Feeding Therapy Practices: US vs. AUS


Bri: Hello, hello, and welcome to The Feeding Pod. This is your host. I'm Bri, Brianna Miluk, and I am a speech language pathologist and certified lactation counselor. I specialize in infant and medically complex feeding and primarily see patients in the home health setting, although I do have some that I see in outpatient or via tele practice.

I'm also an instructor at the university level and a PhD student studying communication and information science. I have a huge passion for evidence-based practice and supporting information literacy in speech, language, hearing, feeding, swallowing sciences specifically as it pertains to social media and translational research.

This podcast is meant to share anything, and everything related to being a pediatric feeding SLP feeding therapist with sprinkling in a little bit about working in academia, being a PhD student, and how to access appraise and implement research into clinical practice. 

Some episodes may contain guests, and I'm already looking forward to some of those coming up, while others might just be me rambling about something that's been on my mind. Regardless, my goal with this podcast is that you walk away not just with newfound knowledge, but with the inspiration to think critically and not be afraid of research.

So, without further ado, let's get into today's episode. Welcome back to the Feeding Pod. This is Bri, and today I am accompanied by Asha Bodycoat and Holly Tickner, who are speech and language therapists in Australia.

And so I'm really excited for us to kind of talk about some of the differences between feeding therapy from one side of the pond to the other and talking about what that looks like, but also just how does feeding therapy also kind of come together in the same way, but also what's different in terms of not just practices, but maintaining certifications and things like thickeners and g tubes and what some of those practices look like.

So, I'm really excited to have you all here and I'm actually gonna throw it over to you all to kind of just give a overview of like where you're practicing what you are doing. Gimme just like kind of a, a brief brief. Who are you kind of thing?

Asha: Mm-hmm. 

Holly: Thank you. Can we start off by saying, I love the way you say Australia? That was beautiful. 

Bri: Thank you. 

Holly: Can you say it again? 

Bri: Australia? 

Holly: Yeah. It's so cute. 

Asha: It's, it's a real different vowel sound, isn't it?

Holly: It's lovely. It's really,

Bri: Is it my little bit of my southern accent coming in or? 

Holly: Maybe. 

Asha: Yeah. 

Holly: It's cute. Anyway, I like it. 

Asha: Yeah, we love it. 

Bri: Thank you. 

Holly: Very broad. Suddenly with my accent. 

Asha: Yeah, yeah. 

Holly: Do you wanna start Asha?

Asha: Sure. I'm Asha. I am, well, we call ourselves speeches over here. 

Bri: Love it. 

Asha: So, speech, speech pathologist is the, the lingo officially, but colloquially we we're speeches. We are based in Perth in Western Australia and we work in feeding pretty exclusively, which, which we love. That's obviously both our areas of passion.

So, I'm based north of the river. It is a very Perth thing to say, like are you north of the river or south of the river. I grew up south of the river, but I made the move north, which is considered - 

Holly: Contentious. 

Asha: Yeah. 

Holly: Contentious. 

Asha: So, I'm in a suburb called Kingsley and I rent a clinic room at the moment from an OT practice up there.

So, I'm there a couple of days a week. And my clinical focus at the moment is mostly neuro divergent children. So, across, I guess, toddler years through to early adolescents and a few other things mixed in kind of picky eaters and a few kind of dysphagia kids as well. But neuro divergence is - 

Holly: Mm-hmm. 

Asha: Is my love.

Bri: Yeah. Well that makes sense that we're in the, the neurodiversity affirming feeding therapy course together. 

Asha: We are, yeah. And I recently did some post-grad training in autism assessment and diagnosis, so this is like my two loves coming together. So, I really love looking at autism as a neurotype broadly and how that impacts the experience of eating. So. 

Bri: Awesome. 

Asha: Yeah, that's me. 

Bri: Awesome. Alright, Holly. 

Holly: Hi, I'm Holly and I've been doing feeding for a little while. I was trying to work out, I wanna hit that 20-year mark, but I don't think that's for like another year or two. So, I could, I I would love to be able to just say I've been doing this for 20 years cause it's just such a nice round number, but I'm not quite there yet.

I spent most of my career working at the Children's Hospital here in Perth. And as the - We, I don't know how you rank your seniority levels within hospitals, but I was the senior, which is like the, the top one for the NICU. Do you call it the NICU? 

Bri: Yes. 

Holly: I don't even know if the vowel is right, if it's gonna translate. Cause like we call them premmies, but you guys call them - 

Asha: Preemies. 

Bri: Pree - Yeah. 

Holly: Where we, yeah. Whereas our is pre 

Bri: Spell it. Okay. How do you spell it though? Do you say 

Holly: P-R-E-M-M-I-E-S 

Asha: Yeah. 

Bri: See, that's why, because ours is P-R-E-E-M-I-E, which is why I always mess up the spelling because I don't understand why. 

Asha: Where did the extra E come from?

Bri: That's a great question. I would love to answer that if I had the answer to it. I have no idea where this extra E comes in, but that's why it's pree instead of prem. 

Asha: I guess I - like preterm. 

Bri: But like why do you, but why do you like spell pediatric with an A? You know - 

Holly: Because of the Brits my darling.

Bri: I know, but that's, you know, I dunno, I don't know where the pre, because it's spelled premature with only one E.

Holly: But you say premature. Whereas we don't, we say premature, so I think it's just - 

Bri: But our - 

Asha: Yeah. 

Bri: Premature only has one E, so I don't know why it switches to two, two for the abbreviation. English is not American English. Just I don't ask questions. 

Asha: Yeah, look. 

Holly: It's all good. Yeah, we don't, and all English. English, generally. 

Asha: Yes. 

Holly: Don't ask questions about the spelling, do you? 

Asha: No. 

Holly: So, I worked in the, the senior for the NICU and for in, we had like an early intervention program for the under twos, but I worked across like airway, voice, s wallow clinics and I did everything really, but medical. So, I did that for quite a while and a few years ago jumped out of tertiary hospital stuff into private practice in the community.

And now I feel like I kind of work with the same kids actually. It's just that they're home now. They're not in hospital. And I speak probably a similar caseload to you actually, Bri, from what I can gather. 

Bri: Mm-hmm. 

Holly: And I still really love it. I'm still doing it after all this time, so yeah. 

Bri: Awesome. 

Holly: I work south of the river, so, I know.

Bri: Okay. So, ok. When you say like north and south of the river though, like how big is Perth? 

Holly: Perth is tiny. It's tiny. 

Bri: Ok. So, it's not like hours. 

Holly: It's not a big deal. No. 

Asha: It's expanding. So. 

Holly: It's such a Perth thing to say, like, I work in the North, like we honestly we're a blip in the scheme of, I think our total population for Perth is 2 million people.

Bri: That is so many people.

Asha: Like new housing developments kind of go outwards, so a lot of it would take like, I dunno. Sometimes I travel like an hour to see a client that is still in like the Perth area, I guess. 

Bri: Okay. So, it's it's pretty, pretty broad. I just like, that just sounds like so many people for a singular area to me. 

Holly: Oh, we're very, probably for Western Australia to be honest. It's probably not really Perth. 

Asha: We've not done any fact checking. 

Holly: I have not done fact checking on that. I should really do a quick Google on that one. I think what's worth pointing out to listeners is that, so we are based in Western Australia - 

Bri: mm-hmm.

Holly: and it's very big. It's a very, very big state. 

Bri: Yeah.

Holly: It's the biggest out of all Australia, but Australia generally is very spread out, so 

Bri: mm-hmm. 

Holly: I think. Like the state of Texas, again, I haven't fact checked this, but like the state of Texas fits like several times into the state of WA. Like we're a big, very spread out state.

Bri: Yeah. 

Holly: So, to get to the top of our state, you would need to fly an airplane, like from Perth. We're kind of like, not even at the bottom. You would need to fly on an airplane for a few hours. 

Asha: Yeah. 

Holly: To get 

Bri: Okay. 

Holly: Over the top. 

Bri: So, it's almost like, yeah, it's almost like a small state because like South Carolina has like 5 million people - Texas has like 25, 29 mil. I mean, they have a lot more. So Okay. That makes, makes a little bit more sense, but still that is, yeah, that's but spread. So. Okay. That's very, that's, that's pretty far to travel for some patients. If you're traveling like an hour sometimes to see, see a client. Okay. 

