Making Sense of Selective Eating - Ep 2
[00:00:00] 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.
[00:00:42] Each episode has an accompanying audio course on speech therapy pd.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.
[00:01:04] Madi Metcalf: Hi, welcome to Making Sense of Selective Eating. My name is Madi Metcalf. I'm a speech language pathologist with an interest and a passion for pediatric feeding disorders. I'll be your host for the SpeechTherapyPD. com miniseries. Today's course is one hour and will be offered for 0. 1 ASHA CEUs. If you're part of the ASHA registry and you want your CEUs reported, you must have your ASHA number and address in your SpeechTherapyPD.
[00:01:26] com profile. Please allow one to two months from the completion date for your CEU to be reflected on your ASHA transcript. Now, without further delay, I would love to welcome Lily Gullion, MS, OTR/L. I'm so excited to have Lily on this podcast to offer that OT perspective, but even better, she's going to be talking about addressing pediatric feeding disorders in the public schools.
[00:01:48] Lily Gullion is a PhD candidate in Occupational Sciences at the University of Chapel Hill, North Carolina, and is a licensed occupational therapist in the state of North Carolina. She has a background as a pediatric OT in outpatient settings and in school feeding. Currently, she is working on her dissertation.
[00:02:04] Dissertation, which is a critical discourse analysis of school meal policies from 2020 through 2024. Additionally, Lily is passionate about disability advocacy and is involved with disability policy organizations. Lily received the 2023 NC North Carolina Occupational Therapy Association Award of Advocacy.
[00:02:24] She is affiliated with Feeding Matters and holds memberships with the American Occupational Therapy Association and the Council for Exceptional Children. Lily's non financial disclosures are that she volunteers with Feeding Matters and is a member of AOTA and the CEC. My non financial disclosures is that I'm a volunteer for Feeding Matters, a member of ASHA, ARCSA, and a member of SIG 13.
[00:02:47] Lily's financial disclosures is that she her doctoral program is funded under a U. S. Office of Special Education Programs leadership grant. CFDA 84. 325H. Her views expressed during this podcast are not representative of this grant or OSCP. And mine is that I receive an honorarium for hosting this podcast.
[00:03:06] And with that, welcome, Lily. How are you doing today? 
[00:03:10] Lily Gullion: Yay! I'm so glad to do this tonight. We've been talking about this for a while, so I'm 
[00:03:15] Madi Metcalf: happy to be here. Ah, I'm so excited. PFDs in the public schools such a really important topic and I'm so happy that you're here to shed some light on it. Just for a quick starter question, Is treating, feeding, and swallowing in the schools relevant?
[00:03:32] Lily Gullion: Yes, it is so relevant. 
[00:03:35] Kids have to eat and have to drink, and that happens all during schools, and kids with PFT are no different. And so it is, I would say, one of the most relevant things that we do as occupational therapists and speech therapists in the schools is to make sure that their eating and drinking is safe.
[00:03:54] And Developmentally appropriate and socially appropriate. All those things that we want to get to with our kids. 
[00:04:01] Madi Metcalf: Absolutely. And really quick. So you're the first occupational therapist that's been on making sense of selective eating for any SLPs that might be wondering why an OT is talking about feeding.
[00:04:11] Can you just speak really briefly on the role of an occupational therapist on a feeding team?
[00:04:17] Lily Gullion: Oh, yeah. 
[00:04:18] So in occupational therapy school, we do have some information about pediatric feeding, and it's Is from a different lens. Typically, we're looking at the occupation of meals in a little bit more holistic, a little bit less specific about musculature and things like that.
[00:04:37] So, with eating, eating is a daily occupation, a daily activity that's meaningful and relevant to kids lives. So it's within our scope of practice. And then eating We, you'll oftentimes see OTs working in feeding in outpatient or in hospital settings, NICU I'm thinking about but then school feeding, it is a little bit different.
[00:05:01] I, I haven't met too many OTs that are in school feeding, but the ones that I have are usually in the minority in their group. They're usually several more SLPs in this area. But we offer a really unique lens to looking at eating in a full contextual way. And I think my favorite way to think about it is in schools, especially.
[00:05:22] There's so many different transdisciplinary activities that happen in schools. Like, when you work in schools, You see and do all sorts of things. You're really working within your scope, obviously, but you're really working with teachers and paraprofessionals and nurses and admin and all these different people.
[00:05:40] So as school feeding team with SLPs and OTs gets a really well rounded view of the kid and how to handle tough situations. 
[00:05:50] Madi Metcalf: I love that perspective of just like each individual can bring like a different lens just to create that better idea of like that whole child sitting in front of you. Because I know sometimes it's easy to get pigeonholed in your area, but there's So much to be gained from listening to other professionals that are on your team.
[00:06:08] Lily Gullion: Yeah, there's, and actually I'll point out too, there's a lot of good information out there that suggests that even physical therapists should be on school feeding teams for adaptive seating and cafeteria mobility and all those kinds of things. 
[00:06:21] So the sLP and OT have a little bit more like consistent role with actual eating, but the school feeding team can be a lot of different professionals.
[00:06:31] Madi Metcalf: Yeah, I was recently moderated for one of Michelle Dawson's course about PFD in the school and she talked that, you know, you might need to be collaborating with the nurse because the nurse is the one that's administering the intro feeds and, like, the school bus driver can even offer some really good things that the kids eating a snack on the school bus on their way home.
[00:06:48] So it can just be such a wide range. variety whenever you're looking in that setting. 
[00:06:53] Lily Gullion: Oh yeah. 
[00:06:54] Madi Metcalf: So speaking about your feeding team, can you explain what the role of the school feeding team is in managing safety during school feeding compared to supporting development and progression? 
[00:07:06] Lily Gullion: Yeah, totally. So there's several different models of like school feeding teams.
[00:07:13] I think starting from kind of the basics, let's say you're in a district that doesn't have an official like school feeding team and a child has an IEP team, that would be your kind of like de facto, like natural way to work on feeding either safety or progression. So for kids that have IEPs or 504s, you can be on their like feeding team.
[00:07:41] They can have feeding goals, which is something that I think a lot of districts don't promote, but that is totally part of IDEA. Let's say you actually are in a district that has a separate feeding team. So that could be either they are people that work like in general on the IEP teams and then also take a role of have a special interest in feeding.
