Episode 5: SLPs role in early identification of autism, parents' social skills, & clinical practice research with Megan Roberts
Episode 5: SLPs role in early identification of autism, parents' social skills, & clinical practice research with Megan Roberts
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(0:12) Tiffany Hogan: In this episode of SeeHearSpeak Podcast, I speak with Meg Roberts about her recent ASHA Leader article on the speech-language pathologist’s critical role in early identification of autism. We also discuss the relationship between parent and child social skills and her love of clinical practice research and early intervention. I was particularly excited to talk with Meg in April, Autism Awareness month. Per usual, we end our conversation with Meg describing her current most exciting project and her favorite children’s books. Don’t forget to check out www.seehearspeakpodcast.com to sign up for email alerts for new episodes and content, read a transcript of this podcast, access articles and resources that we discussed, and find more information about Meg. Also don’t forget to subscribe to the podcast in apple podcast or wherever you are listening.
(1:17) Tiffany Hogan: Thank you Meg for joining the See Hear Speak Podcast. I'll start by having you introduce yourself.
(1:20) Meg Roberts: Great. Well thank you so much for having me. My name is Megan Roberts and I am an assistant professor in the Communication Sciences and Disorders department at Northwestern University. I also lead the early intervention research group, which is my program of research related to understanding how we can best support language development in the tiniest of humans under age three.
(1:46) Tiffany Hogan: Oh, those are some of my favorite humans!
(1:50) Meg Roberts: I love the tiny people!
Characteristics of Autism
(1:53) Tiffany Hogan: I know me too. They're fantastic. They are my faves. So recently you wrote, this month, actually April, 2019 an ASHA leader article on SLP seeing the signs of autism spectrum disorder. For the more novice listeners here on the podcast, will you first just explain how a child perceives an autism spectrum disorder diagnosis? What are some of the characteristics you look for? Who often gives that diagnosis? When are children most likely to receive the diagnosis? And just any other helpful information that can set the listeners up with some background knowledge for our discussion today.
(2:26) Meg Roberts: Happy to! I wish there was a more systematic process to this, but I will say a lot of this varies from state to state. I can speak to what the current processes in Illinois and kind of general principles, but individual providers would really understand their own state's regulations. In terms of like who and who can and cannot diagnose autism. Unfortunately that is more state by state. And so in general, we'll talk about the gold standard to start with. So in general, the first kind of part of the diagnostic process is somebody recognizes a concern. Then they get a referral to a, in an ideal world, a multidisciplinary team. And so in that team would be generally, for the tiniest of humans under three, I'll speak to that. Because that's what the article was geared towards, really targeting early intervention providers who have these relationships with families.
(3:21) Meg Roberts: So in an early intervention, you would get a referral to what we call an Illinois, a medical diagnostic team. And on that medical diagnostic team is usually a developmental and behavioral pediatrician, or it can be a general pediatrician, an OT, a speech pathologist. And in the state of Illinois also what we call a developmental therapist. But in other places it would be, just like when you think of general special Ed. But in general, what we want for an autism evaluation is we want not just one person, we want to see all of the perspectives. And so with that, a speech pathologist is one of the members of the team. I will also say that it's very common and ideal to have, you know, people like social work and psychology as well. In Illinois, the general model for at least under age three, is it developmental and behavioral pediatrician, a speech pathologist, a developmental therapist, and maybe an occupational therapist. And so, it's more of like this arena evaluation in which we're all doing different measures, but all try to make sure that we're seeing the same things or maybe why we're seeing a function of specific behavior.
(4:30) Tiffany Hogan: And what are the criteria then that that team would be looking for to say, this child has an autism spectrum disorder?
(4:39) Meg Roberts: Right, yes. Great question. It's interesting because the DSM has changed over the years, and right now the criteria for autism is really looking for, kind of difficulties in two big buckets. One bucket being social communication, and the other bucket being restricted and repetitive interests. So those are kind of the two areas in which we need to see symptoms. And of course other things like, was it always occurring? Were there always signs from early childhood? And that has a significant impact on, you know, day to day functioning.
(5:17) Tiffany Hogan: And then if I'm correct, the new DSM set aside also, if you don't have the repetitive behavior and you have just the social pragmatics, you could have social pragmatic communication disorder, is that correct?
(5:30) Meg Roberts: Exactly right. You really have to have both.
(5:33) Tiffany Hogan: Okay. Both for autism spectrum disorder.
(5:35) Meg Roberts: Yes, for autism spectrum disorder. And so oftentimes we'll see a kiddo who is super communicative socially, like pointing, showing. It's the kid I say that's looking at the wheels of the train, but he's also being like, look mom, look, I'm perseverating on the wheels of the train. Like yeah, you're definitely perseverating and you have this restricted interest, but you're also super socially communicative about your weird interest. And that kid does not have autism. That kid has some weird interests. You know, the flip side is you could have a kiddo that doesn't have any of those restricted interests, but just has difficulty communicating socially. And that kid also doesn't have autism. That kiddo has a social pragmatic disorder.
SLPs Role in Early Identification of Autism
(6:19) Tiffany Hogan: Oh, that's very helpful to know. Okay, that's great. So back to the ASHA leader article, your take home message there for SLPs, and really any other early interventionists, was that they should speak up and say something to parents if they see signs of autism in their clients. So why are SLPs though in particular in a unique position to do that?
(6:38) Meg Roberts: I will try to make my response brief, because I feel like I could talk like literally for hours about this, and why I was compelled to write the ASHA leader article. I feel like if I were to pick the best, the number one reason, yes we are therapists. But fundamentally the reason why I think EI providers in general are the best is because they have ongoing relationships with families and they have many opportunities to see the behaviors. So they can have this slow conversation, as opposed to this very jarring one hour, two hour, three hour experience with a diagnostic team. And so that's fundamentally the main reason. In addition, why I think early intervention speech pathologists are in a unique position is because we understand social communication, right? So we are able to notice those subtle differences of like, wow, you know, this kid doesn't have words, but he's pointing a ton. That kid is less likely to have autism as the kid who also doesn't have very many words, but also taking the parent's hand to the refrigerator to get milk, as opposed to pointing or vocalizing. And so those subtleties, I think we're trained to observe those subtleties. But also trained in how do we talk about them with families. So we can talk about pre linguistic communication, we can talk about intentional communication, we can talk about joint attention in ways that maybe other providers can.
