SEASON 7 EPISODE 12

[INTRODUCTION]

[0:00:13] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by speechtherapypd.com. The SLP Learning Series explores various topics of speech-language pathology. Each season dives deeper into a topic with a different host and guests who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on speechtherapypd.com and is available for 0.1 ASHA CEUs. Now, come along with us as we look closer into the many topics of speech-language pathology. 

Welcome to season 7. Telepractice, it's not just screen time. 

[INTERVIEW]

[00:01:14] KHK: Welcome to the podcast mini-series: Telepractice, it's not just screen time. Presented by speechtherapypd.com. Thank you for joining us for our episode number 12; Speech Sound Production in Telepractice. 

This audio course is offered for 0.1 ASHA CEUs. I am your host, Karin Hartunian Koukeyan. I've been a speech-language pathologist for over two decades with 13 yearsÕ experience in both special education and healthcare settings. 

And here are our financial and non-financial disclosures. Karin Hartunian Koukeyan is a sole proprietor who consults on telepractice services and works with professionals on accent modification to enhance their communication skills. She's the host of this podcast and receives compensation from speechtherapypd.com for this presentation. Her non-financial disclosure is that she is the current Associate Coordinator for ASHA, Special Interest Group for telepractice, SIG 18. Dr. Tiffany Williams receives an honorarium from speechtherapy.com for this episode. And there are no other non-financial disclosures to disclose. 

And now here's a little bit about our guest today. Dr. Tiffany Williams is a speech-language pathologist with over 15 years of experience in the field. Dr. Williams has worked in the medical and school settings providing services to children and adults. Most of her career has been in early childhood education programs and K through 12 schools. 

Dr. Williams holds a PhD in education with a primary emphasis in early childhood education and a secondary emphasis in multilingual, multicultural education. She has a passion for early intervention, student success, and family engagement. 

Through her company, Our Words Matter Consulting, Dr. Williams strives to cultivate meaningful partnerships between schools, teachers, and parents with the ultimate goal being academic success for children. 

Welcome, Dr. Williams.

[00:03:13] TW: Thank you. So nice to be here.

[00:03:15] KHK: Before we get started with the episode content, I would love to have you share with us how you became a speech-language pathologist. And, specifically, how you came to telepractice. 

[00:03:26] TW: Sure. I think like most SLPs, we wanted to help people. That was my goal, was I enter college and trying to decide on a degree program, I actually wanted to be a physical therapist first. And I got the courses listed out on the sheet and I saw all of the math courses that were required and I absolutely decided that that was not the path for me. Math and I have had a very tumultuous relationship throughout my entire academic career. 

My aunt was a speech-language pathologist in a school. I asked if I could shadow her at work. And I did that. And I absolutely loved it. That was my journey into the field of communication disorders and choosing that as my major. And I've loved it ever since. 

And telepractice came into my life actually prior to the pandemic. I know a lot of people experienced it during Covid. But I was working in telepractice prior to, because I just had my son and I wasn't ready to send him to daycare yet for a full day. And I thought what could I do where I can still use my degree and do what I love but also have that flexibility to be there for my son? And I just Googled virtual speech therapy and came across some teletherapy companies and tried it out. And I absolutely loved it. 

[00:04:48] KHK: We have that in common too then. That's how I came upon telepractice as well. As a mom trying to kind of have a part-time way back into speech-language pathology. Amazing. 

[00:04:57] TW: Yeah.

[00:04:58] KHK: All right. The learner outcomes for today's course. By the end of this course, participants will be able to, one, identify one screening tool and one assessment tool for speech sound production that can be used in teletherapy settings. Two, explain two resources helpful in creating a successful teletherapy treatment session targeting speech sound production. Three, describe three ways to help clients generalize learn speech sound production into settings outside teletherapy. All right. 

And tell us a little bit more about your experience and background in treating speech sound disorders both traditionally and face-to-face, in-person settings, as well as through telepractice.

[00:05:39] TW: Yeah. With in-person therapy, I've worked with preschoolers, that might have been a head start. All the way up through 12th grade. And then even one of my side gigs was working at a private practice clinic as well on the weekends. And so, I worked with children as youngest 16 months I think was my youngest kiddo. 

In the in-person therapy, I've experienced many of the same things that I've experienced in teletherapy. Both with progress, some of the challenges as well. Making that connection with families I think was one of the biggest things that I really liked about private practice speech therapy. Because you get to walk the little kid out to the waiting room. Have that discussion with parents. And get that buy-in and carryover from parents and family as well to just extend what we're doing in speech therapy to the home. 

And when I first entered telepractice, the students that I saw were attending virtual school. They were at home getting their educational instruction. The parents were also in the environment as well. That also gave me the opportunity to be able to connect with parents at the end of session, maybe on a weekly basis just as a touch point, so that I could continue to facilitate that buy-in from parents again into what we're doing in the therapy session. And then, also, when we hit that generalization and carryover phase of our speech sound disorder therapy, that was also a connection point as well. It really is comparable to what I was doing in-person to what I started out in telepractice as well.

[00:07:10] KHK: I love it. And so, let's kind of delve into that, specifically related to assessments. What are some differences between in-person and virtual approaches to assessing speech sound disorders in telepractice? 

[00:07:24] TW: Yeah. I get this question a lot when I share with people that I am working in the virtual setting. Especially if you've never done it before, it can be daunting to think about. But as I shared before, there really aren't that many big differences when it comes to assessment, treatment, carryover. 

The assessment component still that you apply in in-person therapy is still going to apply in that teletherapy setting as well. You're going to want to gather those initial impressions when you first meet the student. Establishing rapport. Getting to know some of their interests. Gauging their level of speech intelligibility in connected speech. Just forming an impression really of what types of errors that you're hearing. Those sound substitutions, omissions, disorders. 

And then moving into that screening component as well, a lot of the school districts that I worked with doing telepractice would want a screening to be done just to rule in or rule out the presence of a speech sound disorder. And so, using some of those same screening tools that I use with my in-person therapy as well, the self have an articulation screener. Super duper. Also has some screening products as well. Teachers Pay Teachers is a great resource. 

And so, I would just pull those resources. Complete the screening just as I would in in-person therapy and assessments. And then take notice if the deviations that I was hearing were age-appropriate or if they're not. And then communicating that back to the referral team. And then moving on to next steps just as you would with in-person therapy as well. 