[00:08:06] Or like in the district I worked in, we actually had an outside feeding team that worked itinerantly across different schools. So there's these, that's kind of, in general, the 3 kind of models of feeding teams. But so taking the ones that are itinerant, this would be a separate OT, SLP, potentially nurse, maybe other units.
[00:08:28] Important specially related service personnels that collaborate with the student and the teachers and the parents to really make sure that the student. is having a safe experience at school. And so those people, the SLP, the OT, whoever, will come and train like the paraprofessionals or the teachers how to make sure that every meal is consistent across the different settings.
[00:08:53] So just like, For an actual example, when I worked in schools before I went back to school to do my Ph. D. I had half of my time was with typical doing O. T. from kindergarten to 21. so I saw those kids. Those were my kids that I was working on all sorts of goals with and then half my job was going across school districts and with an S.
[00:09:18] L. P. my Partner in our feeding team, and we would do evaluations on safe feeding for these kids kind of across school districts, and we would collaborate with the local S. L. P. S. and O. T. S. That saw them in their I. E. P. To make sure that we had all the information so that we can give the best kind of safe feeding guidance for them.
[00:09:38] Madi Metcalf: How would you divide, yes how would you divide your responsibility between the SLP and your OT role whenever you're doing a feeding evaluation? 
[00:09:47] Lily Gullion: Yeah, I think I've seen different districts do this differently. The SLP and I pretty much went to all evals together. So we split it was, it was so, I love her.
[00:10:01] She's my favorite. I've had Two SLPs on that team, and they're both incredible, incredible therapists and collaborators, but both of those experiences were really cool. We got along very well, and we're able to just figure out the timing that we could either collect paperwork, different parts of the paperwork process separately, and then come together for in person evaluations.
[00:10:26] That was really important for our district. We had a lot of very complex eaters. And so we had kids that ranged from like an allergy and maybe even selective eating. But then we had a lot of kids that were trying to wean off G tubes or had very high aspiration risks. So we wanted to make sure that we had multiple eyes on these kids and that we could really figure it out.
[00:10:50] And then we would do follow ups to train the teachers or to check and see if there were questions. And we had a schedule, kind of a routine schedule for that. And we would separate those based on the, I don't know, the kids exact needs and who was more comfortable with what kind of cases. 
[00:11:08] Madi Metcalf: Okay, so we had a question.
[00:11:10] Whenever you're doing the evaluation or working with this, with these kiddos, are you working mainly on like positioning, adaptive eating tools, drinking tools, the sensory domain? Is that kind of what your areas are focusing on? 
[00:11:22] Lily Gullion: Yeah, those are absolutely parts of it. So, We had an evaluation and I, there's plenty of resources out there for different types of evaluations, but the evaluation that we liked had all sorts of things from the environment of the cafeteria or the school classroom where they're eating all of their seating type of stuff, all of their behavioral and sensory type stuff.
[00:11:46] I typically wouldn't do a formal sensory evaluation because that would be the role of their school IEP. OT, and typically we would have those on file for a lot of the kids they had already gone through like sensory profiles. Anyway, but then I would go through kind of like sensory evaluations and then together we would watch and do our observation in person with how the kind of feeding went down.
[00:12:11] And I would also say that I had specialty training in feeding before going into this role in outpatient. setting. Like that was associated with a medical clinic. So I was on a feeding team and had gotten pretty familiar and comfortable doing observations right alongside an SLP and, and doing that kind of interdisciplinary collaboration before going into the schools.
[00:12:37] And I think that's a big barrier to like a confident SLPs and OTs in the schools is not having that kind of background and a trained eye to look at swallows and make decisions about bite sizes and things like that. 
[00:12:52] Madi Metcalf: Yeah, I think that's such a great point that you bring up because I know that there are And so I'm in Arkansas and we've recently had a really big push for getting PFDs to be looked at in the schools.
[00:13:03] Like we just had this really awesome feeding guide for the schools come out. And so, but then that raises the question, a lot of the SLPs and other professionals in the schools, like don't feel confident working with feeding and swallowing. So got to figure out how to make those educational opportunities.
[00:13:21] More available and maybe more teaching in school. But that is a whole other really big topic to dive into. 
[00:13:27] Lily Gullion: Totally. 
[00:13:28] Madi Metcalf: So how does pediatric feeding disorders fit into IDEA and FAPE? And for those that might not know what those are, can you also say what they are? 
[00:13:37] Lily Gullion: Yeah, absolutely. So right now in America for the past couple of decades, we have IDEA, which is the Individuals with Disabilities Education Act.
[00:13:48] So that's the act that provides Pretty much provide special education. There's a lot to IDEA. It's quite complicated. But one of the things that is kind of foundational with IDEA is this provision of FAPE, which is free appropriate public education. FAPE is has a lot of implications kind of across the board for kids with disabilities.
[00:14:12] For kids with pediatric feeding disorders, I think it's especially relevant because it really shows and it actually explicitly talks about in the law that extracurriculars and non academic tasks are still part of FAPE and therefore can be part of the Students individualized education plan, which is that IEP.
[00:14:33] So, for instance very classically in special education OTs will work on, like, toileting tasks or toothbrushing tasks or other activities of daily living because it is part of that child's education plan. So they can write goals for it, they can Collect data for it. They're going to do occupational therapy treatment in the schools in the context for that.
[00:14:59] This is kind of what opens the door for feeding to be addressed in schools. One of the many ways that you can argue that feeding should be addressed in schools is through this free appropriate public education understanding. Now saying that it is quite nuanced to figure out if IDEA and FAPE are appropriate to think through for intensive feeding services.
[00:15:27] So what I, what I kind of mean with this is that we definitely know that kids need to be safe during schools. And then we know that there can be feeding goals written in the schools, but then how intense can we be doing really intense one on one services? Should we be doing things that paraprofessionals can do and the occupational therapist or the SLP is monitoring and there's.
[00:15:54] There's a lot of nuance and a lot of debate on that topic. So one thing to kind of think about, like you were saying in Arkansas, speech language pathologists are concerned about their own competency doing these things. You know, we can't be going into the schools and trying to do some, like, really intense oral motor science.
[00:16:14] stuff when we don't have a medical we don't have anything like in case of emergency. We also don't have swallow studies in the schools. So it's like, you know, there's a limit to what we can really do and how we can see progress and things like that. So there's a lot of people that will argue that it is not educationally relevant.