(8:13) Tiffany Hogan: You know, reading your article reminded me of an experience I had as a CF way, way, way back when. And that was an evaluation that I was doing with my CF supervisor. And it was a child who was probably just close to two. The parents brought him in because he was a late talker. He didn't have any words, and they were concerned. They brought him in, and we were asking some basic questions. And one of them was about social communication, you know, how does he interact? I remember the mother saying, oh, he greets everyone who comes into our house, he's very social. But then when I was observing, I saw behavior that didn't appear very social to me when he was just playing in the room and interacting with the father too. So I asked very specifically, what do you mean by he greets everyone in the room? And she said, oh, every time someone comes into the room he looks at their shoes, he's obsessed with shoes and he touches their shoes, and he just really acknowledges them through acknowledging their shoes. And right then that was a big red flag. Because from the parents' point of view, they see that as social. But as speech pathologists, we have a different sense of what we mean by using social language, as opposed to maybe an interaction point, which she saw as the shoes. So then after the evaluation, my supervisor and I did mention that we had some concerns about his social language use. We did mention the word autism, but I remembered the time, it was a very stressful situation to mention autism. I remember telling my spouse later, it felt like we were giving a cancer diagnosis because the parents were blown away.
(9:55) Tiffany Hogan: They had very limited knowledge about autism. The knowledge they had was based on movies, you know, for instance like Rain Man. They had a very bleak view, and it was hard to hear that word. There was a lot of weight to the word. And so I wonder if that's also kind of what's maybe driving some of this anxiety for parents. Because what struck me in the article, is that you said from your own work, that more than 50% of caregivers said that no provider prior to receiving the autism diagnosis even mentioned autism. Even though they were 100% of them were in early intervention. So they were interacting with early interventionists, likely speech pathologists, like you said, every week and a very personal way. And no one had mentioned that. So I can definitely see how from the speech pathologist view it can be a little scary. But man, from that parent's view, I mean it does seem like that there are some real downsides to not speaking up about the early signs of autism.
(10:57) Meg Roberts: 100%. I did a talk at ASHA in Boston in the fall, and that's actually how the article came to be. Somebody in the audience was actually the editor of the ASHA leader, and she was like, I think you should write an article on this. But what was fascinating to me is that the majority of the audience, even with me kind of like guiding them and giving them specific strategies of how to bring up the conversation, the majority of the audience was still like, oh no, no, I don't think I can do this. I loved how vulnerable they were. Hopefully at the end they felt a little bit more empowered. But it was striking to see that. I think there's several reasons why speech pathologists don't bring up the conversation. One of which is, I think there's misinformation about what's in our scope of practice. It is in our scope of practice to diagnose autism. But, then this is a very big, but by bringing up concerns about signs of autism that is not even diagnosing autism. That is just starting the conversation. I think conflict is hard, and bringing up bad news is, is hard, right? In any domain. I think about when your conversation about CF brings up a great point, a cancer diagnosis. The difference between physicians and speech pathologists, however, is that I'm pretty sure that most physicians have received explicit instruction on how to deliver difficult news. And I'm willing to bet that we, I can speak for at Northwestern, I don't do a good job of that. I do a better job of that now. But I didn't as a master's student, get a ton of instruction on that. I could be better as a professor for sure with teaching that. But I think that there's a gap in our programming and development of new clinicians. And then I think, um, there is this also vulnerability of like, what if you're wrong. And you know, all of the things that come with that. And I think you have to be pretty, you know, okay and confident and really vulnerable and authentic with families. I say to them like, I definitely could be wrong, but I don't ever want to say Coulda, Shoulda, woulda. So I just, I want more information for you and with you because some of these pieces just aren't making sense to me. It's better to know than to not know. I just lay it all out there for them, and so they can kind of see exactly what I'm thinking of, and why I'm thinking it.
(13:28) Meg Roberts: And I can say things like, so here are the things that like don't make sense to me. Like he always makes eye contact and you know, give us big hugs. But he still never points, or he still never will look back and forth with your eye gaze and point. So it's kind of telling the parent like, I see those things that are making me say, oh that doesn't look like autism. But there's also these things that say, oh, these do seem like autism. And so I think having these really open conversations about like what you're thinking and why you're thinking it, make parents, feel more part of the process. And also, just why you were making that recommendation.
(14:11) Tiffany Hogan: And I think it can also be validating even back to my own experience, even though it was a devastating discussion. And one that they were surprised by at the end of that discussion. They felt very validated because they've seen these signs too, they live with the child. They see these things, and then we can kind of label what they're seeing. I really appreciate in your article, you provided a really concrete approach to take. Early providers can take it as a way to discuss these early signs of autism. Can you talk me through that approach?
(14:42) Meg Roberts: Sure. I think the overall overarching framework for the approach is that rather than telling parents what to do, your job as a guide, is to get them to make the decision on their own. The analogy I get is nobody likes to be told what to do, right? Like there's this thing, right? Contingent versus non-contingent help giving. Like if the idea is yours and you want to do it, you're more likely to be successful. And so somebody giving you the recommendation of, oh, you need to enroll your kid in early intervention. Or oh wow, I'm noticing concerns, my kid needs early intervention. That parent's response to early intervention is going to be different even if they both end up in early interventions. And so the parallel in autism is I want families to notice the signs on their own. Not just be like, oh yeah, Meg says he's doing that, and because Meg says he's taking my hand all over the place, now I'm going to go get the evaluation. I want the parents to be like, wow. Yeah, he's not doing that, and maybe that's impacting his language. And so what I do is I start with like a lot of, "I wonders." I wonder why he's doing that. And I start subtly without saying the word autism, pointing out signs of autism. Just start to get the parent to notice the signs. Because ultimately what I want the parent to ask me why. And that's my opening, why do you think he's doing that? Because once the parent asks like why do you think he takes my hand to the refrigerator all the time? Or why do you think he lays on his side and looks at the wheel? At that point I can say, you know what, I don't really know, but I'm wondering if that's going to impact how he is learning language. You know, there are many reasons kids can have language delays. One of those reasons is, autism. Now of course, I don't say that all in the same session. Usually it's a few sessions of "wondering." And then when the parent asks a question, then that's the opening. And then depending on how that parent responds is how, how quickly I will recommend a medical diagnostic evaluation.