Holly: I have a family that travels. They drive eight hours to come and see me. 

Asha: Oh, yeah. 

Holly: Yeah, yeah. So, people will do the distance to get therapy. 

Asha: Yeah. 

Bri: Wow. 

Holly: Yeah. 

Bri: Wow. That's, that is wild. 

Holly: Eight hours one way I should add this one way. 

Bri: One way?! 

Holly: And then they stay overnight and then they'll fly, they'll drive back. 

Asha: Where are they coming from? 

Holly: Outside of Geraldton.

Asha: Okay. Yeah. 

Holly: Yeah. 

Bri: That's pretty far. That's pretty far. 

Holly: Yeah. 

Bri: Do you do you all offer, I'm assuming, but like, do you offer tele practice or are there limitations in Australia? You can. Okay. 

Holly: Yeah, we do offer it. Some families don't have good access to coverage-

Bri: Just depends. 

Holly: Because they're living what we would call, we describe the families when they're living remotely.

Bri: Yeah, 

Holly: so, we have like, you could live metro area at a city or a town, and then you might live rurally, so you're kind of in a country town. 

Bri: Yeah. Mm-hmm. 

Holly: And then you might live remotely. And so, some families, if they're out in like a big station, could be cattle station or something, they don't necessarily, they might be relying on satellite for their coverage and so they don't 

Bri: Wow.

Holly: all have good, reliable connections. And not all kids do great with telehealth or tele practice. 

Bri: Yeah, agreed. 

Holly: So, yeah. Some families, that's just what they wanna do. Or if they need to access a hospital. The only children's hospital is here in Perth, so even if you live a three-day drive from Perth, if your kid needs to go to hospital for a procedure, this is where they have to come.

Asha: Yeah. 

Bri: Wow. Very interesting. That's very -

Asha: I do have some telehealth clients from different states in Australia, so I think I have one in New South Wales at the moment. So, we don't have licensing. I think you guys need a license to practice in a particular state, do you? 

Bri: Yes, yes. Yeah. So, you have to be licensed in the state you're servicing, so I don't have to, for example, if I had a license, I, I live in South Carolina, but if I had a license in say, Virginia, I could treat someone in Virginia.

Even if I'm in South Carolina, they just would have to be in that state. But if I don't hold a license there, I can't technically treat in that state. Now there's kind of like a little bit of wiggle in terms of like you can provide some consults or coaching. You just can't provide direct therapy for someone in a state that you're unlicensed in.

Holly: Okay, how do you get a license? 

Bri: You pay is basically you, you would pay for the license in that state. So, there's certain criteria, like every state has slightly different criteria in what they require in terms of like keeping up with your continuing education or like just certain requirements of what you can and can't do.

And so, you would just have to follow that for every state. So, for example, South Carolina, you couldn't do the initial evaluation virtually. So, if you were gonna see a patient, if someone didn't live in the state and they didn't do the initial eval in person, you can't see the patient virtually you have to do the initial, but other states you can do everything virtual.

So, like, that's kind of where it comes into play. Now there is what's called the interstate compact that's going around where states are signing off saying, hey, we will agree that like, whatever your home state is, you pay a little extra there and then you can treat in all the states that sign up for it.

So that is expected to roll out this year. So, there are some states that are signing up for that to say, because I mean, that just broadens access of care to so many people. It's truly just like, I feel like all it does is hurt the families and the kids by not allowing that.

So, there is like some works to make it happen, but there's just, you know, all the like, finances and politics and stuff that go behind the scenes of it that is kind of a barrier or making it move forward slowly. 

Asha: So how common is it that a provider would have a license in more than one state? 

Bri: Well, mostly because it's expensive so like I pay, you know, like almost $200 a year to have my license in my state. So, if I was to pay that for 50 other states, it's not necessarily worth it for the patients that I would be seeing. So, most of the time people are only paying for the state where majority of their patients are from. Cause again, you can, you can offer cash pay.

So, for example, if someone, I've had a patient, for example, that lived in North Carolina, but I'm like kind of on the border, so they would drive an hour to see me in South Carolina, even if they live in another state. As long as they come into the confines of South Carolina, I can see them. They just have to like be in the state.

Asha: Sure. Okay. So, we can see. Telehealth, I believe, from any state. 

Bri: Mm-hmm. 

Asha: But if you do a certain amount of work where the client is in another state, you need to get a working with children check from that state. 

Holly: Mm-hmm. 

Asha: So, we, yeah, all of our states and territories have their own working with children check, and that's a pretty standard thing that you have to have for anyone working with kids.

So, I believe I can see a few clients in different states, but as long as it's not the majority of my like month of working. 

Bri: Gotcha. 

Asha: I don't have to get there, have the checks, which would be really tricky because I physically most likely would need to be in that state to get the check. 

Holly: You do. You need to present in person -

Asha: Yeah.

Holly: To hand in the document. 

Bri: So, they don't, they just don't want you. Well, which I mean like from a, as terrible as that sound, but like from a business standpoint, like thinking of the state as a business, it makes sense. They don't want you taking majority of what they should, you know, technically be receiving in funding. So. 

Holly: Yeah. 

Bri: But yeah, it's definitely a lot more stricter, a lot more strict here. 

Asha: Mm-hmm. 

Bri: In terms of like not being able to. 

Holly: But I think you've touched on something interesting there about funding. Our funding say for our kids who are accessing therapy. So, we have what's called a National Insurance Scheme for kids with disabilities.

Bri: Mm-hmm. 

Holly: And so that money is shared nationally across kids. 

Bri: Oh, so it's not even state dependent. 

Holly: Mm-mm. 

Asha: It used to be. 

Holly: Used to be. 

Bri: That's what ours is. Ours is state dependent. And so that's, I think, one of the big reasons that they're hesitant because the insurance won't cross, it won't cross states unless someone in another state provides something that anyone in your state doesn't provide.

Asha: Wow. Okay. 

Holly: Mm-hmm. 

Asha: All right. Yeah, no, we have a process that's, it's, it's really in its infancy of, of being rolled out. Like the last, what would you say, like six or seven years? 

Holly: Yeah. Yeah. It hasn't been around for very long in the scheme of things. 

Asha: It's called the NDIS (National Disability Insurance Scheme), and the idea is that we work mainly in early intervention and school age, that, you provide support and funding for children when they're young and they should need less of it when they get older, which is, you know, a fun-

Holly: A lovely idea. 

Asha: Yeah. It's, it's an, in an ideal world, that's how it works. But we know that's not the case. So, yeah. What happens is basically a family would go through like an eligibility process to apply, and then if they are deemed eligible, they'd have a planning meeting.

So, like a delegate from the NDIS would sit down and go through a fairly functional assessment with them -

Bri: Mm-hmm. 

Asha: gather evidence, then they get given for the next 12 months or 24 months, a dollar figure that they can use. And it's kind of broken down into different categories of supports. So, our funding for our services would come out of a particular bucket.

Bri: Okay. 

Asha: And basically, depending on how you choose to manage your funds, you can choose which provider you use it with. And there's, there's a fair bit of flexibility in it. 

Bri: Okay. 

Asha: But sometimes it can be tricky balancing, like say you might have three or four different providers and making sure that you've got enough over the year for everything you need.

Bri: Yeah. 

Asha: That can be a little tricky. 

Bri: Mm-hmm. 

Asha: It's opened up a lot in terms of new services -

Holly: Yeah absolutely. 

Asha: In the last few years. Yeah. It's, it's been crazy how the landscape has changed. 

Bri: Yeah. Yeah. 

Holly: Actually, how? So how does a child get allocated funding through your insurance schemes? It's like, who, just, who signed off on it?

Bri: Yeah. It's interesting because that sounds very similar to our early intervention programs. However, our early intervention programs are state dependent. It's not nationally dependent. So, the programs are for birth to three. And it's the same concept thinking if we support children during this developmental period, most likely they're not gonna need as many services down the line.

Now we know, of course that's not the case for all children, but it really does help quite a lot of children. 

Holly: Yeah. 

Bri: You know, for for many children that's beneficial. So, in the birth to three program, any child, regardless of financial status or diagnosis, can apply and, and get it for birth to three.

However, there is the process where they go through a developmental assessment. This is typically done with again, depending on the state who does this. So, in some states, it's what they would consider, like the lead therapist, whether they think the child's primary need is communication or physical therapy or occupational therapy, you know, they'll lead it.