I just think it's really nice to be able to have that first session when you're completing a screening to really be less formal is how I try to approach it. Because we want the students to feel really comfortable and get past looking at themselves on the camera. That was something that a lot of the students did. They would make silly faces. Or lean to the side. 

Maybe I just went along with that at the beginning to help them feel comfortable with seeing themselves on the camera. And then moving into that screening process. And a lot of times, just as I would approach it with the kindergartner that I pulled from their classroom for in-person therapy, I would just say, "Hey, I'm going to ask you to name some pictures. I'm going to ask you to repeat some words. Listen to your speech sounds." And then we'll talk about what challenges you might be experiencing with your speech at the end as well.

[00:09:53] KHK: I love that you kind of went with it for a while. If they were distracted by their own images. Any other challenges that you experienced when working through telepractice when you're trying to treat speech sound disorders that you want to highlight? And maybe mention how you kind of worked and overcame it. And even if you've worked with other clinicians, what were some of their challenges that might have been unique? 

[00:10:17] TW: Sure. Yeah. Behavior management is inherent in everything that we do as speech therapists. Whether you're working with a student individually or in a small group. And that is the same with telepractice as well. Especially for those younger kiddos or maybe children that have moderate to severe cognitive impairments, it can be really challenging for them to regulate their behavior, attention. And so, if needed, I've taken many breaks during the sessions. Small breaks frequently throughout our session. 

I worked with one student, she had Down syndrome. And I believe she was about 11 or 12. And so, she worked for five minutes and then we had a two-minute break. And in that two-minute break, we watched her favorite YouTube video. And if you can believe it or not, it was Heads, Shoulders, Knees and Toes. She just loved that song. And we watched that every five minutes during our 45-minute session. And she just loved it. 

And at one point, she even went and got her younger brother that was at home with her. He did it with us. Another week, mom was in the living room doing it with us too. It really helped motivate her to work through some of the more challenging material that we did in those five-minute time spans because she knew she was working for that reward. 

That same reward system, maybe a token economy system that you might have used in your in-person therapy. Those same resources can be used in the telepractice setting as well. And I just think it's super important to tie whatever the reinforcer is to a high-interest area for the kiddo. Because that is going to be the motivating factor. And just be ready to pivot. 

Sometimes kids show up to our therapy sessions with different attitudes session-to-session if you see them multiple times a week. And so, just always being ready to pivot. Getting a firm understanding of what their interests are when you are establishing that rapport with them in the first session. Keeping a list of that has been helpful for me so that I can pull from that list when needed during a therapy session. 

Oh, I remember. She really likes this. Let me pitch this today. Maybe today she's like, "No. I don't want it." Well, I'll just go to number two on my list and we'll keep going down the list to see what would be the positive reinforcement that she needs for that session. 

[00:12:40] KHK: I love it. Walk us through what an assessment process would look like over telepractice specific to speech sound disorders.

[00:12:48] TW: Yeah. You'll hear this theme. And what I'm sharing today kind of repeated it over and over. The same as what you would do in-person is what you're going to do in telepractice as well. It's just the method and the modality has changed. Right? You're always going to start with that case history, that parent interview. Because that information is really important to how we look at the results from our standardized assessments that we give. For school-age children, giving that teacher interview or getting the teacher input is super important as well. Because we want to know how this could be impacting the student in the classroom. 

We also want to look at different standardized tests that we can give. Of course, we have the Goldman-Fristoe. We have the Goldman-Fristoe Test of Articulation. And then we have the HAP as well. Of course, you can always transfer your information from the GFTA to the Khan-Lewis as well so that you can analyze some of those phonological processes. 

Observations are something that some districts also require as well. And that can be a little tricky. You do have to get pretty creative with the observations. In my experience, I've set up, had the teacher set up a computer in the classroom. Or if the student was receiving their education at home, I would also ask the parent to set up a computer that's not right in the line of sight so that I can observe how they are using their speech sounds during conversation with a peer, answering a question from a teacher. And it can get tricky because, of course, you don't want to capture other children on camera due to confidentiality. 

If that's not an option, I have asked either the teacher or the parent to record the student during a small group or one-on-one session so that I can hear how they're using their speech sounds in connected speech. And, as a last resort, I've given teachers some specific sounds to listen for in the class and then ask the teacher to report back to me what they heard. Just kind of a hierarchy. I feel like having that computer set up so you can see it with your own eyes is kind of the best way. If that's not an option, then asking the parent or teacher to record. And then, as a last resort, giving those directives to the teacher so they know specifically what they're looking for. 

And then, of course, a verbal sample is something we always need. But I feel like the important thing with verbal samples, whether you're in-person or in telepractice, is making sure that you gather a verbal sample based on context, what you're hearing, so that you're aware. You want to avoid those open-ended questions. How was your weekend? Or what did you do over the summer? Because if we don't have the context and their speech intelligibility is really low, we are not going to understand much of what they said. And we won't be able to make that comparison between what they were trying to say and what the actual words were. 

If you don't know what the child is trying to say, you won't know the errors that they're making. That verbal sample, I would really suggest story retell. I'm going to tell you a story. Tell it back to me. Or I would also use wordless books. A couple of resources that I've used in my telepractice experience, Ormie the Pig is a great video. It's a short Ð it's about three minutes. It's a Pixar. A little short. And this pig is trying to get this jar of cookies off the top of the refrigerator. And he does about 15 different fun, silly things to try to get the cookies off the top of the refrigerator. 

And so, that's a really good video to watch with the child. And then ask them Ð preface it by saying, I'm going to show you this video. And I want you to tell me some of the things that the pig did in the video." That gives you context because you already know what has happened when the child is repeating or telling you what they seen in the video. 

For the older kids, even though Ormie I think spans the age range. Because I've shown that to older kids too and they absolutely love it. But for some older, maybe more mature middle schoolers or high schoolers, there's another great video called Snack Attack. It's wordless as well. It's about a grandma who thinks that someone has stolen the snacks that she got out of a vending machine. And she goes through all of these different antics to try to get her snacks back. It's a really great video. It's engaging. It captures their attention. It's a little bit entertaining. And I think it gives you a good basis to have them retell the story using quite different sounds. 