[00:16:37] I think that that's very outdated point of view. I think that it is educationally relevant to work on feeding in the schools, and a lot of districts have done so quite successfully. But I also think that you, as a feeding therapist in the schools, need to be really conscientious about what you can provide, what you're capable of providing, what the environment will allow for provision.
[00:17:00] You also, you don't want to be pulling out students from their meals, which is their social time, their time to be with other kids, the time that they can be modeled things and be doing you know, more intensive intervention services. So there's some balance to strike, and I think this is a conversation across the board in schools, like school SLPs and OTs have to think about this with all sorts of goals, and feeding is definitely part of that.
[00:17:29] Madi Metcalf: That's really interesting, like just walking such, kind of like a fine line of how do I service this kid without, you know, taking away and like recognizing your limitations while you are in the school. So would you say that sometimes in the school you're going to be looking more at accommodations and modifications more so than that like development of skill and progression?
[00:17:53] Lily Gullion: I think accommodations and modifications are pretty clearly laid out in IDEA that they're appropriate for feeding. So those are things like different adaptive utensils or even support staff nearby or texture modifications. So those things I would really encourage school SLPs and OTs to think and to advocate for because they're not even crossing the line into, is this too intensive?
[00:18:18] So for instance, if you, if it's. Student is safer if their bites are cut up into smaller pieces or if they tend to really over stuff. That's a big concern in schools. And so they do need to have either paraprofessional right there or paraprofessional with every 2 or 3 kids or something like that.
[00:18:38] That can be an accommodation modification that's in the IEP and set. What I love about having it in the IEP and what I really encourage is that that means that if the student goes to a different district, if the substitute teacher is there, if there's anyone else in the classroom during that mealtime, legally, they should be on the same page because they've all read the IEP.
[00:19:02] So for goals I do think that a lot of these goals can be accomplished in school. So, for instance, like I had a student who was in middle school, she had some pretty significant support needs and she was really successful with some kind of gentle queuing with Being able to scoop her food and then the guiding to her mouth was challenging for her.
[00:19:29] But after two years of working in that school and writing goals consistently working with her consistently training all the paraprofessionals of how to do this queuing when to back off when to adjust. We got her eating without that much support and that's the kind of thing that I think schools really have the opportunity to do every day feeding with, you know, with goals is, is really important and it should be done.
[00:19:55] Madi Metcalf: We had somebody chime in and say that they specialize in feeding and swallowing in the hospital setting, but in the schools, not so much. Finding, she's finding it hard to understand how it's her responsibility because she thought that the reason for being in the school was to help our students access the curriculum.
[00:20:09] Do you want to dive a little bit more into how feeding is academically relevant? 
[00:20:13] Lily Gullion: The curriculum is a really good entry point into thinking about our role in school feeding. To access the curriculum, the child needs to have the nutrition and the alertness to do school.
[00:20:26] School is not also just about education, and that's clear. Sorry, not about curriculum. That's clear in IDEA as well. Non academic times are listed as essential portions of the child's day, so that includes like socialization periods. So it's the same argument of, like, why we would need adaptive physical education or any of these kind of non reading, writing, arithmetic times to work with kids with disabilities.
[00:20:54] Students with disabilities need to be included and need to be in their least restrictive environment. For free, appropriate public education, and if that means that they need to have S. L. P. R. O. T. support to make sure that they're able to eat able to be with their peers during meals and able to be safe.
[00:21:13] That is part of our role. 
[00:21:15] Madi Metcalf: It's been really eye opening talking with you. So I know Lily because one of my OT friends here in Arkansas got me in touch with her whenever I was getting into feeding and so that she could offer me that OT perspective. And then she started her PhD, which is really looking at feeding in the schools.
[00:21:33] And I've had a lot of questions about feeding in school. And so we've had a lot of conversations and it was just so eye opening to me. Like, Being able to interact and have those engagements during our day, thinking back on my own school days, like, I really look forward to lunch and sharing, you know, talking about the chicken nuggets with my peers and things like that.
[00:21:54] And, you know, that does bring so much enjoyment to our school day. And if we think back to like principles of learning, if you're not enjoying your time, if you're not feeling safe and nourished, that's going to impact your ability. To have that like readiness for learning. 
[00:22:07] Lily Gullion: Yeah, and I think, you know, it's tricky with the related services to figure out where that line is.
[00:22:14] But I would really encourage if we're thinking through like, what is the school day? It's. It's really not just about the time that you're like learning the curriculum. And something that a lot of speech therapists work on in the schools is like articulation, right? Well, that's accessing the general curriculum and being able to communicate with peers is part of the role of speech in schools.
[00:22:38] And very similarly is being able to complete these daily activities safely and with peers. 
[00:22:44] Madi Metcalf: Like, not only that, but like, I've had patients that were super selective eaters, and they weren't able to feel safe and comfortable eating in their cafeterias. So they would go the whole day without eating a snack or lunch at school, and like, My body doesn't feel regulated.
[00:23:01] I can't focus if I'm feeling hungry because, you know, I forgot my lunch or something. So, yeah, it's a basic human need that we have to have met sometimes. Okay. So you had another question come in kind of in the same I-E-P-I-D-E-A-I-E-P realm what are your thoughts on working or targeting general feeding related supports as a member of the IEP team when there's no direct evaluation information related to feeding, eating dysphagia in the most recent locked evaluation?
[00:23:29] Or does the district not have to have a formal process for evaluating individuals with these needs? 
[00:23:34] Lily Gullion: Great question. So in general there is not a specific recommendation from Department of Ed or USDA about the formality of evaluations. I say that because I just want to cover kind of the. The legalese first and of course, I am also going to say I'm not a lawyer.
[00:23:55] And while I've spent a couple years now diving into the laws around this, it is still hard to understand truly. But so as far as like doing a formal evaluation. That can be something where you're going to need to see case by case, like how much information you need. So, for instance, if there's a kid, if you're a SLP on an IEP team, and You're doing the IEP.
[00:24:26] You're asking about parent concerns and the parent says something simple like, you know, we he had a really hard time with this, with the utensils at school because they're really, they're too light. And he just, I know that he's not getting it. Okay. So maybe the parent wouldn't know that because they're at home and not seeing in schools, but case in point, if there's like something like utensil issue, Okay.