(16:52) Meg Roberts: For example, when I say the word autism, if a parent is like, oh, no, no, no, definitely not. I'm like, yeah, I can see why you might think that, and then I'd give some examples. But I'll say if it's okay with you, let's both be detectives and continue to look at these behaviors to get to the bottom of why they might be happening. So it's kind of this like slow dance over probably a week or two, or even a month or two. Because ultimately what we want, is not to have a diagnosis of autism. That's not the goal. Right? The goal is to get them in high quality intervention to maximize their outcomes. One of the ways you do that is in the work I do is, is by empowering parents to support their child. And if a parent isn't bought in, you're not likely going to get the same effects. And so it's very important for me to maintain that relationship with parents and really partner with them. Even if I'm right, it's not about being right, it's about them and their relationship with their child.
(18:00) Tiffany Hogan: That makes such good sense. These conversations are tough, but it sounds like once you use this approach, and you have some success, the benefit is worth it. The benefit is getting the child and the parent, the services they need to work together and have the parent become the advocate and be empowered and validated. And I imagine over time these conversations can get a bit easier because you can be more comfortable with your vulnerability as a clinician. Then as you brought up, like even if a parent would say, oh, I don't think that's autism. That could be a nice opening to say, you know, there are a lot of really strong stereotypes of autism, but it is on a spectrum. So there's mild to more severe, and it's really about social communication. And even if it ends up that the child doesn't have autism, that's been a nice conversation to have with the parent in terms of education. So it sounds like it could be really good approach. I hope through this article and through the talks you've given, like at ASHA, that slps will feel more empowered to do this.
(19:01) Meg Roberts: You know, it's interesting when you said that conversation is also an opportunity to really kind of change the conversation about what autism is. It's been interesting and I'll tell this story: I was at an eight os training, which is the autism diagnostic observation schedule, research reliability training. You go and you practice in front of an expert with a kid, and they give you feedback. And I'll never forget this. I tell parents this story. There was this eight year old little dude and he came in and I'm doing like I think a mod three and which is an older version of eight os, and I'm having a conversation. And all of a sudden at the end I'm like, are we sure he has autism? Because we had talked about like this, these dinosaurs for so long and I was just so enjoying how like delightful he was. Yes he had this restricted interest, but I didn't try to switch the topic because he just was so knowledgeable! He was just this like delightful kid in a mainstream, regular, you know, second grade classroom. And he'd gotten early intervention from the beginning. And yeah, he still had autism, but it wasn't the first thing I saw in him. And I think that's the thing that parents need to kind of hear, is that it is a spectrum. And then, that the best thing we can do, we don't have a crystal ball. The only thing we know with certainty is that early intervention is better. And the best way to get the most dosage and the best customized intervention, is through a diagnosis. A diagnosis in many states of autism let's you access other therapy services that you are not eligible for if you don't have that autism diagnosis.
Factors that Influence Early Diagnosis
(20:35) Tiffany Hogan: That's a perfect segue to the next question I wanted to ask you! Because I know one of your primary area of research is more accurately identifying these autism spectrum disorders early so that parents and children can work together to get these early interventions that they need. So you note in a recent article about ASD, I'm going to use that for short for autism spectrum disorder, can be reliably identified when a child is two years old, but that most children don't receive the diagnosis to closer to four years old. So what explains this discrepancy between, you know, the time we can accurately give the diagnosis to when they get the diagnosis?
(21:13) Meg Roberts: So I think there's a lot of factors. I also think that we are also diagnosing autism in adulthood more frequently now. So that could, that could be one reason just statistically why there's a difference. But when we think about barriers to early identification, um, between like the two to four year olds. Somebody has to identify a concern, right? And so, somebody has to bring it up. And so I think that's one factor. Is that people might be noticing the signs, but they're not acting on them. The good news is most kids with autism are enrolled in early intervention early, but they're not necessarily have an autism diagnosis. And often for that reason, they might be in EI. People are noticing a delay, but it's not a diagnosis autism yet. I can speak to Illinois and other areas, is that the wait lists are often very long. So by the time you get enrolled in early intervention, you want to see how the kid is doing, then you decide, oh now the parent is on board to get the medical diagnosis. Now I've got them on the list, but the list might be three to six months long. And so you can kind of see how the process is really drawn out. Then a huge bottleneck, at least I can speak to Illinois, is that for kids under three, evaluations go through early intervention. But the only people that can diagnose autism in Illinois are developmental and behavioral pediatricians. And there are so few of them that you can kind of see that bottleneck.
(23:01) Meg Roberts: We've, tried out a new paradigm in our Northwestern University Center for audiology speech language and learning where we have a general pediatrician who we have trained and worked with. And because we're a multidisciplinary team, now we are trying to say, okay, what could general pediatricians do? I think if we can think flexibly about, who can be the first point of diagnosis. I'm not talking about like, you know, continuity of care, like, you know, medication management, seizure, like all the other complexities of autism really do require, you know, a specialist. But I don't think that the, the entry to services and the gateway for an autism diagnosis should go through developmental and behavioral pediatricians. Simply because there's just not enough of them. It's a bandwidth issue.
(23:55) Tiffany Hogan: I would imagine that could be agonizing for parents even though they're in early intervention. Maybe getting some services, but they're still in this purgatory of does my child have autism? Do they do they not have it? And then that limits maybe their acceptance of the diagnosis and maybe even interfacing with support groups, parent support groups. I think ARC is one of them. Like, that they can get together and maybe talk to other parents and, and learn information. And I imagine that's kind of a head game for parents to have to wait that long one.
(24:29) Meg Roberts: Totally. Yeah. And also, you know, you might have a family that's like, oh, I don't know if I should do it and may take them a few months to decide. Then they're finally like, you know what I think it is autism, we're going to go. And now that I've like, I have this idea, now I've got to wait. And then who knows what happens in that, in that period of I don't know, you know, maybe I was wrong. And it's not the best process for parents for sure.
Screening for Autism
(24:52) Tiffany Hogan: So you've written about a screening approach to reduce wait time. Maybe it's the one you were just mentioning. Can you tell me more about that approach? That kind of different cut points and initial screening. The second screening?
(25:04) Meg Roberts: Yes. So if I were queen of the world, I would love it if EI providers, particularly speech pathologist, could do easy screening measures as part of early intervention. These could kind of streamline the process for families. I'll back up and say, when diagnosing autism, you have what we call level one screeners, which are like the general population, right? Everybody gets the m chat at their 18 month old, well baby visit. Right. And that's for just everybody, and they're not already diagnosed with anything.