And then that oral mech exam is also another critical part. Of course, you're not able to reach through the screen and touch the face and give them those tactile cues like we really love to do as clinicians. But online, there are some really great resources. Amy Graham is an SLP. And she has amazing oral mech resources on her YouTube channel. Graham Speech Therapy is the name of her YouTube channel. And she has videos there that are specific for conducting oral mechanism exams in telepractice. Very important to understand how you can ask the questions a different way since you're not able to touch the face of the student. 

And then, of course, having that hearing screening completed by the school nurse or the pediatrician. Depending on where your student is located, whether they're in a public school or at home. And then, of course, that last step is that stimulability testing as well. All of those steps would be ones that we would do traditionally with in-person therapy. And they really do translate really well into the telepractice setting.

[00:18:08] KHK: Amazing I did want to also mention, there is a handout that goes with this course and some of these resources. I think most of these resources will be on that handout. Be sure to download that handout as well. 

I would love to hear about some treatment resources now. Let's talk about some of the differences between in-person and virtual approaches to treating speech sound disorders. Kind of explore some of those challenges and ways to kind of work through those challenges.

[00:18:39] TW: Sure. For me, any type of nasal air emission can be really challenging via telepractice. Because, typically, with in-person, you might give a mirror to sit that right above the lip to look for any fog forming on the mirror to get a true understanding if there are any nasal air emissions there. You can usually hear it a little better in-person as well. 

In overcoming that type of challenge in teletherapy, I've engaged parents or the parents that are in the room with the student during the session to provide some tactile cues as well if they have the mirror. If they don't have it that day of the session, then I always send a follow-up email to either the parent or the parent that's sitting with the student to see if they can bring that to the next session. 

Asking the students to touch their faces in specific ways to provide themselves with some tactile cues is always helpful. And I think that that just engages them more in the therapy session versus just being a participant in it. Just a participant just taking information. Now they're actually engaging in what is going on in the therapy session too. 

I know that different video conferencing platforms have some acoustic changes that you can make. Zoom has an original sound for musicians. And so, it can create more clarity for certain sounds. And using headsets. Because sometimes Ð for example, it could be really challenging to hear the difference between an 's' and a 'sh'. Or maybe that slushy 's' where the sound is coming lateral when it's produced. Headsets are so good for that. Not only for the child to wear, but for you to wear as well as the clinician. Because you can hear it more directly, of course, if you're wearing headphones versus the mic through your laptop or computer. 

And I found also that using headphones tends to help with the attention as well for the kiddos, that if they are in an environment where there could be other noise, background noise in the room, the headphones tend to help them tune that out and then focus a little bit more during the session as well. 

[00:20:42] KHK: I wonder if also there's a correlation between even just the sensation of having the headphones on their head. Maybe they're more apt to focus. That's an interesting perspective. Now what would you say to those clinicians that are convinced that certain sounds cannot be treated over telepractice? I know you said there's sounds that are tricky. But I'm talking about Ð and we've all heard folks that are just convinced that articulation therapy in general is impossible over telepractice. And we've heard all the reasons cited. What would you say to those clinicians? 

[00:21:19] TW: I would ask those clinicians to think back to any student that they worked with in-person that they weren't able to get a specific sound to be produced. And I know any speech therapist that's worked in the school or with small kids in a private practice clinic or home health, you've had those kiddos where you have tried everything you know in your toolbox of tips and tricks to get a sound produced and it just isn't happening. 

And so, then you have to step back clinically to think about what could be preventing this child from being able to produce the sound correctly. And I would be interested to see if, after you've stepped back and done your clinical analysis of what could be a barrier, if telepractice is actually the barrier, or if it could be something else. Sometimes it could just be developmental. Sometimes it could be structural. Sometimes they're just not ready for that particular sound. And so, then we can use other therapy approaches to help stimulate some generalization of new sounds, such as cycles approach. That's a really good one as well. Minimal pairs, contrast therapy is also a good one as well that I've used in therapy. Complexity approach is another great one. I really like that one because you're starting out with some more challenging sounds. And the idea behind it is that you'll get more sort of bang for your buck if you start out with some of the harder sounds versus the sounds that they're already stimulable for but just haven't mastered them yet. And then, also, of course, the traditional motor approach as well. 

Any of those approaches that we use, whether we're in teletherapy or in-person, we could run into some challenges where everything we've tried is just not producing what the result that we want. And so, that same thing can happen in telepractice as well. And we just have to step back and analyze things from a clinical perspective to see what is potentially causing just a plateau or either that barrier and move on from there.

[00:23:18] KHK: Yeah. I think, in general, with all things telepractice, we need to not look at it as it's because it's over the computer. Look at all of the other things that are contributing to the issue and the challenge. I love that. 

When it comes to tactile queuing, I know this is a question that's probably on everybody's mind, what are some ways we can help students or clients that really need those tactile cues and perhaps they're not really able to self-cue? What can we do about that? 

[00:23:46] TW: For those students, I have used food. I like to ask the family or the parent if we can get peanut butter. It's very sticky. You can place that at certain places. If they have a nut allergy, then using an alternative, of course, if you have a lollipop. Things that we would also use in-person could be very helpful in these instances as well. 

And so, the point behind it was giving them a little bit of peanut butter on the tip of their tongue and asking them to manipulate or move that peanut butter to certain places in their mouth that you want them to be aware of when they're producing certain sounds. It could be the alveolar ridge. You're going to want to describe that to them. It feels bumpy. It's right behind your teeth. And you can ask them to rub it first with their finger. And then stick the peanut butter there and just move it back and forth across that alveolar ridge. 

If they need to make sure that their lips are rounding for a particular sound, I've also had students Ð some of them love it. Some of them don't. Using bubble gum or chewing gum and making sure that they're using it Ð they're putting it on their lips. If they can blow a bubble, great. Because that stimulates that round. But if they can't, just the action of trying it and seeing themselves in the camera while they're doing it can help give them an idea of how they need to make their mouth move in order to make the shape that you're requesting. 

I've used a lot of food items for those types of kiddos that just maybe aren't understanding how I'm describing where to put their articulators or how to move them. And then, also, perhaps if they're giving themselves the tactile prompts and cues, it's not helping, then I'll move on to using that food item just to see if we can get over that hump a little bit more. 

And then as a last resort, YouTube has great videos where they have the very large Ð you remember like the large Super Duper mouths? The big mouth? And they will actuallyhave it open on the screen and really give details about where a sound is made. How the tongue should move. And so, giving the same information presented in a different way sometimes can help make that connection too.