[00:24:49] And if it's a simple accommodation, like, you know what, we're going to do weighted utensils, or we're going to do this adapted utensil. That can be an accommodation without like a full on evaluation. Now, I think best practice, like you would check in on that, right? Like you put any accommodation on IEP, you need to make sure that it's being used with fidelity and that it's appropriate and that people know how to use it.
[00:25:10] And but there's a lot of accommodations and modifications that can be rather simple. Positioning to a lot of OT kind of strategies for making sure there's something underneath their feet or if they're able to be in a safe position during meals. Some of those things can be requiring more of, like, an actual in depth look, and then some of those things can be pretty simple.
[00:25:34] So if you don't have, like, a school feeding team with a really big formal evaluation process, you can still do a lot of these things. If there is a school feeding team that you're Like, able to get roped in on, you're going to have more information and potentially that simple thing, like a utensil is actually a bigger thing and could require more and more supports and services.
[00:25:58] So it's great to have the formal feeding team, like, come in and do an evaluation, but I just don't want to discourage anyone, especially from districts that don't have it. Formal feeding teams. If you're on the IEP team, you are certainly part of their school feeding experience. 
[00:26:16] Madi Metcalf: If the child has an outpatient speech therapy evaluation showing a feeding need, can that also be used?
[00:26:23] Like, maybe the parent comes in, they're like, hey, my child's getting feeding services at an outside clinic. We would need, like, these accommodations would help them. Could that be accepted? 
[00:26:32] Lily Gullion: Yeah, I would definitely do a release of information, get all your paperwork, signs that you can communicate with the outside therapist and then see which of those kind of accommodations or modifications are relevant to the school system.
[00:26:44] So, for example, the environment that the evaluation was done in an outpatient setting looks like this. Really different than a cafeteria, which is why it's very nice to have kind of the more formal processes of having school SLP and a school OT to be able to kind of do the, the richer evaluation in the school setting, but let's say you have what you have from the outpatient SLP and it's something like, Okay.
[00:27:11] Cueing or something that is pretty easy to implement in schools that can be part of the school team without doing like a really in depth oral motor evaluation or anything like that. 
[00:27:24] Madi Metcalf: Awesome. So we've talked a lot about like pediatric feeding and we learned last week on the first episode of the mini series that like a pediatric feeding disorder is compromise of the four domains, medical, nutritional psychosocial, and then feeding skills.
[00:27:40] If a kid doesn't have necessarily like feeding skill deficits, they're not aspirating and having, you know, needing thickened liquids or things like that, but they're just kind of falling in this selective eating category, more psychosocial domains. Can those kids, are they still eligible for accommodations even though they're not that complex?
[00:27:59] Lily Gullion: Yeah. So I think these are the kids that are really tricky, actually quite complicated because there's a lot to that psychosocial piece and the nutritional piece that you might not be able to see as clearly as like objectively, like they're coughing a bunch, they're having watery eyes, classic kind of aspiration science.
[00:28:17] I think at schools some of the best things that we can do is work on like supportive cafeteria teams. So what that means is like actually making sure that you're advocating in the classrooms you work at for, okay, what, how long do they have in the cafeteria? Do they have enough time to go through the entire line to sit down?
[00:28:39] Do they need help and support going through? Like all these basic things can really help with the experience of selective eating with the support of environment to you can do some things as far as making sure they have safe foods with them at school. So one way to kind of formally do this is through an individualized health plan, which or they're called a couple of different things.
[00:29:02] But basically, let's say the child has say the child has a really safe food of like applesauce or something that's pretty readily available and can still be in the school setting. That is something that you can really make sure is going to be available. Either during snack times or like special events like birthdays when people bring in treats or things like that.
[00:29:28] And if there's any hardship with the school cafeteria as far as like, Ooh, well, we want to serve whole apples or whole oranges that day. If it's in an individualized health plan, they do need to provide that modification. So those are easier asks when there's like texture changes, but for the selective eating you, it, I have seen that work out as well is to make sure that as long as it's in documentation and it really is clearly put that like, Hey, we need to have this safe food available that it can be okay.
[00:30:04] I think that sometimes it gets, I've seen SLPs and OTs in the schools try to do things like classes or group activities about exploring foods and moving forward down like progression of different textures and things like that or selective eating or expanding their diets. And I would caution, that's where I don't, I, I start to get a little nervous if that's the most appropriate place for those kinds of times.
[00:30:33] When we're thinking about children needing to access their education that starts to get into, are we adding a lot of stress during the day? Are we putting a ton of pressure on kids to perform during the day? Is this really helping them access their education or is this thing like a significant amount of anxiety?
[00:30:54] And you know, you know, with the selective eater kids, like those are, those are hard sessions and they require a lot of prep before and after for the emotional regulation and the readiness. And I don't know if school is always the most appropriate setting for that. I've seen some research articles of schools, especially.
[00:31:14] Schools with classrooms for kids with special eating habits and needs to have these kind of group tasks. But I still think that that's where I would need to see that really flushed out before recommending 1 of those programs. 
[00:31:31] Madi Metcalf: What about the temperature specific kids? Is it, like, okay to advocate for access to, like, a microwave and things like that, for instance, they can eat their warm foods?
[00:31:41] Lily Gullion: Yeah, I've seen that go really well. I've also seen for kids that bring in their lunch that aren't using cafeteria foods the access to a microwave is totally something we just write in their feeding plan and then that works. Sometimes it's been one of those things where I've gotten pushback from staff about, we don't have time for that or they have to move through this very quickly.
[00:32:03] And then it's a, it's a matter of, well, let's really figure this out and figure out how we can make this happen in the schools because the student needs to eat. 
[00:32:12] Madi Metcalf: Yeah. 
[00:32:13] Lily Gullion: So that's the reality of it. 
[00:32:16] Madi Metcalf: And then one more question kind of around, different accommodations and modifications that can be offered.
[00:32:22] So I know that the goal is least restrictive environment and one of the things that we've talked about is engagement in the social mealtime. But what about those kids that might be a little like sensory overload in the cafeteria? There's lots of noise, it's loud, there's a lot of smells going on.
[00:32:35] What if that's just too stimulating of an environment? 
[00:32:39] Lily Gullion: I see that all the time. Like I would say that that is a very common scenario is the cafeteria being the worst environment for them to eat in. And I would go back to some kind of classic special education and IDEA language around inclusion is not a place inclusion is not about being in the same room as everyone else.