But in other states, for example, the state that I'm in its led by what's called an early interventionist. And so, they just do a broad assessment on everything and determine, determine what the child would need and again, state dependent on what goes on. So, for example, in the state of Kentucky right now, early, anyone who works in early intervention is not allowed to do feeding or swallowing. If they want feeding and swallowing services, they have to go through private. It. 

Asha: Wow. 

Bri: Literal, I literally, it doesn't make any sense to me. Like it, I, I don't understand. But like that's one of their rules, is early intervention just doesn't, like, that state was just like, you know what, actually no. And they used to, and they took it away. And so, they're like -

Holly: You know what, that happened here too. 

Asha: Did we? 

Holly: Yeah. With the NDIS because they said that dysphagia, which was just like this all-encompassing term to capture anything to do with mealtimes was a medical -

Bri: Medical. 

Asha: Oh yeah. 

Bri: Yep. 

Holly: Through the hospital. 

Bri: Not developmental. Yes. 

Holly: Not developmental. 

Bri: Yeah. 

Holly: And so, we had a, a big - a huge amount of advocacy go to trying, well, successful, which was great. But yeah, our, our national like - 

Bri: Yeah. 

Holly: Membership, body Speech Pathology Australia did a a lot of advocacy to get it back included in -

Bri: Mm-hmm. 

Holly: our -

Bri: I mean it's 

Holly: disability inclusions. 

Bri: So wild. But yeah, so that's like where it's very state dependent though in terms of what it implies. But with that being said, as long as I can vouch for why a child needs a certain amount of therapy or whatever, they will cover it.

So, there's not necessarily like a budget in terms as long as I can justify why they need as much as they do. And then once a child turns three, if they still qualify and qualifications, again, state dependent, for some states it's like a severe delay in one domain and some it's like two domains have to show a, you know what, there's different criteria, but, and they can continue the service between three and five years old if they still qualify. And then once five years old hits, say the program stops. 

Asha: And how much of that is contingent on a diagnosis? Does that change eligibility? 

Bri: It does not before three. That will somewhat play a role after three years old before three years old. Any child can, regardless of diagnosis. Yeah, go ahead.

Asha: Our intervention stream of the NDIS is under six. As long as the child has delays or difficulties in a few different areas of development they can access without a diagnosis. But essentially, like once they hit six -

Bri: It's like - 

Asha: the NDIS is like, okay, well what's happening? And there are a certain number of diagnoses that will make them eligible for their life. Which is something that has been really tricky with things like developmental language disorder, apraxia of speech, like those things are not reco- recognized. 

Bri: Yeah. And you're like, that's still lifelong. Like that's still, you know, like even though it's a communication disorder, not a medical diagnosis, that is still something that's lifelong going to influence this child.

Yeah, it's tricky. And it's the same thing here. There's certain ones that qualify and certain diagnoses that don't, which is where sometimes like, the conversation will happen, I think, with families in terms of like, I, our treatment is not gonna change with a diagnosis, but your coverage of care could change. And that's why we want to like seek out that, that aspect and getting an actual formal diagnosis. 

Asha: Hmm. And what about schools resourcing? So, for us as well, if we're talking about, you know, going through a huge neurodevelopmental assessment process with the family, often, you know, if they're under six, we're kind of good with the NDIS, you know, we can roll with not having a diagnosis.

But if once they start school getting the support from the education department, there is another list of diagnoses that will make them eligible. So, without that, it makes it really difficult for the schools to put supports in place. 

Bri: Yeah, it's, it's very similar, the schools aren't as... It, it doesn't always require the diagnosis. They just want to know that there is an impact on education in some manner. And I will say that their criteria does tend to be a little bit more, I, I don't wanna say like higher, that's not like the right word, but like they require more than it would in like an outpatient setting from a medical setting.

Cause they're looking at more than just is there a medical influence? They're looking, is there an educational impact here? So, a diagnosis can help. However, I have a patient for example, in the past who had the medical diagnosis of autism but did not qualify from the educational systems' diagnosis of autism.

And so, I know it seems very interesting, but so much of that was just the child over time had just learned so much about how to regulate and advocate for themselves to where, from an educational system standpoint, they were like, I don't know. It doesn't, you know, they're not checking the boxes sort of thing as if someone with autism can fit in a box, but, that's kind of part of it.

Asha: Yeah. And we have well, obviously everyone has, you know, the level 1, 2, 3 support levels for autism, which is another conversation. 

Bri: Yeah. 

Asha: It's possible that the NDIS wouldn't recognize level one as a diagnosis. That's not like an automatic eligibility. 

Holly: Mm. 

Bri: Yeah. 

Asha: So, there's a lot that is happening, I guess, around advocacy for having neuro divergence recognized full stop. Like ADHD is not recognized at the moment. So yeah, just because you have a diagnosis doesn't always mean that it opens up access. 

Holly: No. 

Asha: And we still get a bit of bouncing between health, education and disability services in terms of who's taking responsibility. Just this week, I've had a a client who is, you know, having some really, really significant swallowing difficulties.

Holly: Mm-hmm. 

Asha: And the hospital perceive it to be sensory based attributed to his autism diagnosis. But I'm having a look inside his mouth and I'm thinking, oh no, you need to go into the ENT. So, trying to get him back into the hospital system can be really tricky. So, we do a lot of advocacy. 

Holly: Yeah. 

Asha: Yeah. 

Bri: Wow. 

Holly: There's a lot of *gestures hands up and down*

Bri: Well, I feel the same way as like in the community side there's a lot of advocacy, but I find in the education systems, and again, I have not worked directly in the school system, so I'm speaking from like secondhand experiences here, but from what I understand is it's so much harder to get those types of referrals, those medical referrals, because if the school-based SLP says you should go see ENT, the school has to pay for that. So, if they, yeah. And so, it is very hard for the school-based therapist to make medical referrals because if they say this needs to happen for the child to make progress in the area that's affecting their education, the school has to pay for it.

Asha: That's wild. 

Holly: I'm stunned. 

Bri: Yeah. And so, there's a lot of red tape there. So, they'll usually like, that's where a lot of families will have the school-based services, but they also have the outpatient services. Because outpatient, I can very easily send referrals and say, go see them. Go see that. But if the school-based therapist says, this is influencing their speech, or this is influencing their feeding, which is affecting their education access, the school has to pay for it.

Holly: Wow. We have nothing like that here. 

Asha: No. 

Holly: That's awful. 

Asha: So, we have a, what? What's called the child development service. So, any child, I think it's up to, up to 18, 16, depending on the surface service is eligible for free or government funded services. And that covers allied health, pediatrician, child health nurse, all that kind of stuff.

So, you can, or, and also medical services as well. 

Holly: Yes. 

Asha: Through the public hospitals. So, you can access theoretically, all of that for free. But our wait lists at the moment are, I think sitting at around two years for, even for early intervention. So often if they can, families will opt to go and see a private ENT, for example.

Holly: Yeah. 

Asha: We're, we're in a bit of a pickle at the moment with access to pediatric, especially. 

Holly: In Perth, yeah. Yes. 

Asha: Yeah. 

Bri: I've, I've heard that about. I've heard other countries that have more of that oh my gosh, I'm like blanking on a term. Universal healthcare. I've had like in Canada, I've had therapists speak the same of like the access, like it's like two year wait list and you're like, well they're six months old, so in two years it's not really gonna help what's going on right now. And so, a lot of people will like cross the border from Canada into the US and just pay cash for somewhere because they just, otherwise they're gonna be waiting for a year plus. 

Asha: Okay. 

Holly: A lot of our pediatricians will prioritize the, the babes and 

Bri: It really should be, I mean, it should, there should be somewhat of hierarchy, but that's also hard for the families that have been waiting so long. 

Holly: Yeah. But then the, yeah, the eight-year-old looking for an ADHD diagnosis might end up waiting quite a while to see a pediatrician. So, I wanna, I wanna ask you about service stuff. Service delivery. Cause you were saying for the zero to threes, like we're talking about wait lists and like having trouble accessing services. 

Bri: Mm-hmm. 

Holly: The flip all that. My question is, you were saying that it's up to the therapists, they can kind of say, this is how much therapy this child would benefit from. Yeah. And they'll get funded with that. What's preventing over servicing? 