(25:38) Meg Roberts: Obviously we know some new data about the m chat being not, not super great. Um, but the second level of screening a level two is for kids that are already identified. And so those kids are some measures, and that would be perfect for kids in early intervention, where you could do a level two screening. I would say my favorite level two screening is the stat, which is the screening tool. I think it is the tool for autism in toddlers and young children. It's Wendy's Stone's measure. I love it because they give you some activities to do, right? So you play with some toys, you roll balls back and forth. There's some imitation tasks, but rather than just like a checklist, it gives you kind of like, it's a standard set of materials. It's 20 minutes long. The kids don't generally hate it. You can kind of walk your parents through like what you're seeing. So it's not just like, oh, I completed this checklist on my visit. It's really nice because you can use it as a tool with families. But so then it made me wonder. So we've been using this screening tool, the stat, in our diagnostic, and then also the eight Os, which is the gold standard, which takes longer to administer. It's 45 minutes. I was just noticing that there are just some kids that you just know in the stat, like, you don't need to do the eight Os. I'm like, well, why are we, and then we're just, we're using these resources. And so you have these hell yes and hell no cases. And then the gray in the middle. That's the test. Like I needed to have a more fancy academic name than hell yes and hell no for the academic paper. But basically what we were trying to say is, is there a point in which we are confident that the kid does not have autism, or a point which the kid definitely has autism. And then the middle where we're just not sure. And so we were using the skills of my very amazing psychometric expert colleagues at Feinberg Medical School. We applied some methods that have been used in other fields to say, okay, how could we maximize the positive predictive value, negative predictive value. So basically those kids that really do have autism and don't have autism, so that we could just basically diagnose them with a less intensive measure. This would allow us to save the more detailed medical diagnostics for those like middle ground kids. And so it was promising data. It's interesting to know that that idea could work because the traditional way of doing screening is you have one cut point, right? And in that one cut point you have to say, okay, what is the likelihood that the kids are not going to have it who do? And who do have it that don't? And so you're constantly balancing like who do I care more about? Right. Do I care more about the kids that definitely have autism, that are more likely to have autism or less likely to have it? And so when you have to cut points, you're able to prioritize both, right. And make different decisions.
(28:40) Tiffany Hogan: I really like that idea. So let me think. So I like this idea. So you queen of the world, how would this look? So you would, are you envisioning that a parent would take their child in to the pediatrician's office. And at a certain period of time, maybe it's an age two or even a little before, this 20 minute screener would be given to all children? Or is there another pass even prior to that?
(29:04) Meg Roberts: Yeah. So I will preface this by saying this is not well developed in my brain quite yet. So we need a lot of pieces, right? I believe the stat is fantastic, but it doesn't map quite to the DSM five. Restricted and repetitive behaviors aren't present in there and so it can't be used. So the concept of using multiple thresholds needs to be applied to a measure. And I think we need a new measure. I think we need a new easy measure for early intervention providers to use that will tell us the likelihood of having or not having autism. And then I think it should be open source. I'm queen of the world. Right? Then I want, pediatricians, there to be what we call these diagnostic access centers. So not every pediatric practice has to have a pediatrician skilled in autism. But I would like there to be, like a few maybe in every city, or pediatricians that are in a working group that are care about development and they do like popups. So like you know, one month it's in this clinic, another month it's in that clinic. And they use information from speech pathologists, and they use an efficient measure and they're part of a team. I don't really want general pediatricians doing this on their own quite honestly. But this process, the accelerated process really depends on slps doing the work ahead of time about talking about what autism is. Because you cannot go into a quick diagnostic and have the parents hear the word autism for the first time. It is not okay for them. They will not leave that diagnostic feeling okay. So this accelerated approach is like from the beginning speech pathologist or early intervention providers need to be talking about autism. Parents need to be recognizing the signs. We're maybe doing a screening in the wild. We're talking about the results with the family. We're referring to the pediatrician we're with the pediatrician and the diagnostic, we're doing the new measure, the efficient measure. And then we're referring only the cases that are in the gray to the developmental and behavioral pediatricians. But those wait lists are shorter too because we've already cut out the hell nos and hell yeses. And that would be my, my grand plan. Let's hope someday they will fund me to do my, my grand plan!
(31:29) Tiffany Hogan: Done! I think it sounds great because I mean it's really meeting all the goals that you want. You want accurate screening, you want a diagnosis quickly, but you also want parents to not be blindsided. So you want a team approach and you want it to be quick enough to get early intervention services as they need them, but you don't want it to be so quick that you feel they feel uncomfortable. But you have this nice approach. I think that kind of bins kids, and then you can move forward and kind of get rid of those bottlenecks of those wait lists. I had, we had the same thing when I was a clinician, working at a children's hospital. We would have a year long wait and it was just horrible to see that happening. And-
(32:12) Meg Roberts: That's like half of the kid's life! Or a third of a kid's life! Yeah.
(32:16) Tiffany Hogan: It's just, it's really tough. And so it's, I think it's really, I like your approach a lot. And I love this idea just even just to nerd out for a little bit in terms of the stats portion of it, I like this idea of the two cut points. To have better, you know, have more confidence that the ones you say have autism are likely to have autism, do. But then also this idea of if you have a different cut point, maybe at the lower end of symptoms, you can feel very confident that those kids don't have it on. And then you have that middle zone, right, that middle zone that you're kind of like, we need more information. And this is the zone of which we would want to delve a little deeper.
(32:53) Meg Roberts: Yeah. And speaking about those statistics, like in the study that we did, it was 50% you know, so you might say, oh yeah, well great. You could eliminate, you know, the 5% 5% but you still have 90% in the middle. We were able in this study to show that we could eliminate 50% there. There were still 50% that were gray, but there was 50% that we were almost 100% confident we weren't going to get a diagnosis of autism.
(33:18) Tiffany Hogan: Wow, that's, that's amazing. That's really fantastic. And that's a great point, it's not a small percentage. That 50% is a very large percentage.
(33:26) Meg Roberts: So the thing, I'm sorry.
(33:27) Tiffany Hogan: Go ahead!
(33:28) Meg Roberts: Okay! The thing I'm the most proud of, and I'm proud of a lot of things about this paper. But one of the things I'm the most proud about is that this was not funded by an NIH study. This was a true clinician researcher partnership. This was using clinical data saying as a team, what kind of questions do you want to answer? How can we collect this data together? These were, these were, not research participants, these were patients coming in for a medical diagnostic in Illinois. And we were able to answer this question that has a direct impact on clinical practice using clinicians, using researchers, with quite honestly, you know, minimal resources. Right? And I think that's just, I wished, I love that because I love partnering with clinicians and I love the fact that it was just this really great collaboration.