[00:33:00] It's where students are most successful with peers. So I've seen this in a lot of different ways. Kind of across the board from kindergarten to 21 is students eating in separate environments. Because that's their best environment where they can safely focus on their food when they can expand their food, if that's a safe place, comfortable place for them to do that.
[00:33:23] And then still have socialization maybe with another peer or a couple of rotating peers. There's a lot of kids that will eat in like, separate areas of a cafeteria or even like research, resource rooms, like other eating spaces that work really well. I think that the problem is, is that shouldn't be the natural inclination.
[00:33:45] We shouldn't be putting a one size fits all, like every kid with PFT needs to be in the nurse's office eating. And I do think this is where it really needs to be clearly discussed as an IEP team as not just I'm pulling you into this smaller area, but how can we make sure that the student has a buddy or if.
[00:34:08] Like I've seen it work really well with some students to have music on, you know, on an iPad or whatnot and be able to really be calm and motivated during that meal. And then they'll socialize at recess and they'll socialize the rest of the day, but it looks different for each student. And I think that that's, that's how it should be.
[00:34:29] It should be a pretty individualized process. 
[00:34:32] Madi Metcalf: Yeah. It's. I mean, like, when I was working with, like, language and articulation, like, every kid is a little different. You have to be very, you know, specific in how you approach that child. But one of the things that's just kind of shocked me over and over again is, With pediatric feeding, there is so much variability and like, it takes individualization to like a whole nother, whole nother level.
[00:34:56] It feels like sometimes 
[00:34:57] Lily Gullion: yeah. And it's, it's pretty interesting to see it from kindergarten all the way up. And those different, there's so many different classrooms that are run such different ways. And some of these cafeterias that I've been in. Have been so like wonderfully organized where there's quieter areas.
[00:35:14] There's areas that are a little bit more chaotic. Some of them are much louder in general. It really depends on the school. And I think that that's totally okay. It's just a matter of making sure that that's clearly discussed with the full team to, 
[00:35:28] Madi Metcalf: Okay, so we had a question. So I work in and out of district placement.
[00:35:32] Do you have any tips or tricks to get one on one buy in to assist during lunch? In my experience, I've noticed one on ones will be on their phones or, despite training, we are not notified if there are any changes, whether they're good or bad. 
[00:35:43] Lily Gullion: Oh man, yes. 
[00:35:44] Madi Metcalf: That's a tricky one. 
[00:35:45] Lily Gullion: Huge problem. Yes, big problem.
[00:35:49] That was a very big problem for us in our district. And I am not going to say this was like, this is the best evidence based thing to do. But we did create quite a few ways to kind of address this. So, 1st of all, we started a kind of like a pre test that all paras who had signed off on.
[00:36:11] Let me back it up in our district. We would have paraprofessionals sign off on a feeding plans. Basically, once we had taught them in person and they demonstrated good skills. So, that's how we kept a running log of who was like a trained feeder and then we would make sure to revisit these classrooms pretty frequently and see if they needed additional people trained, or if those were sufficient, or if those pairs.
[00:36:36] They moved around costumes quite a bit. So it's. It was a paraprofessional management game is half of it. So we started doing like a pre test kind of thing for everyone before the school year started during their prep week. They were required by our district to watch a like 10 minute video about Aspiration protocols, like, here's our contact information, what do you do in case of emergency, and remember to check the kid's IEP and see if there's a safe feeding plan or if there's any IEP goals related to feeding.
[00:37:13] Madi Metcalf: Was it the team that made those videos? 
[00:37:15] Lily Gullion: Yeah, yeah, we made those in house, which was nice because we could actually use like examples from our classrooms and we thought that was important because it was, it showed a face to a name to since we weren't there all the time, it was really nice for them to remember who we were the couple, you know, the couple of times a year we were able to come around.
[00:37:33] So we had this like pretest setting thing that was really cool. And I think that worked pretty well for just like basic information. Then we would do their in person training, and we did have a, like, line right on their sign in sheet that was highlighted and said paraprofessionals or, or trained feeders cannot be distracted during meals, like I attest, or whatever.
[00:37:57] Okay, it still happens, though. Paraprofessionals and teachers and other people are still totally on their phones doing meals. We did do pretty random spot checks. That we would come in without telling anyone without notifying and observe classrooms. So we started a schedule kind of a rotating schedule around spot checking a classroom like once a week and seeing were trained paraprofessionals with the students who was.
[00:38:24] Is who was on their phone? Who was actually paying attention? Were they implementing them? And then we'd give them a score and we let our administrator help with a lot of the kind of like, disciplinary action. So, 1 of the problems that we had was what happens if we see paraprofessionals or other trained feeders, totally distracted or not with them during the meals. Oftentimes, like they go and help other students and that would be fine. But if they're a trained feeder for someone with a significant issue, they need to be right there. Right? So, there was a lot of talk about how to kind of navigate this and we, we really did have to have very good administrative support for this.
[00:39:07] And we were fortunate. It ranged across the districts, which administrators were on board with that and which weren't one of our administrators was what would follow up with the paraprofessionals afterward and be like, this is part of your job duties. Like, this is a non negotiable. And then other administrators totally didn't.
[00:39:26] Didn't pay attention. And that was very frustrating. So I, you know, that's kind of some things that we did in our schools to make sure that the one on ones were were appropriately implementing things. But it, it's challenging. That was really challenging. 
[00:39:44] Madi Metcalf: Do you have any tips for if someone's school district doesn't have a feeding team, some things that they can do to kind of advocate that one gets put into place, if that's something that they are wanting to pursue?
[00:39:56] Lily Gullion: Yeah, so oftentimes these feeding teams develop from an SLP and an OT or an SLP and a nurse or an SLP and a teacher or something, noticing that there are students that need feeding services. There are some great resources and I would point to Emily Homer. You don't have to recreate the wheel for like starting a feeding team.
[00:40:16] There's some great resources about how to get admin support and buy in how to build a feeding team, like what that looks like in the process, what you guys want to do on your feeding team What you don't want to do on your feeding team. And all those kind of strategies are really helpful. Fortunately, when I was in the district I was in, we had an admin that was very Focused on feeding.
[00:40:44] Oh, thanks. So she pushed for us to be really hands on, which was excellent. So we didn't have to do that advocacy. But in some of the other districts in the state I was in, that was a big issue. So. One thing that worked well in our setting was a school had determined that there were some big feeding issues and competing questions and the team did not feel competent about this.