Bri: Ah, ah, yes. So, there are people that have to approve it. So that's why I say you have to justify. You have to justify why the child needs... typically one visit a week, you're, you're good, you're golden. You're probably gonna get that pretty easily. If you go into two to three or more, you're gonna have to justify it.

So, for example, I could justify a patient with childhood apraxia of speech getting four to five visits a week because the literature shows more frequent speech therapy services is what's gonna benefit. And to be honest, I cite research in my reports to show -

Asha: Yeah. 

Bri: Why a child needs a certain service a certain amount of time. The other thing is like certain changes to care might show why we could prove it. The biggest thing is you just have to justify it. Now with that being said, I have literally had, I've had one denial before, and the denial actually wasn't feeding based. It was speech based. And they said it was a child who had an AAC device and I was requesting speech therapy services, you know, for the, the AAC device.

And they denied it because they said, why would a child need speech therapy services if they're non-speaking? And I was like, that's literally why they need it. I'm sorry, who, who just read this request. Who are you? Because 

Asha: Wow. 

Bri: Absolutely not. Now, when there's a denial, you can go back and say, hey, let me talk to you about this, because, let me explain it.

Unfortunately, this ended up being one that the caregiver had to appeal. This is also a child who had like a medical diagnosis, like a genetic diagnosis they had, like, there's no way they should have been denied it, and they did end up getting the services. But usually it's just, if you don't show why it's medically necessary, then you're, you might get denied.

So, you do have to go for like authorizations. Now there's some insurances, so like just regular old Medicaid, a lot of times is just like go, like, you know, just as long as we're seeing progress on their progress reports, like you're good to go. But other insurances are stricter. 

Holly: Okay. 

Asha: How often do you have to submit a, a progress report?

Bri: It depends. So technically with Medicaid state dependent, so Medicaid is like the state funded insurance. 

Asha: Mm-hmm. 

Bri: So, this is based on income, so depending on the state, but for example with like South Carolina, like technically I don't like once a year. But there's other insurances that are like, we will give you four visits.

And so, I am basically submitting a progress report after like two to be like, I'm gonna need more than two more. So, it really just depends on the insurance. A lot of the time, I would say on average, every three months for, for most insurances. Now with that being said, for example, Medicaid doesn't require it, but every year I will still do a progress note every three months. So regardless, I want the progress note and I wanna share the progress with the family in terms of like what exactly is going on. So, yeah. 

Asha: We also have a system called Medicare. So that's our national. 

Bri: Okay. So, we have Medicare too, but that's only after age 65 Medicaid. 

Asha: Oh yeah. Okay. Okay. So, Medicare is, is everyone. 

Holly: Yeah. 

Asha: And there are some allied health services that you can get a rebate for on Medicare, but -

Holly: To get private. 

Asha: Yeah, yeah. You go to a private clinician with a referral from your GP and they say, you know, in a calendar year you can have. I think it's, it's up to five allied health. So, you might have five speech pathology or three speech and two OT and we have to report after the first and last session.

But I don't think I've ever had a private client who after the, the five sessions, I'm like, cool, you're good to go. So, 

Bri: So that's in a year? That's 

Asha: for the calendar year, 

Bri: that's not a month? 

Asha: They basically, they can still access services, but then they would need to use their private health insurance or or pay privately. Yeah. 

Bri: Oh, okay. Okay. That makes sense. 

Holly: Just like giving a little bit of money back just to say like, thanks for not blocking up the public health system. Thanks for going privately. 

Asha: Yeah. 

Holly: You know, 

Bri: Yeah. I think that's pretty, I mean it's like somewhat similar to our like private health insurances. Like private health insurances are like, you pa-, you actually do the opposite, so you pay until you hit your deductible and then they'll cover it.

So you do the pay and then, and then depending on your plan, it might be like, oh, you pay, and when you hit your deductible, which might be like $1,500 or something, then they'll cover 80% of the rest of them, or some insurance will cover a hundred percent after that point in time. It just depends on your plan. But you're paying like every month to have the insurance, plus meeting the deductible. So even once you meet the deductible, you still pay every month to like maintain your insurance. 

Asha: Yeah. 

Holly: We have actually, we have the Medicare threshold as well. 

Asha: Mm-hmm. 

Holly: So, I think it's like $1,500 and then, then they pay.

Asha: Okay. Our, our private health insurance, like anyone can sign up for it if you have the resources to pay your monthly premium. 

Bri: Yeah. 

Asha: And you have like a limit and annual limit on how much they will cover for a particular service. So, I might have $350 of physio rebates available on my level of cover, but that will be taken up in 60% of, that'll cover 60% of my session fees until I reach that $350 cap.

Bri: Okay. Got it. 

Asha: And then I have to wait until the next... 

Bri: Yeah, ours is, so the, like the caps or like the, we call 'em deductibles comes from every health service. So, it's not like you have to reach $1500 of Allied. It could be like you have surgery and you met $1500 and everything else, medical is covered. 

Holly: Yeah. 

Bri: So, it's not like category specific necessarily. There might be like slight variations in like the percentage covered after you meet it, but your deductible is just like anything healthcare related can go to that deductible. 

Asha: I'm interested as well in autism assessment because I'm in that world here. How do families access assessment in America? 

Bri: Yeah, so it's similar in that like it has to be someone who is trained in it, and that is usually a psychologist or a pediatrician, or it could be a speech language pathologist.

Some states don't allow SLPs to do the diagnosis, which, is a conversation in and of itself. But most of the time, most of the time it is a developmental pediatrician or a psychiatrist or psychologist. But it is pretty intensive testing. So, most people will use like the ADOS I'm sure that you're for, are you familiar with that?

Asha: Yeah. 

Bri: Okay. So, a lot of times it's something like that where, but I will say like the, I feel like there's more and more people getting trained in the assessment because the wait list to get an autism diagnosis is just like unbelievable. I mean, I, I don't think I've had a family wait less than six months, though I'd say on average it's close to a year. 

Asha: That's pretty similar here, to be honest, depending on which system you go through. 

Bri: Yeah, yeah. 

Asha: And our states have different requirements for who's involved in the assessment. So, you wanna be pretty careful that you've got that, so that at the end of the assessment it'll be recognized by the education department in your state -

Bri: Everywhere. Yeah. That's how I mean. But like I said, like ours is a little bit different sometimes, depending on the education system, cause they'll do like a medical diagnosis of autism versus a educational diagnosis of autism, which like kind of doesn't make any sense in my brain. Like it's not like your autism just like comes off when you go to school. But, I think that they're looking at does it, does it impact their access to education versus not kind of thing. 

Asha: Mm-hmm. 

Holly: That's rough on the family and the kids to kind of have to. 

Bri: Right. 

Holly: Revisit that part. That's 

Asha: And then prove it. 

Holly: Prove your disability. Ah -

Bri: Right. Yeah. Well, and it's weird too because like, for example, the kid I'm thinking about like he still qualified for services without the educational autism diagnosis. So, it's kind of, I'm like, so, so it is influencing access to education because he still requires - Yeah. Again, it's like, oh, he didn't meet like a certain checkbox basically is, is kind of, it sounds more than looking at the child. 

Holly: He looked examiner in the eye once, so, you know, can't, can't take it. 

Bri: Right. 

Holly: Yeah. 

Bri: Yep, yep. Exactly. 

Holly: I wanna ask about feeding therapy. I wanna ask about feeding therapy today, 

Bri: Yeah. 

Holly: because sometimes I think it looks very similar to how we do it here in Australia. And then other times I get glimpses usually on social media and I think -

Bri: Yes.

Holly: Oh, it looks so different to what we do. 

Bri: Yes. 

Holly: And Asha and I have done, we've done our various training courses and things over the years -

Bri: Yeah. 

Holly: Where there've been us presenters and definitely some of the content is very, very different -

Bri: Yeah. 

Holly: To what we would do here. So, what would, I would just love to know, like, it looks like -

Bri: Yeah.

Holly: When you are doing some feeding therapy. 

Bri: Okay. 

Holly: Are you like, are you doing cooking? Are you, are you hands on? Are you touching their mouth? Are you sitting opposite them across the table? Are you in their kitchen together? Like, what does it look like? Because I would love to get a sense of where the overlap is.

