards too. I felt like empowered them a little bit more to help the kids in new ways.

Marisha: Yeah. I love those tips. I think those are really helpful. I'm curious too, because I feel like every SLP has a slightly different strategy. In terms of how I approached this, like in my therapy sessions and I think it could be helpful depending on what we're working on with the paraeducators. I like to collect just like a quick, like if I'm working on WH questions, the student walks into the session, I like to collect just like a quick little probe with maybe like five, usually five maybe 10 questions just to see where they're at. Then, their level of accuracy independently helps me determine how much support I'm going to give.

Marisha: Because I feel like I was constantly documenting the level of support. I felt like it wasn't totally consistent. This can maybe be like another thing that we talk about. I use that data to decide what types of support I want to give the student and how many of the supports I want to give. Because I think we would respond a lot differently if they're at 20% accuracy versus 70% accuracy.

Marisha: I think that's a strategy that worked really well for me. I love that you mentioned the data part too.

Lauren: Yes. I do the same thing, especially for non artic kids. I kind of like beginning of the session do 10 trials and see where they're at before we start drilling, drilling to see how much modeling or do I need to get up my tongue depressor or whatever had they might need. I do, I love that. Yes, take that initial data. Then, figure out what supports will work for them and where might they be at.

Lauren: If you work from inferences, when you ask them some inferencing questions, what could they do? Then, if you gave them that visual, could they do it? Then, so on and so on. If you took them away or add anything they need to add. Did you need to add more prompting to that?

Marisha: Yeah, no, that's super helpful. Then, yeah, I'm sure that could generalize to the paraeducators too. Or, maybe we could even, if they're helping us, generalize skills that we're targeting, we can let them know how the student did on the probe with us and have that indicate the level of support that they use.

Lauren: Yeah. I do a lot of my therapy pushed in in the classrooms. A lot of times, the paraprofessional is in the room when I'm doing therapy. It's easy to grab, as long as they're not working specifically with another kid or whatever. I can easily grab them and model something for them or show them a new way to support the student. Or, hey, he's been responding really well when I'm giving him these visuals. Next time, can you give him these visuals and see if he can respond a little bit better?

Lauren: That's one thing that's good about pushing.

Marisha: Yeah, that's amazing. Such a good strategy. Then, I'm curious too, because I started to touch on this, but in terms of the documentation, especially if you're working with the team, do you use any kind of template or anything to help document the level of support? Or, have you found any helpful tips there and just making it, I think, teaching and making sure everyone has the same vocabulary to start is super helpful. Do you have any kind of, I don't know, template or anything that you use?

Lauren: I have tally sheets that I use. I use SLP toolkit. On there, there's a little data section. There's a dropdown of the type of prompts that you can use or you can type in notes. That's how I do my speech tallies. Then for the team, like for the SPED staff, everyone, they're allowed to take data how they see fit. I don't want to step on the special education teacher's toes too much with the way that she takes data. I do encourage them to make a note of that support.

Lauren: In the data sheets that I had, I would always put the type of prompt and then the level of prompts. Was it low, medium or high intensity or like a direct verbal prompt or indirect, that kind of thing. I try to be a little bit more specific and so I would encourage them, the paras and the teacher to jot down the type of support that they were using so that whenever another person is working with them, then they would be able to know where to start.

Marisha: Yeah. Perfect. That's awesome. I'm always looking for different ways to document that consistently because I feel like if I say minimal cueing, that's probably something different than ... everyone would interpret that a little differently. I think that's super helpful. I think the shared vocabulary is a huge start. If we can describe what we did using that vocabulary, then I think that's much easier to understand. Just being able to be a little more specific. You would definitely give us the tools to make that more doable.

Marisha: Then, I'm curious too, could we walk through just one more example, because you mentioned your inference as resource, so maybe we could just run through an example there. Maybe like a sample session. Like a student walks in and we're going to work on and for instance today, and so we do a quick probe. Let's say, they're at 20% accuracy. What would we do? What could we do after?