(34:25) Tiffany Hogan: That's really fantastic. That's the ideal because then you also see, because it came through an organic process, you also see that the outcome has such strong clinical relevance. Because it blossomed within that clinical partnership.
(34:39) Meg Roberts: Exactly.
(34:40) Tiffany Hogan: So yeah, so you're talking too about access. Because so much of the work we do involves parents who have a concern right up front and so they have a level of education. Probably it's already there. Or maybe they're already in a system that gives them a bit of support to get their child some services, but there're many that are falling through the cracks with these approaches. Did you have something that was based on video? I'm remembering something like thin slices. Can you tell me about that?
(35:09) Meg Roberts: So a fantastic postdoc in my lab Lauren Hampton. We had read this paper where you could, it's borrowed from psychology, where basically if you take a thin slice, a little snippet, but you have more people rating a smaller amount versus one person writing a big, a larger amount. So the classic eight os, 45 minutes long, one person rates it. Or could you use an approach where you could have two minutes but 10 people rate it? So you're kind of comparing like what is the diagnostic accuracy using like a different approach. So what she did, what we did in the lab, but Lauren really spearheaded it, was she looked at like what is the max, what's the ideal duration and the ideal number of raters? Right. And so it could be as little as, you know, two minutes with five raters and so would it, it's not ready for prime time, but it's really a beginning idea to say, okay, maybe in particularly places in like rural areas where you don't have access, or the waitlist or even longer. Are there other kind of ways that you could increase the confidence in the diagnosis? And one of the ways is, you know, a shorter sample, but that multiple people people rate it.
(36:24) Tiffany Hogan: Oh that's interesting. Yeah, that's really interesting. Ties in nicely to maybe the idea of just having, um, you know, video sent in or kind of merging together different kinds of alternative approaches to maybe net a broader range of people in a system that isn't so resource heavy.
(36:42) Meg Roberts: Exactly. Right.
Parents’ Social Skills
(36:45) Tiffany Hogan: That could be great. So you mentioned parents, and I want to jump to another study you have. So you have a study in which you examine the influence of parents pragmatic skills or their appropriate use of social language on their child's expressive language skills. And then parents use of language strategies. Can you tell me a little bit about that study?
(37:05) Meg Roberts: Sure. This is my fantastic, soon to be finished, PhD Student Elle, Stern. I'll do a quick plug for her. She will be on the postdoc market and she's fantastic.
(37:20) Meg Roberts: She is! So she wanted to look at, well I'll step back in time. So I was, I believe in parent mediated interventions. I believe that as speech pathologists we should be teaching parents how to support their children's language development. And so I was working with this dad at the time. And I was just like, this guy loves his kid so much, he is so invested and engaged, but he is having a really, really hard time learning the strategies. And it made me think, wow, we are so focused on the child. And it's really about the dyad. And so I want to be very clear that I am not going back in time to refrigerator motherhood in which I'm blaming the parents. But I'm saying that we, and I'm a mother of four, I bring something to the table. Some things are harder or easier for me. Like, I cannot I am not a nice mother when the TV is on, somebody is whining and someone is flying a helicopter. I, I am an introvert. My processing goes out the window. Like I just can't do it. So that's my, that's something that influences my ability to implement whatever I want to in that moment. And so when we apply that to parents of kids with autism, there's a lot going on and they bring something to the table. And so it may be easier for some parents to learn some strategies than others. And I'm not saying, oh no, we don't teach some parents to, to implement strategies. I'm not saying that at all. I'm saying that some strategies may be easier for some parents and wouldn't it be nice if we customized what strategies we use not only for the child but for the parent? And so this study that you speak of was the kind of the pilot work for this RO one clinical trial that I'm currently running, funded by NIDCD, in which we're looking at this very issue. Which is on the continuum, we have two general buckets of strategies for kids with autism. Right? We have more of the directed, you know, adult driven strategies. And then we have these more naturalistic responsive strategies. And those are kind of the two main frameworks. And it's, there's evidence supporting both, but what if certain parents do better learning one set of strategies than the other? It would be beneficial for the child if equal, if both work equally for the child. Wouldn't it be better for clinicians to base what we choose what we teach the parent based on the parent? And so that's the purpose of this grant is to develop these like more adaptive interventions based not only on child characteristics but on parent characteristics.
(39:56) Tiffany Hogan: Oh, I love that because we often think about the question, what works for whom? But that who, what works for who, is the child! I love this because this time it's for the parent. My husband and I were just talking about this recently. We have three children, about how duh, we bring ourselves to the parenting situation. It's not all about the kid! Just the same exact things like when it's hectic or when things are going on or just our biases or our ability levels come to the table. So I love this because it sounds like you're asking what works for whom in both cases, the child and the parent, and then how does that synergy occur. That's, that's really, really important. So what did you find in that research?
(40:39) Meg Roberts: Well, you'll have to have me back a different time because in the land of clinical trials, you are not allowed to look at any data until your last participant is done! And so we are entering our last year. So we have about nine months left. What not to do when you are trying to make tenure: do a clinical trial in which you can publish nothing until the end of the study!! (laughing)
(41:02) Meg Roberts: But hopefully coming soon will be the results, results of this study.
(41:10) Tiffany Hogan: Oh, well, okay. That is hard! And we will definitely have you back to talk about it once you have that work. But is there anything you tell us about even this study that EIL did that can give us some insights to possibly the clinical trial?
(41:25) Meg Roberts: Absolutely. So what we did find the preliminary data suggested that, strategies that require a parent to basically put yourselves in the shoes of the child and respond the way they would. So for example, when an SLP world think of an expansion for example. And so the kid says, meh! while pointing to the milk. Often parents might say you want the milk? But as speech pathologist, we would want the parent to say milk. Right? Because we would want the parent to model what we'd want the kid to say. And so that ability to perspective take in the moment to put yourselves and the child's shoes, that is harder for some parents. Where as opposed to prompting, where you're setting up the environment, you're giving the milk and the juice, that is easier for some parents. And so, some parents of kids with autism have just different learning styles and it's easier. So parents that have kind of these different patterns with how they speak, have a harder time with, for example, those responsive strategies.
(42:36) Tiffany Hogan: This makes me think too about, us as professors, teaching clinicians. That possibly the work you're doing might be helpful for clinicians too. Because clinicians may also have difficulty taking that perspective, and giving them ways to do it. Having kind of what they bring to the table, and having that dyad is important. And so I think this has broad applicability, not just in autism research but in language intervention period.