Asha: Mm-hmm. 

Bri: Yes, me too. Okay. So yeah, this is super interesting and it's funny too, cause I definitely come across therapists too, that I'm like, what are you doing? Like, that is not what my therapy looks like. No. So I agree, but I, I am curious how our practices overlap or maybe slightly differ. So, okay. I definitely take a more hands-off approach.

So, I am not typically putting my fingers in a kid's mouth or anything like that. I also, I'm so sorry to all my physicians that I work with, but if I'm concerned about something going on, like from a tonsil standpoint or something else, airway related, and I'm like, gosh, it would be great if I could look in there if that child is orally aversive, I'm just gonna make the referral and make them hate the doctor because I need a trust and rapport with them.

So, like, I'm so sorry physicians, but I ain't getting in there. I'm concerned I haven't even looked, but I would love for you to take a look because I'm not ruining, I am not ruining the trust that I have with this child. So, I'm like, I'm always like -

Asha: Yeah. 

Bri: I'm, I'm so sorry to you, but I, I'm not gonna ruin that for me and so that's kind of a big, that's a big one for me. I always compare that -My like justification of it is I love, do y'all know who Brené Brown is? Is that, is that Universal? 

Asha: Oh yeah. 

Bri: Translatable. 

Asha: We love Brené - love Brené. 

Bri: She's so great. Love her, I love her take on building trust with like the jar of marbles. So, she talks out when you build trust, like one marble goes into the jar, but if you lose trust with someone, a whole handful comes out. So I always think about that with every patient that I'm working with because if I've built up trust and then I put my hands in their mouth cause I really just wanna get a looksie and I lose that whole handful, well we're just, we're back to ground zero.

Sometimes we're negative. We're negative marbles now. And like, well is that really worth it? So, from a hands in their mouth kind of standpoint, I am pretty hands off. Most of my sessions are coaching a caregiver on how to respond and how to support the patient. I'm usually sitting there if I am, you know, sitting with the patient and stuff.

I try to have like, food on my plate as well, so it looks like I'm just engaged in the mealtime with them. But for the most part it's, it's a lot of parent coaching, which is why I also feel like tele practice is also very effective for my approach of feeding therapy, because I usually am not super hands-on.

Now with that being said, if I'm working with a child who's more medically involved, like from an oral motor standpoint or a positioning standpoint, then it might be a little bit more hands-on. But again, very, very much like, I have a spoon here. And so even if a child has, like, for example, super, super high tone and spasticity, I'll at least put their hand on top of mine and be like, okay, would you like a bite or would you not?

Like you guide me, you tell me what direction to go. And so very, very much that realm is kind of how I, I present my sessions and my goal is like always going into it where the caregiver just feels like they know the strategies, they know the cues, they know how to progress on their own. I'll talk to people about for example, I have a patient that and I feel like I'm saying a patient, I feel like I've had so many patients like this where we've, you know, progressed to a certain point.

But maybe open cup is hard because they have quadriplegic, spastic CP and holding an open cup and bringing it up to their mouth is tough. I'm not gonna keep them on my caseload for that. Like that's a skill where I can give the caregivers the strategies, they can go and practice that. I don't need to see you every week to, to work on that skill.

You know, if we have everything else as safe and functional, effective and enjoyable, those are kind of my four like keywords I work on. Then, then you're good. Move on, refined skills later. You don't need me. Like feeding is not the end all be all. There's so much more to life as important as I think that I am.

There's a lot more, there's a lot more benefit to other things in life. So that's kind of my approach to it. With that being said, there are quite a few approaches in the US that are not that. So, I've had I've had families come who have been through providers where they weren't allowed in the room. I've heard that more times than I can tell you. 

Holly: That is an outlier absolutely. For us you just would not find that situation here where parent wouldn't be that room. 

Asha: No, you would, you would actually. 

Holly: In speech therapy? 

Asha: Yes. I've had conversations this week. Mm-hmm. 

Holly: ABA though, or -

Asha: Mm it depends.

Holly: I know with ABA often the parents aren't -

Bri: Well, I was gonna say it's a lot heavier in behavior-based feeding, which is like literally makes me throw up in my mouth. 

Asha: Okay. We weren't gonna say it, but. 

Holly: We weren't gonna be that - 

Bri: Well I'm gonna say it. Ughh. 

Holly: Like you said it first, so -

Asha: Yeah. Yeah. We, we've done a, a lot of training across all different types of approaches and it's, 

Holly: That's been the worst.

Asha: Yeah. 

Holly: Oh, it's bad. 

Bri: It's -

Asha: Yeah. 

Bri: It's horrific. And what's scary is that in the US a lot of those practices are children's hospitals. 

Asha: Ghasp. 

Bri: Yeah, yeah. Most of them are. And they're like, we're this multidisciplinary team. 

 (Content Warning: Feeding Trauma) 

Bri: I one time had a patient, I'm just gonna tell you this story cause this one, ooh one gets me heated. So, I had a patient who went to this multi-disciplinary program through a children's hospital. It's like, we're multi-disciplinary, we'll rule out all the things. They primarily just saw a psychologist and an SLP, mom was not allowed in the room. She wasn't allowed to enter the therapy room until the child accepted bites from the therapist.

Then they would bring mom in to teach her the strategy. She secretly took a video of the session cause she wasn't allowed to have her phone out. Like no pictures, no videos. Yeah. And she secretly took a video one time cause she was behind like the mirror glass. And literally it was, it was, I mean, it was escape extinction, so it was non- removal of the spoon.

So, here's the bite. The kid is like turning away, doesn't want anything to do with it. If they didn't take the bite within like 10 seconds, they would ignore the kid, represent it. When he took the bite, he would have five seconds to swallow the bite. Like literally hit a timer. If he spit it out, they would re-scoop it and put it back in his mouth.

Asha: Ghasp. 

Bri: If he did swallow, then it was like they had this like toy that they were like, yay, great job for like 20 seconds. Ding. Did the same thing again. Had the timer, had the bi-. This kid came to me and immediately I was like, what they ended up doing when they discharged from this intensive feeding program, they basically had like an oral motor tool, like a specifically, it's a tool that has like this like squishy knob with, I don't wanna say like the name of it, but like -

Asha: Yeah, yeah, yeah.

Bri: Little spiky things on it, whatever. It's an oral motor tool. 

Holly: Yeah. 

Bri: And they would put it in puree. He would, they would hold the top of his forehead, wipe it on the back of his tongue, and he would have five seconds to swallow. He had delayed gastric emptying. They never investigated that he was vomiting three or more times a day. That's why he wasn't eating. Yeah. And he had been through eight weeks of that therapy. 

Asha: Wow. This is -

Bri: And this was like not long ago, like this was, yeah. And always like parents are like, it was horrific. I hated it. But they're, they have all these professionals telling them like, this is great. Oh my gosh. He did so awesome. And like - I get so heated, I feel like my face is getting red. I'm, I'm hot. 

Asha: Yes. Okay. So, you can't hear this if you're just listening to the podcast, but we are in shock that is - 

Bri: Yeah, yeah. 

Asha: Outrageous. 

Bri: See the responses! Go watch it on YouTube and you'll see the actual response. 

Holly: So many curse words I want to use right now. 

Bri: I know. 

Holly: That is, that is... So here, that would be illegal. 

Bri: It should be. But see, this is, what's frustrating about this is the literature, and this is where I get frustrated, is the literature shows that this works, right? It gets the child to eat, like so does Stockholm Syndrome! Like that also is a thing that doesn't mean it's ok. 

Holly: Torture. Torture works. Tortures a great way, way to get people to- thing -

Bri: Long term what's happening? Yeah. No. And that, like that mm-hmm. 

Asha: Yeah. See, I, I said to you last week, I really feel like, you know, I don't have a lot of dishes to do in clinic at the moment. 

Holly: Yeah. 

Asha: Because I'm not actually doing a lot of sessions where we are working with food when the families come to see me, I feel like I'm doing more phone calls every week to say how are things this week.

I call it like a maintenance phase. Like we are just gonna be okay with how we are at the moment. Our goal is not to, to lose foods this week, or, you know, we are just working through some medical complexities. Yeah. We are not even touching the foods. I'm just -

Bri: Yep. 

Asha: Supporting the family through this. 

Bri: Mm-hmm.