[00:25:57] KHK: I love that. And I wonder if you would be able to give us a few examples of difficult sounds that you've kind of worked through those challenges in either providing tactile cues, visual, any cues really. Maybe some specific sounds that are difficult and how you've been able to be successful in eliciting those sounds over telepractice. 

[00:26:19] TW: Sure. So the 'r' sound has always been a nemesis, whether it's been in-person or telepractice. Just depending on the kiddo that you're working with. Many, many years ago, almost I would say towards the middle of my practice, I attended a professional development course on eliciting 'r' sound. And just wanted to add some more tools to my toolbox for how to get this sound elicited from kiddos. 

And so, for this one, I did use food again to make sure that the student was gliding his 'r' sound. I wanted to make sure that his tongue was in the right place. I used my hand as a visual. We drew it out on the whiteboard, on Zoom. We watched YouTube videos. And I just could not get his 'r' refined to the point where he was making a close enough approximation for us to move past just that sound and isolation phase or at the end of a syllable phase. 

What I did was the little Toothettes that you get at the hospital with the pink sponge on the end. I actually ordered some on Amazon. Had them shipped to the student's house. Let mom know these are coming. And then we used those therapy. And the way that we used them was to insert the sponge part. And I gave him instructions on how far back to put it in his mouth. Because we don't want to gag and have what comes from that. We discussed. There was a lot of pre-teaching before we moved to actually using it. 

And so, he would use the Toothette, put it towards the middle back part of his tongue. Bite down on the stick. And I would just have him making his best 'r' sound that he could while he's elevating the back of his tongue. Because his tongue just kept sinking down while he's making that R sound. That was one way. And, of course, that's the resource that I provided to the family. Sometimes you're able to send a link to the family. You can ask them or the school to see if they're able to provide that manipulative for them to use during speech therapy.

Another tricky sound has always been that lateral 's' sound where that air is coming out of the sides. And, again, going back to what I spoke about earlier about not being able to get a sound produced and then taking that step back to look at some clinical analysis of what could be preventing it. And when I did that, it wasn't teletherapy. It was the child had a spacer in the roof of their mouth. 

That between me evaluating them and doing my oral mechanism exam and there wasn't a spacer. To him starting therapy with me. No one mentioned that he had this dental apparatus put in the roof of his mouth. I took a step back. Asked some questions. Figured out that that was indeed what was causing that 's' sound to be lateral Ð for the air to be lateralized. 

And then when there's a structural issue there, we have to resolve that first before we can look to correcting the sound. But outside of that, using either lollipop or some type of Ð I like to use tasty treats because I find that to be most motivating. Candy cane. Anything to just touch the sides, the blades of the tongue to give them an idea of what parts of their tongue need to be pressed up against the inside of their teeth to seal off the air from coming out of the sides. 

And so, I've often used myself as an example as well to imitate how they're producing the sound in error. I will give them that production in air and then correct it. And then giving them those tactile edible prompts to touch the blades of their tongue and then the insides of their teeth to figure out where their articulator needs to be placed in order to help correct the sound production as well. The 'r' and any lateralization of air have been tricky ones for me. 

[00:30:12] KHK: A couple of questions are coming up now for me. One, what kind of tips would you have for the parent? Because we're not always dealing with parents. Now parents might be very comfortable with putting their hands on, or near, or inside their own child's mouth. And even then, that might be a little tricky for some folks. But if you're dealing with facilitators, e-helpers, paras at a school, they're not always going to be very comfortable with that. And I know some of the kids are going to need help. They're not going to do it for themselves. Any specific tips that you find might help in this situation? 

[00:30:48] TW: Sure. I think that speaking with the parent or the facilitator prior to the therapy session is always going to be helpful. In my experience, I've had good relationships with them. I was able to send them a quick email, "Hey, for the next session, I'm going to have you do this." I send a quick video so they can kind of be aware of what I'm going to ask them. 

But if you're new to the district, new to the site, new to the facilitator or the para, having a conversation with them on the phone or via email is always helpful so that they understand what their role is and specifically what you're asking them to do. And the why behind it as well. Because as educators, for those working with kids, we want to help. Right? That's kind of our North Star. We want to help the children. 

And so, that's how I really frame the conversation in order to help this child make the progress that they need with their speech sound production. It's going to be really important for you to be my hands in the room. And I'll send a quick video so that they can see what it is that I'm asking them to do. I've either recorded myself doing it. Or, I've sent a short YouTube video as well to give them the guidance on what it is that I'm asking them to do. And then answering any questions that they may have to help them be a little bit more comfortable. 

But you will sometimes need that additional set of hands on the other side of the camera to help the students. And so, I think if you can educate the facilitators in a concise but informative way, and empowering them to know that they're not hurting the student, this is part of what we do as speech therapists, and that you're an extens Ð that they're an extension of you in the room has often times been a way to get them to feel a bit more comfortable with it. 

[00:32:30] KHK: Sounds good. And I'm sure gloves help too.

[00:32:34] TW: Oh, always. Gloves and masks. Gloves and masks. If they're really concerned. 

[00:32:40] TW: Lots of Ð because those things get slobbery. And then we need somewhere to see. 

[00:32:46] KHK: All right. Let's talk about some ways that these skills can be generalized into other settings. Basically, bringing these skills outside of the speech session. In this case, it would be moving it outside of telepractice. 

[00:33:00] TW: If you are working with students who are at home, receiving their speech therapy, getting that buy-in and collaboration from parents is key. Making sure that they're understanding what we're doing in speech therapy. The why behind it, the how behind it, and what the end goal is very important to getting them to be on board and taking it seriously what we're doing in therapy, so that they can help with that generalization and carryover as well. 

That same is true for teaching staff as well. And I know teachers can be difficult to get in touch with because they're busy. Right? They have a whole school day. Shooting a simple, quick email. And when I say quick email, I just mean not a novel link email. Just give the information that's needed. Because this day and age, we don't have a lot of time to read a very long email. But it could be something super quick. Johnny's working on his 's' sound. These are some words that I like for you to make sure that he's saying incorrectly during the school day. 

And I would just make it short. Maybe three words. Five at the most. Something that you feel like would be easy for the teacher to remember. But also giving her some buy-in into what we're doing in therapy to make sure that she's able to carry that out in the classroom. Just her observations of it as well. 