(43:07) Meg Roberts: No, I think you bring up the point. If I were queen of the world and I could give everybody a superpower, I think I could solve a lot of the world's problems, not just in speech pathology. I would give everybody the ability to like put yourself in someone else's shoes, right? Like the world's problems solved!
(43:22) Tiffany Hogan: Oh! Absolutely! It's not a cliché when you say like walk a mile in someone else's shoes. It is not a cliché. This is so true.
(43:32) Meg Roberts: Totally. And so if we could give parents that ability with their child or the therapist's ability with the parent, like before we make judgments about their parenting. Let's think about how hard life must be sometimes, right? And that, you know, we're all just doing the best we can. Every parent cares deeply for their, for their children. And so I think if we could all do that all the time, it would, it would just help everyone.
(43:56) Tiffany Hogan: Yeah, I think that makes sense. And you bring it up also this everyone wants to do good. And I have several friends that are social psychologists. Of course it's social psychology is all about the context. So who you are is ultimately driven or your performance, whatever that means, is driven by the context. So for instance, I mean you mentioned the parenting context; that it's noisy and someone's doing the helicopter, the TV's on. But that might not be your best parenting mode context. Right? Versus a different context where you're able to just bring your best self or do what you really want. And so it seems to me you're creating, you're tying even in social psychology where you're bringing a context that can create a better interaction between the child and the parent. And I think that idea of context ties into the theory of mind that you're mentioning. And empathy. I really look forward to the results.
(44:47) Meg Roberts: Yeah, I hope it will be interesting. So oftentimes you kind of have, like when I do a traditional clinical trial, I sort of have a hypothesis about- and I do have a hypothesis here about what types of styles will be better with what types of strategies- but. I'm very interested because I could be wrong. There was an undergrad thesis who looked at, it's called the broad autism phenotype. And so it's subclinical characteristics of autism that parents demonstrate, so it's not full manifestation. Like it doesn't impact life, but it's just these like subclinical, you know, like I took the test too. I flag on rigid, and you know, but what was interesting was that she was looking at like resilience and self efficacy. And she was looking at them in relation and how the broad us isn't phenotype influences it. And this was just an undergrad thesis, but I was thinking, I had one idea in my brain about like what the results would show. But it actually turned out that, parents who could identify more with their child and had more of a subclinical characteristics actually had higher self efficacy, higher resilience. Because they just, I think we're more confident in, in understanding their child. It was very interesting because I was like, oh, well maybe if they have difficulty. But it was, it was actually the reverse. and so it was really interesting. And so I liked that finding because it, it shifted my own assumptions and made me think, oh, this is, this is a really interesting point about how we might think that difficulties in implementing a strategy, may be a negative, but it could be a positive in these other ways. So thinking about just the whole parent has been really fun and I just, the parents in our study are awesome, and I've loved every, every single one of them. And what they bring and how excited they are to participate in science and just their willingness to, you know, complete all the forms. We've got, we've just got the best parents here and in Chicago.
(46:52) Tiffany Hogan: That's fantastic! Yeah. Let me think about this. So one thing I always say too is everything is on the continuum now, right? So everything is on a continuum. So even thinking about the characteristics of autism as you mentioned. So just to paraphrase what I think I hear you saying is that if you have a parent. So okay, that parents can take, you know, you can administer something that gives them an idea or it gives you an idea of where they are on a continuum with characteristics that are more likely to be associated with autism. So let's say rigidity or maybe even difficulty perspective taking, right? So maybe you have a parent who has difficulty perspective taking. That might manifest in the dyad as trouble, maybe doing a certain language strategy that you mentioned like with milk. But on the other hand, the fact that the parent has a similar characteristic to their child may add resilience because that parent can maybe empathize in a different way.
(47:48) Meg Roberts: Right. I got this. Yeah, I know. I'm like this, like we got this kid don't worry! You're rigid, I'm rigid, and you're going to navigate it and I'm going to help you because we're in this together.
(48:02) Tiffany Hogan: Exactly. Like a matching characteristic. That is really fascinating. That's really cool.
(48:08) Meg Roberts: It was cool to see and it would say, yeah, it was really, it was, it was cool to see.
Clinical Practice Research
(48:14) Tiffany Hogan: Oh, that's really awesome. Well, you mentioned that you are passionate about clinical practice research. I'm also passionate about clinical practice research, and implementation science. You recently conducted a study thinking about the amount of research published by ASHA journals that really counts as clinical practice. So tell me about that paper. What counts as clinical practice research?
(48:35) Meg Roberts: Okay. So what we did. I'll tell you why this paper came to be. I a few years ago wrote a paper and it was published in pediatrics. And that's like the Creme de la creme of pediatric journals, like juicy impact factor. I was so proud of it.
(48:58) Tiffany Hogan: Fancy!
(48:59) Meg Roberts: Yes haha. But four people read it, I know nobody read it. And it was just like, I know I'm on the 10 year, I'm doing the things that publishing and the fancy journals. I'm doing all the things. And then there was this discussion on an ASHA Community Board about coaching of parents. And it was a group of people being like, basically just basically saying it's too hard. I don't want to do it. And then I wrote a little blurb about it just in like regular language, and I used some data to support it. And it went everywhere, and lots of people read it. It made me realize that, I'm not sure how clinicians... I would be interested in how clinicians make decisions about what interventions and what strategies they use. But then ultimately, what we hear a lot of is that they pick up an ASHA journal, and they flip through it, and there's just not a ton of stuff they can use. And yes, my fancy schmancy was in pediatrics, which unfortunately speech pathologists can't read, right? Because they don't have access. And so the, the journals that speech pathologists have access to are the ASHA Journal. Those are free. So we chose to focus and say, okay, I want ultimately I'm queen of the world in this podcast, and I want all kids to have very good outcomes. The way to get good outcomes is to get good intervention and to have speech pathologists that are using evidence based practices. That's my, those are my beliefs. And one of the ways of implementing that is to know what works, and the current evidence and to keep current. But it's also hard as a speech pathologist practicing for years to also know, I'm so tired of hearing like all these things don't work, but not having anything that does work. And so it's too hard. Well that doesn't work, you know, or a motor doesn't work, facilitative communication doesn't work. So we know what doesn't work, but we don't know what does work. And so it made us think. Okay. And then I was on this committee with ASHA. This crisp committee with Howard Goldstein and we started to try to develop a metric for how could authors answer a series of questions that could get at the extent to which their research is clinical practice research. And so we designed some questions, and we looked at the last 10, I think actually 11 years of all the ASHA journals, only in speech pathology. So we didn't look at AJA, the American Journal of Audiology.