Asha: And, and it feels like, oh, am I, am I doing my job as a feeding therapist? Isn't there meant to be food on the table? 

Bri: Right. 

Asha: In our sessions? But I am so aware at the moment with my neurodivergent kids, my autistic kids. 

Bri: Yeah. 

Asha: Especially that if I push them too much, all I'm doing is getting them to mask in feeding therapy. And masking is not just social interaction. It is I'm gonna comply with what you are asking me because it gets me out of this. 

Bri: I was gonna say cause I want to get out. Yeah. 

Asha: Yeah. 

Bri: But long term there's no changes. Which is why a lot of those studies that they claim why it's effective are short term. None of them look at what, how the child is responding in another year or two or five.

Holly: Yeah. Actually, I just, am I allowed to like cross promote here, but - 

Bri: Do it, throw it out there. 

Holly: So, I am lucky enough to be a writer for the informed SLP. 

Bri: Yes. You can throw them out there. Love The Inform SLP. 

Holly: I, I mean, I'm figured you'd be happy to be happy to have them mentioned because I know you love their stuff too. But yes, I write for the Peds Med section and yeah, reviewed this excellent systematic review article looking at the use of ABA and behavioral therapy for chewing teaching chewing skills in particular. And there was this great line in it, and basically it was that the behavioral approach is excellent at teaching compliance with an activity, but not the functional skill.

Bri: Yes. Oh, that's such a good - 

Holly: And that's exactly what they're measuring. 

Bri: Yep. Yep. They are. That's why I'm like, yeah. I mean, it works at what you're trying - 

Holly: It works. 

Bri: Right? But like, define success, define works. Define effective. What are you -

Holly: Compliance? Compliance means? 

Bri: Yep, yep. 

Asha: Yeah - 

Bri: Yeah. Strap me in a chair and tell me I can't get out until I take a bite. I'll take a bite -

Holly: And hold my effing head down! 

Bri: Holding it! 

Holly: That makes me angry. 

Bri: I know. And then meanwhile, like the child had delayed gastric emptying. Like nobody was like, maybe he's refusing cause he's throwing up four times a day. No, it's all behavior. It's just, 

Holly: I, let's, let's use so much that like the vomiting is behavioral, like -

Asha: Yeah. 

Bri: Well here's my thing. Let's say, let's say a kid is making them self vomit. Okay? Let's say, let's say they're doing that. If they would rather do that than eat, like that in and of itself is a problem. Like, ok, let's say it is a behavior, like that's also -

Asha: Let's that's step back. Yeah, I, I do feel like that is something that we do quite well here is like, well I think we do anyway. Is not launching into a particular type of therapy until we've done a really thorough evaluation. 

Holly: Mm-hmm. Mm-hmm. 

Asha: I think we do that quite well. Like we are making referrals off to ENT, to gastro, to pediatricians, and often a lot of the time, like we are not gonna jump into really like, I guess, volume driven outcomes or variety driven outcomes until we know that that child is. I guess has the, the foundation to participate in that, right? 

Holly: Yeah. Yeah. And then, and so then we're working on things like just maintaining a positive relationship with mealtimes. 

Asha: Yeah. 

Holly: Even if they're not actually eating, but just that like being around food is okay and doesn't have to feel scary or -

Bri: Yeah.

Holly: Being able to like watch mom eat and they can cope with that and that's gonna be all right. So -

Asha: Or they've got some sort of control over the way the food arrives at the dinner table or the way that they arrive at the dinner table. 

Holly: Yeah. 

Asha: Yeah. 

Holly: Yeah. Yeah. I think autonomy is really pushed here, like around 

Bri: Well, I think that, yeah, I definitely think that that is where a lot of feeding therapy is headed in the states.

And I, I would like to say, I don't wanna say majority, cause I can't speak for the majority, but I, I know an abundance of therapists, which, you know, obviously I have my own bias, that's who I surround myself with is, is responsive in nature and, and wants to move toward that direction. But unfortunately, There is still a lot, and like I said, majority are out of children's hospitals, which is the places I think parents assume they could trust the most.

Asha: Yeah. 

Holly: Absolutely. 

Bri: And it's not all children's hospitals. There are some really great ones, but I think its kind of like a authoritative bias that comes into play there. You assume that would be the big authority and be the best option. And unfortunately, it isn't always. 

Holly: And I can see how it's, it has happened. Right. Because there is a lot of research behind the approach, like behavioral studies have been around for decades and decades. Yeah. But some of the oldest research that you can call upon and because they do write it, so it sounds like it's working. 

Bri: Yeah. And it sounds like it's -

Holly: Evidence based, right? The hospitals will say, we wanna use a program that works.

Bri: Works. 

Holly: And so, then they look at the research. Apparently it works. And so, then that's what they do. Like, I, I don't think that, I would hope that they're not like intentionally going out of their way to run programs that are damaging, but ayy. 

Asha: It's, it's, it's all -

Holly: It gives me shivers down my back. 

Asha: It's all in the outcomes, isn't it? Like, what are, what are you measuring? 

Bri: Well, when you look at the, if you look at some of the websites that like promote these, they say like, 98% of patients leave taking 50% more by mouth. 99% of patients leave. And it's like, but what are they enjoying taking it by mouth? Are they, how are they taking it?

Is it, is it a tool that you're wiping on their tongue? Does that really count as oral intake? Like, so they place these stats that again, makes it seem like their program just has it together. I've seen multiple children that did like a tube wean through one of those intensive programs, and six months later they're back on full G-tube feeds.

Because anything that was gained was because I just want to get out of this situation, not because they actually learned the skill. Which goes back to what you just said, Holly, where it's like it's teaching compliance. It's not teaching the skill, it's not teaching the, what they're actually trying to achieve.

Asha: Mm. 

Holly: And these kids have enough medical trauma to deal with, let alone therapy trauma. On top of that, like we, I see a lot of medically complex kids as part of my caseload and -

Bri: mm-hmm. 

Holly: they, it's, it's real trauma. 

Bri: Yeah. 

Holly: I can't imagine - and then it makes me angry that the parent is then expected to continue to perpetrate that experience onto their child that is so -

Bri: Yeah. 

Holly: Irresponsible and awful -

Bri: Mm-hmm. 

Holly: to affect the, that attachment relationship. Like, I mean -

Bri: Yes. 

Holly: Imagine like, so your parent, like your mom for that child is supposed to be the person that you turn to in a time of fear and worry, but then suddenly the thing that's giving you fear and worry the food in front of you, you turn to your mom and she's the one giving it to you. Like that is so confusing for a child that is so disruptive, deeply disturbing for that relationship. I -

Bri: Yeah, I know. Which, I mean -

Holly: Deep Breath. 

Bri: You know, I think as. It's horrific to even say, but that is why they don't allow the parent there in the beginning. Cause the parent is the safety net and the child's gonna be looking at them like, please save me. They wait until there's some compliance before they bring the parent in. 

Asha: Hmm. Yeah. And, and do you know, I think another thing that we reflect on is when you have manualized approaches or programs, it's, it's much easier to communicate those and train people in them when there is a set number of steps and you have to do it this way.

So, I can see from a commercial perspective as well that we've ended up with all of these options and programs that then have their own evidence. Because that's how you sell something, you package it up and -

Bri: Mm-hmm. 

Asha: It's, you know, it's easy to digest for a therapist who wants to feel like they're doing a good job.

Holly: Yeah. That's what I like about your stuff, Bri, that you put up on your Insta page, for example, is that I love how there's so much nuance in what you talk about. So even when you're talking about the controversial stuff, the, you know, things about tongue tires or cups or whatever it might be that you've - but I, I do, I really appreciate that you bring nuance into it and so that kind of black and white thinking, because that's the tricky bit. So, in Australia I do, and Asha as well do training and mentoring and stuff for -

Bri: Yeah. 

Holly: Working in feeding therapy. And so many times my mentees will say like, oh, I saw this thing on Instagram, right?

Like, I saw this infographic, I saw this, I saw this meme, I saw this page, whatever it might be. And the stuff that sells is usually really black and white stuff, because you're going, oh, this is the answer. Like, this is what I need, this is what I'm missing. They -

Bri: And they present it as fact based. That's it. 

Holly: Like here's the solution to your problem. I want that. But when you actually, but you know, but then my mentees will say to me, but I feel like there's something missing, right? Like, I, it like I get it. They're like, what about this? And so, then we have these great discussions, which is excellent. I love my mentees. They're very deep thinkers. 