Lauren: Okay, so it depends on the type of inferencing skill. With my students, a lot of times, they have to, in class, they have to answer inferencing questions and then they have to find text evidence. A lot of those inferences, making inferences tasks are text-based. If I'm using a text and I go through my level three or my least invasive, so like just a text and I want you to answer the inferencing question and they're at 20%. Then, I would pull a task that has visuals and the text.

Lauren: For example, the resource that I have, it's three levels. Then, the third level is just text and the second level is text and a picture. I would use that one. Then, we would see where they were at. With that one, if they got a higher percentage or if they were still pretty low, I might back up to just the picture prompt. Because my first level is like just a picture, no text. Can they answer inferencing questions? Because that would tell me, if they still can't answer interesting questions based on just a picture, then it doesn't matter.

Lauren: It's not the texts that's hindering them. It's not the language and the grammar and the syntax and all that that's getting in their way. It's the skill of inferencing in general. You understand? I would have to back up to that level and start there. If they performed a little bit better on the text with the visual, that might just tell, okay, well, they just need some more experience with interacting with the text. They had this visual that support it, so they could use those picture clues. They just need a little bit more experience using text to find, to make that inference or whatever.

Lauren: Then, that would tell me I could stop that that level too and work on that at a little bit higher percentage and then go on to the one without the visuals where they're just using the text. That's how I use that resource and how I would target that, just backing up. Because like inferences, there's no physical prompting but if they could not do it at that level, they would back up to this level and then they would use that visual prompting. Then, I would be using my verbal prompts.

Lauren: If that's not the case, then I will be using my gestures. Then, I would even go down to modeling. This is how we'd make inferences. You would constantly back up and back up until you exhausted all your efforts basically. That's how I would do that.

Marisha: Yeah, that's perfect. I think it's super cool and interesting just to hear how different SLPs approach it. I think it's cool too because we can use our clinical judgment. Starting with the probe, I guess, we can decide if we want to use the least to most or most to least type of approach. If it's the first time we're introducing the skill, maybe we want to start with the most and do a lot of that modeling and all of those pieces.

Marisha: These hypothetical examples are so hard because we're missing like all of the contexts that we use. Yeah, I think, that was a super cool way to put these things together. I think that resource is genius because it makes it so much easier to scaffold a skill that could be tricky to break down like if we just had a text to look at. I love using that in therapy and I super appreciate it.

Marisha: Okay, awesome. Is there anything else that you think is super important to address or any last remarks or things you want to share?

Lauren: I guess we definitely, as SLPs, we don't want to keep these tragedies ourselves. If you have this type of this knowledge and you've gotten some good practice with it, definitely, I would encourage you to share those with your teachers and other educators so that you can provide that, a good support system for your students. I guess that would be my final thoughts.

Lauren: I would just encourage you just to keep at it and talk to your team.

Marisha: Yeah. We just spent almost an entire hour talking about prompts and cues. Because I have been getting some questions about it, but I think if you had asked me a couple of years ago, it's like, yeah, that's just something we do. There's not a talk about it.

Marisha: It's definitely something that we have. I mean we went through a lot at school and we spent a lot of time building that knowledge and building those skills. They're incredibly powerful for our students. Yeah, I completely agree that this is something. Yeah, I think we just take for granted the knowledge and skills that we have. This is definitely a skillset that can really benefit our students.

Lauren: For sure. For sure.

Marisha: Yeah. Thank you for breaking it down in such an easy to understand way. I'll be linking to, you have a blog post about it and then I'll link you to The Autism Helper so that other SLPs or other listeners can find that visual. I'll also link to the inference resource that you mentioned because I think that's a really great example of some of the different strategies that we can use.

Marisha: One last thing, where can SLPs find you if they want to learn more about what you do or just read more about your resources?

Lauren: Yeah, you can find it at busybeespeech.com. That's my blog and my website. I am on Instagram and Facebook at Busy Bee Speech. On Teachers Pay Teachers, I am a Lauren LaCour Haines. If you need to reach out, you can always email me at [email protected].

Marisha: Perfect. Thank you so much, Lauren. I so appreciate your time. You are an incredible SLP and blogger and just resource and friend. Thank you so much. Thank you to everyone who listened in today.

Lauren: Thank you so much too.