[00:41:10] And it was There were a huge caseload at that school and the SLP and the OT were like, absolutely not. We're not feeding trained. So they paid for our district to come in and train them and for our district to come in to the admin and say, well, they're going to need more funding for training.
[00:41:28] actual feeding competencies too, because knowing the rules about school feeding doesn't mean that they're going to actually be able to implement safe feeding practices. So they're going to need professional development and all of that needs to come from the district. So, so it was helpful for them to get like another school feeding team to come in and be like, no, this is an actual huge problem.
[00:41:49] Madi Metcalf: That's really awesome. And I know that Emily Homer was the person that got in touch. I think it was Easterseals in Arkansas that set up our PFD guidance document. But Emily Homer came in and kind of helped give them like an outline for it and help kind of support that process. So they're definitely like awesome.
[00:42:07] Resources out there. Let's see. So we touched on this a little bit, but kind of keeping in mind that, you know, we can't put that, that extra responsibility on the school based SLP, that they're going to be the sole person. Advancing feeding skill, diet, texture, progression, all of that. Can you share a little bit more on what that collaboration with the, you know, the, well, actually two steps back.
[00:42:34] If the school notices a feeding difficulty, is the school able to refer out to an outpatient clinic or does that get a little muddy? 
[00:42:42] Lily Gullion: That's a pretty muddy. The legal teams that I've worked in would not like that. So typically, let's say a teacher, if they notice something that was a red flag, like.
[00:42:54] I mean, it could be anything, but let's say some, like, really difficulty with chewing or the student looks like they're not chewing at all. Once you have a feeding team in place, that's the natural way that evaluation can get started where we can come in and be the ones to reach out to parents, reach out to the other Outpatient, SLP, and OT and make those, excuse me, those kind of connections.
[00:43:19] If there's not a feeding team yeah, that would rely on the SLP and the OT to make a connection with if there's outpatient on board, what is going on with outpatient. It gets really challenging with referring to medical services outside of school, and I would, Very much hesitate on that kind of thing.
[00:43:39] There's typically a nurse in the school districts that also should be part of this school feeding team. To be honest, I've had a really rough time with that. SLPs and OTs are overwhelmed. School nurses are really overwhelmed and very itinerant and oftentimes don't understand PFD. So we are the kind of first line for supporting kids in the schools.
[00:44:04] And that's where I'd go back to, again, SLPs and OTs have this information and is within their scope of practice. So if it's a competency or confidence issue The SLP and OT needs to feel empowered to find resources to better understand PFD and what it looks like and how to do things with it to make that school safe environment for the student.
[00:44:27] As far as like, if there is an outpatient provider on board that's where collaboration, it's really challenging to collaborate. I'm not going to sugarcoat that outside of schools. Once you work in schools. And vice versa, you know, outpatient, when I worked as an outpatient therapist, it was so hard to figure out, like, who is the speech therapist or who is the OT or what are they doing in schools?
[00:44:51] And it's a process. It is really a challenge to like find contact information, but that collaboration can be really necessary. For instance, this, I'll give you an example, is this one child that we evaluated in schools and he had this really big choking risk. He overstuffed so frequently, so we had him on kind of a protocol where his teachers needed to be watching him during meals.
[00:45:19] He didn't need a one on one, but it was some, some sort of supervision where he couldn't have Like nuts or pretzels or popcorn at school. So some of like the hard and crunchies was was a no go at school. Then I reached out to his, I finally found his SLP who is private. Reached out to her and she was like, oh man, popcorn is like his favorite motivator.
[00:45:47] Like, this is what we end all of our speech therapy sessions with. Like, he loves popcorn. This is gonna be a huge issue. And so then I went back to the school and I was like, how often do you eat popcorn? Because I was like, why are we still doing popcorn in schools? It's such a choking hazard, but whatever.
[00:46:00] Like, that's fine. Why are we doing, what are we doing during, like, movie days and classroom videos? And she was like, oh, we do popcorn for everybody. And now we don't give him anything. I was like, ah, man, that's not what we need here. So we ended up I talked to the outside SLP and she was like, you know, he really likes the, like, white cheddar.
[00:46:18] We could do, like, a pirate's booty or one of the smart pops. Something else that was, like, a little bit easier for him to manage. So we switched him onto Pirate's Booty and then just switched the whole classroom onto that during like movies. And it was, it was like a huge game changer. So he could still be safe.
[00:46:33] He could be included. The whole class got a cool treat. And that wasn't during cafeteria time, but that was an accommodation that really made his whole school experience like so much more conducive to his eating needs. 
[00:46:47] Madi Metcalf: Oh man. And talking about just like inclusion with what you said earlier, which I loved, it's like inclusion is in a place.
[00:46:53] It is how the kid is going to fit in with their peers best and I love that because were any of those kids suffering because they didn't get popcorn on movie day and they got another tasty treat like no they were still having this really awesome movie day experience and that kid got to connect with his peers but if he would have just been like withheld that popcorn that would have been devastating for him especially because it was his absolute favorite snack. 
[00:47:17] Lily Gullion: I know. And that's one of the, that's one of the kids that he didn't have, like, I was their itinerant school feeding therapist, but he didn't have a SLP that was like on his caseload during his IEP team. So it was just one of those things where it was like, okay. This is a little bit unusual, we need to address this, and he didn't need, like, full beating therapy in schools to get him to the point of popcorn, we could just switch it to a pirate's booty or whatever, and he was, he was good to go, and it was such a, kind of, simpler fix than a full on, like, course of treatment, you know what I mean?
[00:47:56] Madi Metcalf: Is there ever a time and place in the schools where the SLP would be responsible for doing like oral motor work or working on feeding skill or managing pharyngeal dysphagia? 
[00:48:11] Lily Gullion: I have talked to many SLPs that feel comfortable doing that in schools and have written really good feeding goals and they have the kind of supportive environment for that.
[00:48:22] Thank you. So I don't think it's out of the question. I do think that safety and inclusion are number like one tied for number one legal responsibilities and kind of ethical responsibilities as OTs and speech therapists in the schools. But I do know that there are some SLPs out there that have had a really good results with doing like more intensive services.
[00:48:45] Again, it just depends on the setting. I think it really. It would really be kind of child dependent and IEP team dependent. If this is the parent's like number one goal and this is very important to them and this is where they see their child gaining the most independence in school, this can be a really appropriate independent daily living goal or like self management goal on an IEP.