Bri: Mm-hmm. 

Holly: But it bothers me that it's out there, all of this really right fact based black and white information being put out there when so much of what we do is problem solving and -

Bri: mm-hmm. 

Holly: Really looking at the gray in, in situations 

Asha: mm-hmm. And, and being able to synthesize, synthesize information from a number of different sources.

Holly: Yeah, yeah. 

Bri: Not one. 

Asha: To inform your approach and, yeah. Yeah. Yeah. And also, I think the thing that drives the changes that I've made recently over the last couple of years is values driven as well, like me as a clinician, as a person -

Bri: Yep. 

Asha: When I, you know, sell a service to a family, I want it to be driven by my values. And that is a lot about now a child relationship with food for their life and also the relationship with their family and what the experience of eating in mealtimes is like. 

Bri: Yeah. 

Asha: And that's not just about the bites that you're taking. And I don't wanna be a person that, you know, creates more stress for a family.

Bri: Yeah. 

Asha: That's, that's not what we're here for. 

Holly: Mm-hmm. Yeah. 

Bri: It's interesting you bring that up cause I had a conversation with a student one of my undergrad students over the week where we were talking about like, has the family ever said, I don't want, you know, have you, have they ever just said, I don't want feeding therapy for, or I don't want therapy from you, or I don't like you as a therapist.

You know, like those types of conversations. And one time I had a family who after the initial phone call, did not wanna work with me. And the reason was they were fully convinced that their child had ARFID. Now that's a whole diag, it's a whole discussion for itself. But this was a child who was two years old and they were fully convinced it was ARFID and I said, you know, my approach to therapy is that we make sure we've ruled out other medical diagnoses. We investigate, you know, and, and going through that. And they were just like, we're not interested in other referrals. We just want. Like fe, we just want behavioral feeding therapy and -

Asha: mm-hmm 

Bri: and I said that I'm not the therapist for you.

And like that goes into though the value side. I am not going to push any type of therapy on a child unless I know that they are safe and comfortable. I'm not. I just am not. And so that's like the one time it's come about where they were like, oh, we've been seeing this psychologist, but like we're doing cognitive behavioral therapy, but it's not helping.

And I still am in the back of my head. I'm like pretty convinced this child had EOE, like eosinophilic esophagitis because they would take tiny bites of everything, chew everything for a long time, but would drink anything. But a psychologist diagnosed them with ARFID and they were like, that's what it is.

And I'm like, no, no, no, no, no. Like, have you ever seen a GI? And they're like, we're not interested. Actually, what they told me was my husband's a head and neck surgeon. I think he would know if my kid needed to see a GI I'm like, that's not really relevant, but anyway. 

Asha: Yeah. Yeah. 

Holly: Thank you for sharing that. 

Bri: Thank you so much for sharing that. But I still think your child should see a GI but that was like an example of like a value side where I was like, if you come to me, this is how I will approach therapy. 

Holly: But that's, that's the therapeutic relationship, isn't it? Like that's, that's where the magic happens. It's the old, like, what we do is science, but actually what we do is an art, like what we bring to the relationship is what makes the difference.

Bri: Yeah. 

Holly: Otherwise *gestures and unclear word* could just go off and read a book or -

Bri: Mm-hmm. 

Holly: watch a YouTube video or you know, like I, I -

Bri: Right. Like the science gives us that foundation, but we ultimately have to then kind of like you were saying, Asha, like synthesize it and then apply like you have to, because there's so much nuance. I think 99.9% of what I do is that gray area, like -

Holly: Absolutely.

Bri: That's, that's majority of it for sure. 

Holly: And then making parents who want black and white answers feel it's okay to sit in the gray. Like it's okay. 

Bri: Yes. Yeah. 

Asha: Hmm. And there's also a lot of reflection required for yourself as a person. Like you are not just coming into therapy as a therapist, like you've done your qualification and now you know, you know, I can just apply everything as it's meant to be.

Like you're bringing your own personal experience and your own experience with food and your own experience with how you were parented in your mealtime. And often, I mean, that's certainly something that I wasn't thinking about with an awareness as an early career speech pathologist. But being able to get into a space where you can acknowledge that with families and you can ask them what their experience was, you know, the parents.

Bri: Yeah. 

Asha: It's so much easier to build that relationship with them when they can see that you are considering them as a person, and, and, and you are able to acknowledge your own, how your own experiences show up in feeding therapy as well. That's super important. 

Holly: Yeah. 

Bri: Yeah. That's a great point. I think a lot of that goes into that like, you know, culturally responsive therapy and that's kind of where, I know I make some people mad on Instagram when I talk about, like, I don't care if you watch TV during the meal. Is that how your family eats mealtimes? Or like, I don't care if you sit at the table. Do you all sit in the living room and eat dinner?

I'm not gonna force you to go to the table. Like, what is your cultural norm? Like, what happens in your home? That's what I care about. Like trying to force my idea behind what a meal is supposed to look like isn't gonna help anyone.

Holly: Your standard sort of, yeah. 

Bri: Yeah. 

Holly: I even like basic things. I had a family not so long ago and like the OT had recommended a highchair for their little guy who needed a lot of extra supports, like the supports for meals and the dad was saying to me like, ah, this is not gonna work for us. And I'm thinking, this is like, they recommended like a beautiful highchair. It's gorgeous, you know, like all the right padding and everything. And he's like, no, we sit on the floor to eat. They can't be up in a highchair. It's gonna be like a meter off the ground. 

Bri: It's not gonna work for us.

Holly: I need my kid down on the floor where we're all sitting.

Bri: Mm-hmm. 

Holly: So that was fine. We went off and found a highchair that could be down at the floor -

Bri: Sit on the floor. 

Holly: Like it was no - but it's just cons, like, like considering just asking like, what does it look like? Like actually what does it look like? 

Bri: Yeah. 

Holly: Where in the house are you and -

Bri: Mm-hmm. 

Holly: And are you even all sitting together at the same time?

Bri: Yeah. 

Holly: Or is dad actually at work in the morning and the big brother is serving up breakfast with the little brother and mom is, you know, getting ready for school, for the kids. 

Asha: And what would make the biggest difference for you? In the context of a mealtime, not, you know, okay, how do we get everyone at the table at the same time, you know, perfect positioning -

Holly: Perfect nutrition. 

Asha: Perfect nutrition. How do we work towards that? It's actually like, what, what can I do with everything I know and everything that I've worked to accumulate in terms of knowledge to make this better for you? 

Bri: Yeah. Like what actually matters to you? What, what is the part that, that would make that difference there? Yeah, it's a great, yeah, it's a great point.

That's, I always present to my families. I always say like anything that I say as like, I would recommend, or I think we should, whatever is a suggestion, and if it doesn't work for you, I'm like, literally just be like, Bri, thank you so much for that. Not gonna work. Because my job is to critically think through what will work.

Like I have tons of things that I can throw at you, but don't just say, yeah, that, that sounds good. If it doesn't actually sound good. Like -

Asha: Yeah. 

Bri: There's, there's that two-way piece too. And, and kind of opening up that discussion, I'm like, all right, what do you think about, you know, let's try this. And it's like, don't nod your head at me and say, okay, sure.

If you're like, no way, no way in hell is that gonna work for me, Bri. But thank you so much for that. Like, let's, let's try something else. 

Asha: I have been saying to families recently, you know, I'm gonna give you this, you know, write up of, of what you found most useful from today. But if you come back next time and say, everything went really well, I'm gonna be suspicious.

Like if, like, if that was how simple it was, you wouldn't need to see me. And I know that you have already tried everything that you can think of to make this situation better for your family. So, I want you to come back and tell me that it didn't work. 

Bri: I love that. I love that. I'm gonna be suspicious if it all works. Well, it already, like, I was just gonna say, that just opens up the discussion of what didn't work, you know? 

Asha: Mm-hmm. 

Bri: It, it makes the family not feel like they're gonna, like, hurt your feelings by saying something didn't work. You're like, I, I expect something not to work. So, tell me which thing it is.

Holly: Absolutely. 

Asha: Mm-hmm. 