Also, with students that I worked with that are at home, I've allowed parents to observe the session during the last few minutes so that they can see what I'm doing in therapy. Talk about what we worked on for that day. Possibly what we're going to work on for the next session as well. That way the kid knows, "Hey, my therapist is going to be sharing what I'm doing with mom or dad and I want to make sure that I'm doing a great job." Or at least putting them on notice that mom and dad are aware of what we've been working on in speech. 

If you're in the school system, of course a teacher Ð it would be very challenging for them to observe the student during the therapy session. That's when I pull in the facilitator or the para so that I can get their attention to have them be the second set of eyes. And that way, they can communicate with the teacher what it is that I'm asking the student to do outside of the speech therapy room. 

And just like in the in-person setting, when we're walking kids from their classroom to our therapy room and then back to their classroom, we're engaging in therapy even as we walk down the halls. As that facilitator is walking the student back to the classroom or going to get the kiddo, giving her some words, "Hey, ask Johnny to say these sounds. Ask him to say these words." And that way, she is carrying over what you're doing in your direct therapy with them while they're in front of the camera in the hallways just like you would be doing if you were in-person.

[00:35:43] KHK: That is actually a great tip because the student might be warmed up and be ble to have some successful productions. And maybe even encouraging the para if it's appropriate to share it with the school staff or teachers to the tips. That's amazing. Do you have any specific challenges that you anticipate when treating speech sound disorders via telepractice? Anything outside of what we've already discussed? Or if you want to kind of delve a little bit deeper into some of the things we've mentioned. And then how you would address those challenges? 

[00:36:18] TW: Yeah. One of the main ones with teletherapy is I call them my happy clickers. They like to use the mouse and click all over. And you can track their eyes. You could see, "Oh, they're looking at something else on the screen other than just the video for our teletherapy session." And that again is most addressable when you have the facilitator or para with eyes on the kiddo as well. Or the parent there as well. 

My happy clickers have been a challenge. Other challenges have been kiddos that are just very Ð they like to move. And you're asking them to sit in this chair for their 30 or 45-minute session and focus solely on what you're doing. And so, giving those breaks to get up and do some gross motor activities is a way that I've found them to help overcome that as well. 

And then sometimes you have kids that they just aren't interested. Not in telepractice. But in just speech therapy in general. They just don't want to be there. And that sometimes can be the case with in-person therapy as well. And that's when I think it's really important to connect with high interests that they have. 

For instance, I had a student, she was working on pragmatics. But I found out that she loved Minecraft. And I, as an adult, have no interest in Minecraft at all. But we know as therapists, we can show that we're interested in things and ways that make it meaningful for the child. I was at the grocery store and I happen to see a Minecraft magazine on the shelf right next to the register. I'm just flipping through it and I'm like, "Oh, my gosh. I think my student would really like this. I brought that back. 

I have a document camera, an external document camera that I use during telepractice as well. I have the magazine on the side so the document camera is able to look down on it and show it on the screen. And she was amazed that I had this magazine. She was so excited to tell me about all the things, and the characters, and the different materials you can source in Minecraft as well. It was a high-interest activity for her. And we used that magazine throughout our therapy sessions for the entire school year. It was pretty thick. And there was a lot of information in there. 

We used that throughout the entire school year for reinforcement during our teletherapy sessions. And that helped give her some buy-in and more interest into what we were doing. I used that as like a little carrot for her to, first, engage with me. And we would start out our sessions with me asking about what materials she sourced if she played Minecraft that day or the day before. 

Then we would roll into my plan therapy activities. And then throughout that session, we might go back to the magazine to talk about it. Or I would save it for the end and take like the last three or four minutes to have her just openly share some of the cool things that she saw in the magazine. And almost Ð in a way, she's teaching me about Minecraft. And so, it just really opened her up. And she looked forward to come into our sessions. 

[00:39:15] KHK: What strikes me about that Ð and I really love that example. Because it's really no different than what you would have done if you were working with this student in-person. I love that, that you were able to do that over telepractice and have it be such so rewarding for this student. 

I've also wanted to comment a little bit more about the gross motor movements. I know people give movement breaks. But I've also heard there's actually potentially some research or evidence that if you practice when you're doing these motor movements, it might help generalization. Have you heard anything about that at all?

[00:39:52] TW: Yeah, I have. And I try to do that. Sometimes it doesn't line up exactly, of course, the sounds that they're working on and the gross motor movements. Maybe the videos or the activities that you're doing don't align directly. But if you can incorporate what they have learned into the reinforcer that you're using for that gross motor movement, that would just be like the cherry on top. If you're able to do that, I would definitely incorporate it. 

For my student that I mentioned before that like the Heads, Shoulders, Knees, and Toes, it was perfect that she liked that song because she's working on her 'sh' sound. Of course, you say the word shoulders many times in that song. And so, then she was getting some practice with her 'sh' sound then as well. 

If you can align it, that would be great. If you can't, then I would think of some creative ways to maybe insert some of the words that they're working on or the sounds that they're working on in that gross motor activity. If, let's say, they're working on their 's' sound and you're getting ready to start the video, require them to say start the video. Something with that 's' sound in it. If they're working on some stops, go to make you press the start button for the video. Something along those lines that just incorporate some of the sounds into what you're doing to get the activity started, or ended, or actually during the activity itself.

[00:41:13] KHK: Love it. I love that kind of functional practical kind of way of working on different sounds. Please describe for us your approach to conducting assessments for speech sound disorders remotely. How do you really ensure that there's accuracy and reliability in your assessments? And if you could also touch upon maybe aspects of technology that we could also be aware of to kind of help facilitate accuracy and reliability in the assessment process.

[00:41:43] TW: Yes. One of the things I learned very quickly when I started out in telepractice, again, I was seeing students that were at home, was that parents wanted to help. They wanted to give the prompts to say that word again. Or from the other room, they can always, within earshot, "You can say it better than that." And so, I had to learn quickly to make sure to educate parents as well before the session where I was assessing the student. 

I'm going to be asking your child to say different words. And I need to hear exactly how they say the words without any prompting. And I would let them know, if they say the word or the sounds in the word incorrectly, you won't hear me correct them because I am collecting information to guide the treatment plan or the goals that I'm developing. Please don't provide any cues or reminders to use certain sounds correctly. Just really allow me to grab a snapshot of what their skills are in that moment. 

I've also shared that with the facilitators as well. I haven't had the experience with facilitators interjecting as much as parents. But just giving them that knowledge ahead of time of what their role is, which is really just to be there to support the child and make sure they're focused on the screen during the assessment. 