[00:49:11] We did have, I know of one kid that was in like third grade and still using a bottle at school and an SLP wrote an IP goal and managed to get him to open cup drinking within that school year and just imagine third grader with a bottle to open cup within that year that changed his, his special education path pretty significantly.
[00:49:39] Madi Metcalf: I, kind of going back to like, is feeding relevant in the schools? I know that it might not be curriculum, but that socio emotional piece is also so much of what we get out of school. And, I mean, you know, if there's a kiddo at school that isn't understood by his peers because his articulation is so poor, right?
[00:50:01] Well, like we're able to work on that granted that does kind of directly go back to like, well, they can participate, participate in class discussion, but that socioemotional piece isn't lost. Whenever you talk about communication. Yeah, it has to come into play too. When we think about feeding. Cause like, what is that going to do to that kid of self esteem if he's on a bottle still?
[00:50:19] And none of his peers are like, you will probably end up getting bullied. 
[00:50:23] Lily Gullion: Totally. 
[00:50:24] Yeah. And so those are Yeah, and like, you know, in education right now it should be, and it is, a big push for mental health. And I do think PFD and all health care services in the schools are really appropriate for this conversation.
[00:50:42] I think that there's A lot of just kind of tradition in the schools if we don't do that, or that's too medical. And that's not, that's not really the case, and it, it doesn't have to be, certainly, and our legal precedent and our publication precedent shows that this is totally within our alley. And it should be for a lot of kids.
[00:51:03] You know, in the OT world, a lot of kids work on handwriting for like years and years and years, and that's totally fine. Not, not dissing handwriting, but it's like, what is really going to make significant differences in a kid's life? Some handwriting skills. Yes, great. But also some of these feeding skills are really, really important and can potentially lead to more independent living settings post education.
[00:51:28] Madi Metcalf: I'm not very much into schools, but isn't that a really big conversation once you get to like junior and high school is like that transition piece and like, Are they going to be independent on their own? So, like, 
[00:51:40] Lily Gullion: exactly. So, in schools, you need to be thinking about transition from kindergarten on. So, really, we need to be thinking about students long term living situations, job situations and activities of daily living is what I mean by that.
[00:51:54] And so, Adapting adaptive utensil, like positioning things, all of those things can be small implementations in the schools that can have really long lasting effects on their health and well being. And that's totally our role. 
[00:52:08] Madi Metcalf: I love that. So.
[00:52:11] What would you say, like, your three biggest tips are for if an SLP takes us back to their school tomorrow and they're like, I really want to implement this and they get pushed back what are those three things that you would think about, like, saying to advocate for implementing a feeding team?
[00:52:32] Which is basically what this conversation's been about, but if you were to, like, condense it down. 
[00:52:37] Lily Gullion: Yeah, I would say that, with kids with pediatric feeding disorder and also just kids kind of like in general School meals are really an important part of their day. This is the time of day that they refresh.
[00:52:53] This is the time of day that is socially kind of charged. This is an important part of their day that we need to not overlook. It is part of their educational experience and legally can be part of their services. So I want that meaningful health kind of discussion to be here with school meals.
[00:53:13] We also do have a responsibility, I think, with that to make sure that safety and inclusion are the biggest things that we're looking for. So that safety piece. Is both physically and emotionally really important to the child's well being and long term outcomes and then inclusion. We should be thinking about this with every kid in schools, not just kids with PFT, but especially not overlooking kids with PFT.
[00:53:43] And then kind of a third thing, if it's like safety inclusion, I would say collaboration and like a willing willingness to talk with administration with people across districts is something that can work pretty well. You know, at the time being this, there is no like. This is the way that we do this federally.
[00:54:06] This is all state by state decisions about how school feeding looks and it's pretty localized, but communicating with people in outpatient and in other settings in your area and then communicating and collaborating with people across districts and across local local agencies can be really, really helpful to understand what we can do as SLP and OTs.
[00:54:30] Madi Metcalf: We had somebody come in and say that safety inclusion related to feeding being our top priority has been a really helpful perspective shift for me when thinking about feeding support in the schools. And they said, Thank you so much. 
[00:54:39] Lily Gullion: Oh, God. Yeah, I think that sometimes, especially when I started this, it was very fearful.
[00:54:47] It was very fear driven and it was a lot of pushback of, I don't want to do that. That is, I'm going to get sued. I'm going to lose my license. Like all these things doesn't have to be that way. It can be much simpler with our trained eyes as therapists to make sure that all kids are having a safe and happy experience during meals.
[00:55:09] Madi Metcalf: So with your PhD kind of focusing on, I think, like policies and procedures around feeding, do you foresee the future holding more federal regulations around how PFDs are managed in the schools, or do you think it'll be kind of more locally state managed? 
[00:55:27] Lily Gullion: Good question. I think this will stay a state issue.
[00:55:29] I don't see this, you know, Talk to me in 10 years, but I don't see this becoming like a super big federal issue. It's kind of hard in the federal space or in the larger policy space for some of these like special health care needs are really small percentage of kids to have their voices heard.
[00:55:48] That's where I think that if we as SLP and OTS kind of change the culture within our local districts and communicate and figure out what's working in different districts. We'll gain more momentum than waiting for like a legal case to specifically tell us we have to do this or that this is the one way it should be going.
[00:56:07] Madi Metcalf: I love that. And I don't know, it might even be better staying at that state local because then you have more kind of flexibility to like genuinely create that like individualized plan versus like, well, we have to abide by X, Y, or Z. Yeah, 
[00:56:21] Lily Gullion: if. Exactly. If you're in a really rural school and you don't have the personnel, something like having really lofty IEP goals for feeding is not going to be appropriate.
[00:56:32] If you're in a different district with a lot more people, a totally different run cafeteria some of those things you will be able to accomplish in the schools, but that's why, you know, I, I think that as having these conversations and keeping the door open for people to realize what's. Working in what's good in their district for the kids they see is really important.
[00:56:54] Madi Metcalf: So being an outpatient SLP working with pediatric feeding, I've often advocated for my kids to have access to microwaves and, you know, just different accommodations throughout their day to give them better access. When kiddo gets to have the option on days that he feels overwhelmed by the cafeteria to go to a quiet room, but like he gets to have a say in when that happens.
[00:57:15] And That like having these conversations with you has been so eye opening to me on like, what is appropriate to ask for the school? Because the first couple of times that I went and asked for any kind of accommodation, they said, we don't touch feeding in school. We don't do it. And I was like, but wait, my, my patient is getting home from school every day, starving.