Holly: I worked with this amazing OT years ago when I first started in feeding. Shout out to Jill Griffith, if she's listening. Hey Jill. And she was a big advocate of basically get- helping the family to fire you. So basically, getting them to a point where they don't need you anymore. 

Bri: Yeah. 

Holly: And her big thing is always that you get the family to be the problem solvers. So, she doesn't even offer strategies and suggestions. She will support the family. And so, she does a lot of wondering. So, like I wonder what would happen if, or I wonder what you're thinking is going on here, or I wonder why that mealtime went so much better. Do you know when the family comes in and they say, ah, they're actually ate you food this week.

Like they eat pizza. And so rather than be like, oh my gosh, that's great. Okay, well if they're eating pizza, let's get blah, blah, blah, blah, blah. She would say like, I wonder why, like, and she would just leave it open. So, she wouldn't even offer what her thoughts were initially. She would just wait for the family to offer up their suggestions as to why they think it worked and her, yeah.

So, her whole thing is to try and pivot the relationship around so that the parents are starting to reflect and problem solve, because then if they can come up with the strategy themselves, if it doesn't work, it's not our fault. 

Asha: Mm-hmm. 

Holly: And so that external locus of control is not as obvious. It's not like, well, the therapist told me to do this and it didn't work.

There's much more impetus for change if it's something that you have decided that you think should be done. So yeah, so that's, I think also ties into this like -

Bri: Probably helps with like that's also probably helps with a lot of like buy-in and like wanting to try it cause like I truly think this is gonna work. I feel like that is very similar to a lot of parent coaching approaches too, of like -

Holly: Yeah. 

Bri: Okay, so I've helped, you know, we've problem solved through some things, but now what do you do? But I love that of like, oh, wonder why? Wonder, wonder what would happen if we then or. 

Asha: Yeah. 

Holly: Yeah. 

Asha: Yeah. Is there anything else that you wanted to capture before we finish?

Bri: I wanna start doing with guests like a rapid-fire thing. So, I'm just gonna ask you like -

Asha: Mm-hmm.

Bri: three questions and just like, tell me, tell me off the top of your head. So, let me pull up my questions really quick. 

Asha: Woo. Okay. 

Bri: Not to put you on the spot. 

Holly: That's exactly what you're doing actually. 

Asha: Yeah. Rapid fire. 

Bri: Except I am, I know I was about to say, not to put you on the spot, but to put you on the spot. So really quickly, I'm gonna give you just three rapid fire questions, and it's meant to be rapid fire.

So, I want you to answer in like a word or just a couple words or a sentence. It's not meant to be like, don't elaborate very long, just like what is the first thing that comes to your head. Okay? All right. So, the first one is, what is one thing you think all feeding therapists should know? 

Asha: Attachment theory.

Holly: Oh, good one. Responsive feeding. 

Bri: Okay. Love both of those. All right. What is your favorite thing about feeding therapy? 

Asha: Snacks all day. 

Holly: Babies. 

Bri: And babies. I love it. All right. Your last one, and this one's kind of a little bit more, a little bit more fun. What is your favorite food to use in feeding therapy?

Asha: Oh, for what? 

Bri: So, what's your go, what's one of food that's just like a go-to? You're like, oh, I'm working on - 

Holly: Chicken Crimpies. 

Bri: I don't even know what that is. 

Holly: It's a cracker. It's a delicious, delicious cracker chicken cream. I don't even know why I said that. I don't, I mean -

Asha: That's so random. Out of everything? 

Holly: What are you go- you haven't said a word, so -

Asha: I, I can't Ah. Oh. Freeze dried fruit. 

Bri: Ooh. All right. Okay. These are good. Yeah, these are good. 

Holly: I'm gonna stick a Chicken Crimpy. 

Bri: I feel like both of you are thinking like you're gonna pick a food to work on, like chewing. Like that's, that's where like my, my brain went. 

Asha: No, no. Mine's. Mine's not chewing. Mine is like -

Bri: Variety? 

Asha: Make make a juicy, scary thing. Less scary as an intro. 

Holly: Oh, mine was just cause they're delicious and if I have to eat something with the kid in the room, I figure I might as well pick something tasty. 

Bri: That's where my brain went too initially I'm like, what food do I like to eat with the kid?

Holly: Yeah. 

Asha: Okay, well if that's it then I'm going Nutella bagels, obviously. 

Bri: Now we're just sharing like favorite food overall? So. 

Holly: Or YoGo? I think you should, one of the rapid-fire questions should be, what is one food you hate working on in feeding therapy? 

Asha: Yeah. 

Bri: Okay. Throw that in there. 

Asha: I have a blanket. No bananas. Bananas make me gag. And I will, I will not. No thanks. 

Bri: What's yours Holly? 

Holly: Fresh blueberries? 

Bri: Fresh blueberries? You won't do it. That is so funny. That's so funny. 

Asha: I didn't know that about you. 

Bri: See, I don't eat red meat, so that's my thing. The family wants to work. 

Holly: Oh, I'm also, I'm vegetarian. Yeah. So, yeah, that makes -

Bri: But those are, but here's the thing. If a kid is working on it and they hand me a piece, I'm gonna chew my way through that piece of food. I'm gonna do it. I'm always like, FTK - for the kids. I can do it; I can manage this bite of food. That's only, those are the only ones that I'll do it for. 

Asha: Yeah. That I, I feel the same way about concoctions that kids make, like they've, they've made toast or a sandwich that they're really proud of and they offer me some. I'm like, thank you so much. I would love to try this. 

Holly: Yeah. 

Asha: Oh. 

Bri: You do? Do you do like one bite, and then you're like, I'm just so full. Oh. Oh. I'm just -

Asha: I'm listening to my body and I feel full but thank you so much. 

Bri: Yes. I love it. 

Holly: I'm full of this food. 

Bri: Yeah. 

Holly: The worst I had was, it was vanilla yogurt with apple juice mixed in and sprinkles.

Asha: Oh. 

Holly: And then fruit puree and -

Bri: Oh. Mm. 

Holly: He was eating it and he was liking it, and he had never eaten fruit before. Any fruit flavors. You were just like, and so mom and I were like, hooray. And then he wanted all of us to eat it. My gag reflex has never worked so hard in its life to dampen off. I was like *gagging sound* 

Bri: Yeah. You're just like, I'm in another place. I'm not here right now. 

Holly: I'm in a happy place. 

Asha: This is the food that I'm learning about. 

Bri: Yeah. This is also your therapy time. 

Holly: I've learned to eat a lot of foods actually, as part of feeding. 

Asha: Yeah. I've also tried a bunch of foods from cultures that aren't my own and that's been really cool.

Bri: That is one thing that's very enjoyable is learning about -

Holly: Mm-hmm. 

Bri: a lot of different, different foods for sure. For sure. 

Asha: Mm-hmm. 

Holly: I learned swear words in other languages. I learned that cous cous is a really dirty word in Diri. Yes. 

Bri: Would've never known that. 

Holly: So, I recommended to a family, I was like, oh, maybe you could try like adding the cous cous to the puree, and the dad was like, and it's like burst, it's like it's a rude word for female genitalia.

Asha: Really? 

Bri: And you're like, oh. So, don't try that. 

Holly: Maybe don't, don't be doing much with that one. 

Bri: It's so funny. 

Holly: Mm-hmm. 

Bri: Alright. Well I appreciate you all so, so much. This was such an awesome conversation and it's been fun to learn about some of the similarities, some of the differences, and be able to chat through that. So, thank you so much for hopping in, and -

Holly: Thank you. 

Bri: Look forward to continuing to chat with each other. 

Asha: Yay. Thank you for having us. 

Holly: What a pleasure. 

Asha: Oh, how about we send you some Australian snacks? 

Bri: Oh, please send me some. 

Asha: Ah, okay. And then next time we catch up, we'll we'll do snack reviews. Okay. 

Bri: Yes, that's perfect.

Bri: Thanks for tuning in to the Feeding Pod this week. If you enjoyed today's episode, please don't hesitate to share this podcast with your friends and colleagues. And leave us a five-star review wherever you're listening from. If you're interested in learning more about pediatric feeding and swallowing, be sure to follow Bri - me - on Instagram @pediatricfeedingslp or check out my website where you can get access to more courses and information, www.pediatricfeedingslp.com.

Again, thanks for being here and listening to my ramblings, and I hope you'll keep listening. Until next time, cheers.



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