(51:40) Tiffany Hogan: Right.
(51:42) Meg Roberts: And, we didn't look at the, hearing section of JSLHR, and we basically every article, we looked at it and we said, is there data? Is it about, you know, x, y, and Z? And so for it to be clinical practice research, it needed to be. So the basic premise is that a clinician needed to be able to pick it up and be able to use it immediately. Right? And so there's a lot of clinically useful information in research. So for example, um, there might be a correlational study that shows that, kids with autism are, you know, if you have one child with autism, you have a 25% chance of having another kid with autism. So that's clinically useful. But it's not clinical practice research because yes, it helps you counsel families, but it's not this algorithm that says, okay, if you give this test, this kid will have autism or this kid won't. Right? And so clinical practice research is really about specific tools and strategies that you can use in clinical practice. And so they were basically three big buckets: assessment, intervention, and then kind of implementation. And so what we found was that unfortunately over time there hasn't been an increase the amount of clinical practice research. So it's about a quarter of what you read. So one in four articles. Then the problem though with that is then it's, we looked at it by domain. And so you might think, oh, one and four is not bad. But then you start to think about, well, I'm a fluency expert or I'm in EI, or I do dyslexia, or I do swallowing. Then you're just cutting the pie into even more tiny pieces. And so basically what we found is that there's been a pretty flat rate of clinical practice research in ASHA journals and we don't know why. That was not, the purpose of the study. It was descriptive just to say, you know, what's going on. And then kind of the next steps and what we sort of talked about in the discussion was why we think this might be the case and what we can kind of do in the future to help increase the amount of clinical practice research.
(53:47) Tiffany Hogan: So yeah, what are the barriers in your mind, and I can speak to those as well, but what are the barriers, and then what do you think we can do to increase it?
(53:55) Meg Roberts: I think clinical practice research is really freaking hard to do. I think it is hard, and it is not sexy at all. There aren't that many people doing it. It's hard to get it published because when you have not that many people doing it, you have not that many people reviewing it, and chances are the people that are doing it are your friends and then there's conflict with you. And so you have non clinician scientists reading grants and non clinician scientists reading papers. And there's also not many of us. And also there's this advice that people give junior faculty about that it's too hard, and you should do this other work. And so from the PhD side, I think it's hard work to do. From the part I'm excited about, is why aren't clinicians doing some science, right? So like there's this expectation in medicine, you know, for MDs to be doing science and contributing to science. But there's not that same expectation for speech pathologists. I think of course PhDs can definitely, you know, be better, do better. But I also think as a field practicing clinicians need to take it on too. You know, you're frustrated with the lack of evidence based practice. Okay. And I know case loads are yucky and I know at least in my case, you're driving from family to family and it's hard. But is there a way that we could advocate for better, you know, on the ground science happening as opposed to just this top down? So that's my, my take. What do you, what's your, where do you think we need to be Tiffany?
(55:26) Tiffany Hogan: Well, you know, I think that this is a constant discussion in my lab and in my thinking about research. I just was talking to a doctoral student and we have a finding we want to publish and you know, this is a pretty common discussion. Okay, let's publish it in an ASHA journal because this is what clinicians needs to know about this. But what about the impact factor and oh, I'm going to go up for a student grant. And so what about putting it in a larger impact? Like you talked about pediatrics. You know, larger psychology journals, or what we look at like journal of experimental psychology. We know, so it's this kind of catch 22 we're always grappling with. How do we get it to clinicians, but yet how do we also, you know, meet kind of the standards that we're up against as well, like impact factors? So for the audience, impact factors are related to how many times articles are cited in a specific journal. And some journals have wider readership and they have higher impact factors. And then the impact factor determines how junior scientists are evaluated yearly. How, you know, how much, how they can get future grants. And I always think about what these partnerships, it's all about currency. You know what, and I don't mean just the green stuff. I mean like what is the currency that you have to have on your yearly evaluation? So you know, as a faculty member, you know, your yearly evaluation, most places, even if you're not a research one, has to do with what service have you done for the department. Meaning what committees have you served on? Or how are your teaching evaluations looking? And then what have you disseminated? So what articles have you published? How have you written up your science? And then with the dissemination portion, especially in research universities, it's about, you know, what is your dissemination rating and how many people are reading your article? And what journals are you publishing in? And even though I think ASHA is making big gains in their impact factors, it is going to be limited just naturally by the fact that that's a smaller set of people reading. Compared to a larger set of like general psychology, even though it feels big. ASHA is big. But not compared to general psychology or pediatrics. And so, and you mentioned, you know, slps doing research. So you're an SLP and you're in the schools and you want to do research. It's still about your currency because maybe you're a special ed director doesn't encourage that at all. So it's almost seen sometimes as a negative. Because maybe if you do that, then you're not spending as much time on your clinical caseload or whatnot. And so I do think we have to think about how to change the system and how to change that currency, right? It's the currency and you know, what's valued in a system. And so I think those are, I think some big barriers that we encounter. But I think what ASHA can do and funding agencies I think have a very strong role in this, is that they can say this is important. You know, if this is important, then the, the Universities say, oh, okay, that's important. Great. So for me, for instance, Institute of Education Sciences grants, it was really a revolution when they had these gold two grants. So gold two grants are actual grants to fund you developing an intervention.
(58:52) Tiffany Hogan: In the past, if you wanted to do an intervention study, you'd have to have the intervention already developed and you'd have to have some kind of research support on it. Well, that doesn't happen overnight. You have to funding. So the fact that an institute like the Department of Education said we're going to fund development was huge. And now in IDCD now has the mechanism of translational research grants. I think that's also huge because it's saying, you know, we want to fund research that is more implementation science, more translational. I think that's what needs to happen. Is it does come down to the infrastructure and the funding aspect. I think that's really critical. And I think the work you did, Meg like on the Crisp Committee is so critical because you're trying to say what are the barriers and how can ASHA be a force for good? How can ASHA help to create a system in which more clinical research has done.