The way that a lot of companies have developed their digital assessment materials throughout the pandemic, it's been really helpful to us as telepractice. When I first started, I was using the actual physical test plates themselves and having that held up. Sorry. Not held up. But put on the table next to the child. The facilitator would have the assessment materials and she would angle it so that I could see part of it, they could see it. And so, I would have to tell her when to flip the page and those things. We've come a long way in that regard to where we don't have to do that. 

The way that these digital assessments have been developed, I think it lends itself to having the child be able to focus on the screen. If you can maximize the window so that the child is only seeing the digital test plate on their screen would be super helpful. I tend to like to have their camera turned off so that they aren't distracted by seeing themselves. And then just making sure that Ð especially for the articulation assessment, that I have my headphones on. So that I'm not missing out on any distortions of sounds that I might not be able to pick up on if I'm not wearing my headphones. And I also ask for the child or the student to be able to wear headphones as well.

[00:44:20] KHK: That makes a lot of sense. Thank you for going through that. And then, I guess, if there are glitches or just, I guess, internet connectivity issues, at what point do you say, "Okay, this is going to not work." and just kind of stop, put the brakes on this? Because I know we try to really be positive and make this work. But at what point would you say this isn't going to work? 

[00:44:46] TW: Yeah. If there are a lot of audio or visual glitches that are happening, there's a lag in being able to hear them. Maybe you hear them but their mouths are moving on the screen. Or vice versa. And you're not able to troubleshoot that, then I think that might be a time when you need to just stop the evaluation and maybe look into a speed test to see what their upload and download speeds are. Also, checking your own devices as well. 

I like to connect my laptop directly into my router so that I'm not relying on Wi-Fi, even though I have good Wi-Fi and we stream things here at home. But I want to make sure that if there are connectivity issues, I want to be able to say I can rule myself out because I'm hardwired into the internet. Most kiddos that you're going to work with for telepractice are going to be using the school's Wi-Fi. 

And so, then, that way, you know that your device is set up adequately. And then you can troubleshoot to see if there's any way to resolve the issues that they're having. And if they're able to hardwire, that would be great. Sometimes you might need to have them on a different device or a different location in the school to kind of help overcome some of those tech issues as well.

[00:45:56] KHK: That's very helpful. Thank you so much. What strategies do you use to engage and motivate clients outside of what we've already talked about? Or if you want to kind of reiterate some of the things that have really worked. Particularly with children, when you're doing specific work on articulation or phenology during teletherapy sessions.

[00:46:16] TW: Yeah. A lot of the digital resources that we can use now during our teletherapy sessions have those reinforcers and those rewards embedded in them. You might have stars that appear on the screen if they do something correct. Or there might be applause that happens in the background. Ultimate SLP is a great digital resource. Boom Learning is also very interactive. 

I like to make the session as interactive as possible. If the student is able to click on things when you asked, ask them to and not when they're not supposed to be clicking, it's very helpful to have those interactive activities. Because that, again, engages them in the session. It's entertaining for them. And they're not just sitting there as a vessel taking your instruction and then following your directions. Using those interactive tools. 

If you need to use a static type of activity, like a worksheet, Super Teacher Worksheets has some good ones. If you need to use something like that, then allowing the child to highlight certain sounds on the worksheet. If it's a PDF, you can use the highlighter tool there, so that they can find the letter. If they're younger, maybe they're just finding the letter. A little bit older, they're looking for a specific sound. That way, they're engaged in the therapy session. And that could be a bit of a reward as well. 

Even for some of my tougher behavior kiddos, I've recruited the help of teachers or parents to have something tangible for them to experience at the end of the week. If we have therapy twice a week, whatever that last day of therapy is, maybe they get extra time at a sensory bin in the classroom. Or maybe they're allowed to read for more time Ð a little bit more time than other students in the classroom. 

For one of my students, he liked to just take a walk around the lower level of the school, so he could earn that time out of class to just take a quick two, three-minute walk outside of the classroom with his pair. And that was something that he worked for. Again, finding what their interests are. Connecting that to either what's going on in the school or at home could also be a way to reward and be a reinforcement for therapy. 

[00:48:29] KHK: And that segues really nicely into the next question I really wanted to get your feedback on. How do you collaborate with all of these key stakeholders? The parents? The caregivers? Other professionals that are involved in the student or clients care especially when telepractice where, again, you're remotely communicating with them? 

I mean, we can give the ideas for the activities. But how can we make this motivating or meaningful for them to execute the suggestions that we're going to give them? And any other additional ideas on how to help with those generalization activities would be very, very welcomed. 

[00:49:11] TW: Yes. I started out with sending emails in telepractice. That's how I learned quickly. That a wordy, lengthy email doesn't usually get read all the way through. I started using more concise language. Bullet points to point out exactly what the things are that I want them to focus on. 

And then I moved to using Google Voice. If you have a Google Chrome account, you can get a free Google Voice account as well. And that is how I use Ð that's what I use to text message parents. And some teachers will also allow you to text them as well. That way, I'm not giving out my personal phone number. The facilitators or the pairs might also allow you to text them. And that way, you can communicate with them quickly. Right? 

Email can get lost in an inbox sometimes. Text messages, people typically have their phones with them at all times. And you can send a link for a video. You can send a quick text message to say, "Hey, this is what we worked on today" Or, "This is what the student is working for this week." Or, "Can you listen for these specific sounds in the classroom?" Text message via Google text or just a digital phone number. 

I would shy away from using your personal cellphone just because you want to make sure you set up boundaries between personal and work. And so, that way, you're able to communicate quickly. And I feel like a little bit more effectively with those key stakeholders in the district for the school that you're working into. 

[00:50:37] KHK: As far as the videos, would you use a specific app or just the videos that you can take from your smartphone? Do you recommend anything? I know certain schools have Ð especially during, I think, online learning where there was only the option of distance learning, there was like Flipgrid, I think. Do you have them download an app? Or do you just use your own camera on the phone and do it that way? 

[00:51:02] TW: Yeah, I typically will share a YouTube video or something that I feel like is really easily accessible, so then they don't have to download an additional app on their phone. With the parents, for the kiddos that I saw that were at home, I did ask parents to download specific apps on the iPad or their phone so that they could use some of the same materials that we use in the therapy session at home. But I didn't want to burden teachers with that as well. I would try to find a short YouTube video that discussed, or follow through on, or elaborated on what we were working on in the therapy session. And that seemed to work really well. You can just tap it. Watch it quickly. Share it to your email if they want to. But it's just something that they can have with them pretty easily. 