[00:57:33] Saying that like they were upset the last half of their day because they were so hungry. And so being able to just bring that awareness like, Hey, this is how this kiddo is going to be safe and feel included in their day. And having that language to, you know, advocate that the meal time is part of their academic day.
[00:57:50] And it does have a lot of meaning and value. And they need to be nourished so that their brain will work. 
[00:57:55] Lily Gullion: Or even like keeping a snack at the desk. Okay. You know, it's something simple, but it's like, if we can advocate to the teachers that like, no, that's really helpful is for them to have a preferred snack at their desk, that can change their day.
[00:58:09] Madi Metcalf: Yeah. 
[00:58:10] I think the biggest thing that I hope people take away from this podcast that like feeding in the schools doesn't have to be scary. It can be like looking at That patient or your student and thinking, what can I do to make their day a little bit easier? And it doesn't have to just be the FLP. They can reach out to a support team, find the fitting person in your community that you might be able to ask for support.
[00:58:32] If you can ask for support in a very vague, do you have HIPAA in the schools? Is it like, is it still HIPAA? Or does it have a different 
[00:58:38] Lily Gullion: You do have rules like that. 
[00:58:39] Madi Metcalf: Okay. 
[00:58:40] Lily Gullion: You do have rules like that. 
[00:58:41] Madi Metcalf: But maybe just kind of. Brainstorming about things like a feeding person in your community, but it doesn't have to be this like big, scary, you have to be a feeding expert to address it just to get them to that safe and includes, included point.
[00:58:58] Lily Gullion: Exactly. Yeah, most cases are accommodations modifications. Like the really intense feeding services is a very small percent. Not that we shouldn't include those students as well. That's absolutely a huge need. But for people, I think just getting into it or feeling a little bit more uncertain or nervous, or if they don't have admin support, knowing that it can start really small and kind of build up is, I think, something that we can all kind of move forward with.
[00:59:28] Madi Metcalf: And the last thing before we close out, do you have any other other than Emily Homer? Do you have any other favorite like resources or guides that you could share around school and feeding the schools? This is also on the spot. 
[00:59:42] Lily Gullion: Yeah, great question. I would say one thing that I really like is there's actually a USDA document from 2017 that is an official policy document called accommodating children in the mealtimes.
[00:59:55] That lays out. The USDA like rules about school feeding and that really helped me when I was first kind of getting into this and I still refer to it constantly as far as like, wait, what is the rule here? Like, what is an accommodation? What's in a reasonable accommodation? Who should be on the school feeding team?
[01:00:15] So I think, yeah, if you have that one, there you go. Yep. That one's really, really helpful. That one off the top of my head is is pretty solid. There's some other resources that I do refer to through like national kind of channels but they're a little bit more about like school health or inclusion situations and less specific to PFT.
[01:00:40] Madi Metcalf: And then one last question. If you do have concerns regarding like physiology with swallowing, allergies, medical related issues impacting safety, what do you do if they don't have an outpatient SLP on their team or OT that's doing feeding? 
[01:00:54] Lily Gullion: Yeah, so, if you're in the schools, the first like kind of line of defense would be the school nurse, the school nurse is going to be the one that has information about their their health in like a more general sense, and then also reaching out to their physician and people like that is appropriate.
[01:01:13] I think that the nurse is oftentimes the gatekeeper for that kind of information. And then for an SLP and OT, you can always talk to the parent. I think that we kind of forget that sometimes or we're afraid that parents are going to give us a hard time for some reason, but I have called so many parents and been like, Hey, wait, is there something that I need to know about this?
[01:01:34] Or do you have an, have you ever talked to your physician about feeding or do you do this or what's going on? Those conversations are invaluable and necessary oftentimes for the health. But yeah, I would say get the nurse on involved and then figure out if there's other professionals that are being seen in the community.
[01:01:56] Madi Metcalf: Awesome. Well, Lily, thank you so, so, so much for spending your evening to come on Making Sense of Selective Eating to talk about feeding in the schools. I think this is such an important topic, and I hope that you have kind of debunked some myths about feeding in the school SLPs feel a little bit more confident about feeding Helping their kids that might have feeding challenges feel included and safe during their school day, during meals.
[01:02:22] So, so much. Do they, Madi, do they ever have my contact information or is it on the thing? Oh, I don't think they do. Do you want me to, do you want to say it out loud really quick and I'll put it in the chat box?
[01:02:32] Lily Gullion: Yeah anyone is free to email me if you need anything or just want to talk things out, and maybe I can send you some resources, but I'm at l g u l l i o n, which is my last name, at u n c dot e d u, and I can, I can put it in the chat, too, if you want.
[01:02:50] Perfect. 
[01:02:51] Madi Metcalf: Yeah, that works. I spelled it. I might have spelled it wrong. Okay, perfect. Well, for all of our attendees tonight, thank you so much for attending our second episode of Making Sense of Selective Eating. If you missed the first episode where we covered what PFD was with Stephanie Cohen, you can come and listen to that, and we'll be back next week with another episode kind of continuing our train through the land of selective eating and pediatric feeding disorders.
[01:03:18] We'll see you next time on another speechtherapypd. com podcast. Thank you.
[01:03:25] Announcer: Thank you for joining us for today'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 are part of the ASHA registry and entered both your ASHA number and a complete mailing address in your account profile prior to course completion, we will submit earned CEUs to ASHA.
[01:03:54] Please allow one to two months from the completion date for your CEUs to reflect on your ASHA transcripts. 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. Each episode comes with an accompanying audio course on SpeechTherapyPD.
[01:04:16] com Available for a 0. 1 ASHA CEU. And just for our listeners, get 20 off any subscription with promo code SLPLearn20. SpeechTherapyPD. com is run by SLPs for SLPs. They've got the largest library of ASHA CE eligible courses out there, and they're adding fresh content every week. Remember, it's free. Use the code SLPLearn20 to get 20 off access to over a thousand courses for an entire year.
[01:04:50] Head over to SpeechTherapyPD. com for more information and start earning CEs today. Thanks for tuning in to the SLP Learning Series. And don't forget SpeechTherapyPD. com is your go to for all things ASHA CEUs. Your positive reviews and support mean the world to us and we'd love for you to drop us a quick review and hit that subscribe button.