(59:51) Meg Roberts: Right. And yeah we just need more people doing it at all levels. I think the clinical doctorate is another interesting way, right? So people that don't necessarily want to lead research labs and be in necessarily in traditional academia, but more want to be either a team scientist or even like a clinical assistant professor. Or they want to even, I would even say be in administration, but in want to use data to guide decisions. I feel like Northwestern started a program two years ago and I've been impressed with the types of students we're getting because they're all practicing clinicians all wanting to dig deeper. And they take, I mean they take two research courses with me and they're having to do a systematic review as their project and they have to do like this culminating project and it's like giving them the skills but also skills to do in their real life setting. Right? So I think, I think PhD is one avenue, but I also think post master's degree, we also need to think about how do we develop different leaders in our field? We have to give them the tools to do so because our masters degrees really short. Right. So it's, it's too much. Right. And it, and also they don't have the questions. You don't have questions when you're a masters student. You're just trying to learn the skills. The questions come when you're out and practicing. You know, I'm sure all of your listeners, I have one question they wish they knew the answer to but might not know how to solve it. That's what I want to give practicing clinicians, those tools to say, you know what, I'm going to try to figure this out.
(1:01:24) Tiffany Hogan: Yeah, I agree. And I think it's those partnerships. I think it really boils down to partnerships and to active listening. So you know, when I work with a school, the first thing I do is just listen. Like what is the environment? What's your currency? What matters to you? What questions do you have that you want to answer? But then there's also bi-directionality of, okay, here's what I can offer. Here's what the currency is for me, and here's how we might work together. So it's this kind of shared, it becomes a different product. So it's like the school's clinician may want something, I want something. Ultimately when you come together it forms a third kind of entity. That's the research project that is something that is a compromise, I think between what's needed. It's a back and forth between the researcher and clinician. And you're right that, you know, the SLPD could be a nice model for that. Yeah, it really could.
(1:02:21) Meg Roberts: Well, and what you say about partnership is so important and I think all funding agencies are recognizing that, right? So IDS and NIH all have these mechanisms for these partnerships, because we realize that on average, the 17 years it takes for something to get from, you know, research to practice is too long. And the best way to do that is to involve stakeholders from the beginning. But that is all hard, that is hard. You want to talk about some hard skills that no one ever taught me. I mean, that is flexibility and active listening and more flexibility and vulnerability and, and it's fun. It's the most rewarding thing probably I do, but probably you do too. But it's tough stuff.
(1:03:02) Tiffany Hogan: It is tough stuff. I agree. It's worth it, but it's tough. Well, let me think. So as we're wrapping up here, I do want to ask you two questions I always ask every guest. The first one is, what are you working on now that you're most excited about?
(1:03:18) Meg Roberts: Well, I care a lot about autism. I'm, we just started a UO one grant, which is a clinical trial by NIDCD with Pam Hadley. University of Illinois, Urbana, Champagne and, and Kaiser at Vanderbilt. And it's the first UO one ever funded by NIDCD in child language. So we're super stoked about that.
(1:03:38) Tiffany Hogan: Oh wow! That's fantastic!!
(1:03:39) Meg Roberts: But it's with old kids. I mean these kids are 30 months old and they go on to be four years old in the study. I know you guys are all laughing at me, they're ancient, but I do pre linguistic. What I'm excited is that Pam Hadley is my grammar tutor, and I'm learning all about syntax and how we support that earlier in development. She's stretched me so much to be a better speech pathologist and I love learning new things and so it's a new intervention of blended intervention. So I'm excited to think about how we transition kids from kind of early word learners to making sentences. And so I'm really excited about that, about that new grant.
(1:04:14) Tiffany Hogan: Oh, that's great. Well, we'll definitely be watching for your findings and hearing more about it! That's great. Then my last question is what is your favorite book from childhood or now?
Favorite Childrens Book
(1:04:26) Meg Roberts: Oh, that's a good one. So I have four kids, so we read at lots of different levels in my house. I really love Not Quite Narwhal where it's about this, whale, narwhal, not a unicorn or, but I can be whatever I want to be. It's a picture book. It's good. Just got a really nice message about like how you define yourself, and how you have the control over your own identity. Which is my current favorite in the household right now.
(1:04:54) Tiffany Hogan: Oh, that's fantastic. Well, I have to say an awesome byproduct of doing this podcast is every time I talk to a guest, I always run out and buy that book for my kids. So we're getting a lot of variety in the house more. And so I'm excited to try that book! I had not heard of it.
(1:05:09) Meg Roberts: I will say the other book, we do a lot of audio books, for the older kids, is called The Magical Misfits. It's just Neil Patrick Harris actually is the narrator and he does a really, you know, he does a really good job telling it. But what I love about it is it just, it's this just really cool story of resilience, but also I just love the fact that the guy, the main characters, are just like two guys and it's just there two guys. The guy has two dads and and it's not a thing. It's just like, it tells me that we are just, we're at a point where that's normal. And I loved that, that my kids are just like, yeah, he has two dads. And there's no label to it. It's just like the main character has two dads and they go on this amazing, you know, journey of magic. The kids always request to listen to it. So Magical Misfits is my other plug audio book.
(1:05:55) Tiffany Hogan: There we go. And what ages do you think that's the best for?
(1:06:01) Meg Roberts: Well, so we listened to it in the car, and I have a six and a six and a four year old that listen to it. The four year old is like poor four year old, she gets dragged along. I would say six to eight is a little bit better.
(1:06:12) Tiffany Hogan: Hahah and that's great. I have a wide gap because I have a two year old, four year old, and a 13 year old. So I bet the 13 old might like it too maybe?
(1:06:20) Meg Roberts: Yeah. So my Land of Stories is another a series that every of my two olders, my eight and 10 year old loved. They devoured like you know the one thousand page books in lke, days.
(1:06:37) Tiffany Hogan: Oh this is fantastic. Okay, Meg, well thank you so much for chatting with us. And this is special too because as you mentioned it's autism awareness month this month, April. So I'm excited to get this podcast out to the listeners and thank you for joining me.
(1:06:52) Meg Roberts: Thank you for having me. I think we talk about dissemination and what you're doing is getting information out in a way that people, when they're driving to home visits or wherever they are, can really learn from others. So thank you.
(1:07:04) Tiffany Hogan: Thanks so much!
(1:07:08) Tiffany Hogan: Check out www.seehearspeakpodcast.com for helpful resources associated with this podcast including, for example, the podcast transcript, research articles, & speakers bios. You can also sign up for email alerts on the website or subscribe to the podcast on apple podcasts or any other listening platform, so you will be the first to hear about new episodes.
Thank you for listening and good luck to you, making the world a better place by helping one child at a time.