[00:51:48] KHK: I'm a big believer in keeping things simple. I love that for sure. What are some technology or tools that you utilize to enhance the effectiveness of teletherapy sessions for speech sound disorders? I know you've kind of touched on them. But let's really kind of summarize them at this point.

[00:52:07] TW: Yeah. The document camera, the external document camera is something that I feel like is helpful. Because not everything that we use is going to be this interactive digital material. Sometimes it could be static. I remember I had a student who was younger and really loved PJ Masks, the cartoon. And at that time, my son was about the same age. And he also had some of these little figurines from the show. I just went to his bedroom. Borrowed some. And I used the document camera to show the figurines on my desk doing certain actions. And I had the student using specific words with sounds that we were targeting to tell Catboy what to do to Owlette. Some of the characters from the show. 

Having that document camera can help you bring more static materials to life. And so, you're not relying just on the digital materials. Again, hardwiring your device into your internet router or modem is going to be very helpful to just make sure that any connectivity issues are on your end. 

I also have used the media recorder on my computer as well. If you have a system that can record. For kiddos that I need to have them analyze their speech in a deeper way, I've recorded just the audio on my computer and then we play it back so that they can listen to it and analyze it themselves. 

And I've gone as far as creating a simple Likert scale and reviewing it with the kiddos. Of course, age-appropriate. One being, you can't understand anything that you're saying. Five being, all of your sounds were perfect. And then we would record him either reading or a small snippet of him talking about a high-interest topic. Then we would listen back to it together. And we would stop at the end of each sentence or each thought if it was just conversation, and then we would rate it and we would compare. 

For this one, I gave you a score of this. What did you give yourself? And he honestly was scoring himself appropriately. He wasn't just giving himself fives just because he wanted to be done with therapy. But I was able to just get that buy-in from him in using the recordings, which is something we would also do with in-person as well. Using the recordings is something that can be helpful as well to just enhance just the engagement during the therapy session and also the effectiveness as well. 

Because I feel like if you're just asking them to think about how their speech sounds in retrospect, sometimes they're not able to hear it in the moment. Having that recording is super helpful for you to be able to show them, "Hey, on this one, your 's', I could hear the air coming out. Do you hear that? No. Okay, let's play it back and let's listen to it again." And you can have multiple exposures to the same production to help them hear how their sound is being produced and what they can do to correct it.

[00:55:05] KHK: I love that. And what age ranges do you think this activity would be appropriate for? Would you use this for like preschoolers as well? Or what ages do you think is appropriate for this? 

[00:55:16] TW: For the recording, I would say a more mature second grader. Probably third and up would be more appropriate. I think that they're able Ð their acuity is just a little bit better to be able to hone in on those specific sounds. If you are working at just the word or the sound level, then maybe some of the younger kiddos, like kindergarten in first grade, would be able to actually hear the difference and make those judgment calls. And I use really simple, "Give me a thumbs up. Did it sound the way it was supposed to? Or can we make it better?" 

I've used the thumbs up, thumbs down with them. If you're working with younger kiddos, I think just that that sound, the isolation level. And then, also, at the word level, in a specific position of the word would be more helpful to getting them to hear their sounds more accurately. 

[00:56:04] KHK: Very good tips. Let's highlight some examples of evidence-based intervention techniques that you incorporate into your telepractice sessions for phenology and articulation.

[00:56:15] TW: Yeah. Some of the same techniques that you would use in-person. The Cycles Approach by Hodson, that's one that can easily be incorporated into a teletherapy session as well. Weiner's Minimal Pairs Contrast Therapy is also another good one. Van Riper's Traditional Motor Approach is definitely tried and true. I know a lot of therapists have used that for many years. And then Gierut's Complexity Approach as well is one that could be used in telepractice. Those same therapy approaches that you would use in-person are also transferable into the telepractice setting as well. 

[00:56:55] KHK: Thank you so much. I know we're digging into our grad school textbooks some of these names. But they are very familiar for sure. How would you monitor progress and then evaluate outcomes when providing teletherapy for speech sound disorders? And what are some good methods to use for these measures remotely specifically? It can get kind of cumbersome. And I know we tend to still rely Ð those of us that have been around for a while rely on those sticky notes. But we're seeking practical advice on how can we monitor progress.

[00:57:32] TW: Yeah. With in-person therapy, I've always had data sheets for my students so that I could look at their data sheet to track progress over time. And the same is true in the teletherapy space as well. I am more old school than I think I like to admit sometimes. I like a nice legal pad. And I take my data by hand. I trust computers. I use them every day for work. But technology can be friend or foe. It just depends on the day. 

I like to take my data by hand, so that, that way, I can make sure that I have it with me if I'm doing my session notes. While my son's at swim lessons or football practice, I can have my notes with me there. But there are some digital materials that will allow you to capture data while you're actually conducting your teletherapy session, which I definitely think is more efficient than handwriting it and then transferring it back into your IEP software that your district may use. You just have to figure out what works best for you. 

But I know Ultimate SLP, some of the platforms that some teletherapy companies use, have that in-therapy data capture that you can use. And that way, you're able to not only take the data there, but then also track the progress as well from session to session. 

The same that you would do in in-person therapy with maybe your studentsÕ folder, or their binder, or your data sheets, you can incorporate those same data tracking methods in your telepractice as well. And I will say, it does take a little bit of getting used to with taking data digitally. At least a did for me. Because I didn't start my career out that way. Making that transition was a little bit of a learning curve. 

But once you practice it, as with anything, practice makes progress. We say that to our students. It applies to all areas of life as well. Practicing with it, you get more efficient at it. And I think that will help you be able to simply copy and paste if you need to track data in progress for Medicaid billing or in your platform's data tracking as well.

[00:59:40] KHK: I know a lot, like you mentioned, some of these programs or different tools incorporate Ð Ultimate SLP incorporates the data tracking tools. Are there other tools or apps that you're aware of that we could mention that would help with that? Or where people can look for additional tools? Because I know people are developing apps constantly for this.

[01:00:04] TW: Yeah. I know Super Duper has an app as well that will allow you to input the goals in there and then track their data as well. If you're working with a teletherapy company, most times, the platform will have a way for you to track the data right there in the platform that they use for their teletherapy session. I would always start there, is the best way. So then that way, you're not putting more work on yourself with tracking data in two different places. You can track it right there in the therapy session as well. 

Teachers Pay Teachers also has some digital materials on there as well for you to be able to track your data. But a simple Google search of digital data tracking for speech therapy will give you a list of apps that you can download. Just find one, I would say, that is able to be used on your laptop. A lot of them, you can download the app on your phone. But I wouldn't suggest tracking data on your phone and you're looking down and you're looking up. Have something that you can use on your laptop so that you can just seamlessly be engaged in the session and then clicking your pluses, or minuses, or however you're taking data right there on the screen. And having a second screen is so helpful in telepractice. 

I was not a fan of a second screen. My first year doing teletherapy, I just said, "I don't need a second screen. I can just make this box small here and I can make this box big here." And then I got a second screen and it was like my mind was blown. Why have I been doing this harder than I have to when I can have the activity up on my second screen and have it large enough so that I can take my data on this screen at the same time while I still have full-view of the student in the camera as well?

[01:01:48] KHK: Amazing. And I also want to give a quick shoutout to Dr. Tara McAllister of NYU who's also doing some specific biofeedback research for the sound 'r'. And if you want to Google her name, I believe her project is called BITS Lab. But if you Google Dr. Tara McAllister NYU, you should find that. But that's some really incredible work she's doing with biofeedback, specifically on the speech sound of 'r'. 

I did want to also, as we're kind of wrapping up here today, address two final thoughts. One being, that we do work with a lot of individuals who may be exposed to other languages, how do you address those cultural and linguistic diversity issues when working with students remotely over speech sound disorders? 

[01:02:44] TW: Yeah. Again, it goes back to kind of the theme of what we've been talking about today the same way you would with in-person and I think in an even greater way. Because there are so many digital resources out there in various languages that you can pull from. Bilingual SLP is one that comes to mind. And you can have ready-made materials right there are your fingertips. 

Of course, the cultural diversity piece as well. I've oftentimes, in the session with the student, researched some things about their culture so that they can share with me. We pick out words that have the sounds that we're targeting. And so, then to just give them that buy-in. 

With in-person, I might have to go find the book at the library or another physical material. But when you have the teletherapy session in action and the child is right there, you can do your search, your Google search prior to the session so you know what is going to be pulled up. And then that way, you can explore their culture and their language with them in ways that are applicable to your therapy session and the sounds that they're working on too. I feel like we kind of have the edge in the telepractice space with being able to just have so many resources literally at our fingertips.

[01:03:55] KHK: That is definitely the truth. I find myself learning something new every day, honestly, in this field. Would love to wrap up with a specific case or a scenario where you had some particular Ð like you made a difference basically working over telepractice. And what factors contributed to this success that you might have had in this specific case that you worked on? 

[01:04:18] TW: Yeah. I had a third-grader. She had a repaired cleft lip and palate. She was working on her 's' and 'z' sounds. She also was wearing braces at the time. And we had a lot of nasal air emissions. And I just could not figure out Ð she was a transfer student. So, I didn't do her evaluation. She came with her IEP already established. I was just picking up where the last therapist left off. And I just could not figure out how to get her to have the sound and the airflow in the correct direction. 

I walked on through a short oral mech exam with a little flashlight, just like a penlight almost, and shine that up in the roof of her mouth. And I'm asking mom, what does she see? Giving her some comparisons about when you put the light up to a surface that's going to be harder and flush, it'll be a darker color. When you put it over something that may have some air or space behind it, it's going to be Ð you can actually see the light shining through it. And sure enough, she is scanning the roof of the mouth. 

And at first, she did it a little bit quickly. Not really fully understanding what I was looking for. I asked her again, go back and really just take your time. Looking with the flashlight and kind of explain to her why I was looking for it to be able to address maybe where this possible nasal air emission was coming from. And sure enough, with that small flashlight, she told me that she saw an area in her child's soft palate that she felt like the light from the flashlight was going through. 

And so, they went to the orthodontist first. And then the orthodontist referred them to the oral surgeon. And it turns out she had a submucous fistula. She had a small little hole there that was covered up by soft tissue but it was still there and some air was escaping through there. And in talking with mom, she said when the student had her cleft lip repaired, she somehow tore out the stitches too early. And so, then they had to go back and do a second stitching of it. But they did plan for a surgery over the summer to help repair and have that fistula closed up. And she came back the next school year and that nasal air emission wasn't there anymore. 

And it was through the same techniques that I used that I would have used in-person that I used through the extension of having the parent being an extra set of arms for me in the room. And using my clinical skills to help break down what it is I wanted her to look for was super helpful. 

I think in all the clinical knowledge that we have and all the clinical jargon that we know, being able to break down our knowledge into more just general everyday language is always helpful so that we can communicate what it is we want the facilitator, or the para, or the parent to be a to do on the other side of the camera as an extension of us since they're in the room for the student. 

[01:07:21] KHK: I love that. That's an incredible success story. Well, we're at the end of our time. Thank you so much, Dr. Tiffany Williams. We truly appreciate all the research, education, expertise you provided about this topic, speech sound production in telepractice. Thank you for your time. And we'll see you at another episode of speechtherapypd.com.

[OUTRO]

[01:07:43] ANNOUNCER: Thank you for joining us for tonight's course. To complete the course, you must log into your account and complete the quiz and the survey. If you have indicated that you're a part of the ASHA registry and entered both your ASHA number and a complete mailing address in your account profile prior to the course completion, we will submit earned CEUs to ASHA. Please allow one to two months from the completion date for your CEUs to be reflected on your ASHA transcript. Please note that if this information is missing, we cannot submit to ASHA on your behalf. 

Thanks again for joining us. We hope to see you next time.

Thanks for joining us at SLP Learning Series. Remember to go to speechtherapypd.com to learn more about earning ASHA CEUs. We appreciate your positive reviews and support and would love for you to write a quick review and subscribe. If you like this and want to hear more, we are offering an audio course subscription special coupon code to listeners of this podcast. Type the word SLPLEARN for $20 off. 

With hundreds of audio courses on demand and new courses released weekly, it's only $59 per year with the code. Visit speechtherapypd.com and start earning ASHA CEUs today.

[END]




SLPL S7E12		Transcript

	©Ê2024 SLP Learning Series	29