By: Jessica Oswald, Occupational Therapist
Parents wonder about their children’s futures at a very early age. Questions they ask may include:
What will my child be when they grow up?
Where will they live?
Will they attend post secondary education of some kind?
Parents of children with medical diagnoses or disabilities consider many of these same questions, but also find themselves asking:
What supports are available if I am not around?
What skills are required for independent living?
What skills are required for employment?
What living options are available?
Early transitional planning can help answer some of these difficult questions and potentially reduce some of the anxiety parents feel about their child’s adult future. The goal of transitional planning is to prepare for time at which primary caregivers are no longer available. Federal law requires public schools to begin transitional planning by age 16 for children on an Individual Education Program (IEP), but can begin sooner than that if appropriate.
TRANSITIONAL PLANNING MAY INCLUDE:
Involving the child in making decisions about the future
Creation of a financial plan
Preparation for life after high-school
Exploration of post secondary education
Preparation for independent living (including transportation)
Investigation of programs, services, activities, information, and supports in the community
Consideration of opportunities for future vocations/internships/employment/careers
Adaptation of current therapy goals to meet changing needs/priorities
Therapists (Speech, Occupational, Physical, Counseling) help to prepare youth for these life transitions and independent living when possible. Collaborate with families is paramount in determining priorities as the child ages.
SKILLS OCCUPATIONAL THERAPISTS TARGET FOR TRANSITION INCLUDE:
Self care skills (i.e. brushing teeth, showering, toileting, etc.)
Household management skills (i.e. laundry, cleaning, etc.)
Money management skills (i.e. getting the correct amount of change, utilizing a debit card, budgeting, etc.)
Kitchen safety (i.e. preparing and cooking food including reading a recipe, cutting up ingredients, utilizing cooking appliances, etc.)
Community mobility (i.e. safely crossing the street, utilizing community transportation options, etc.)
SKILLS SPEECH THERAPISTS TARGET FOR TRANSITION INCLUDE:
Work related methods of communication (i.e. resume writing, interviews, generating emails, being able to listen to a voicemail and take a message, etc.)
Vocabulary and language associated with the workplace (i.e. time clock, uniform, break, etc.)
Concepts of time (i.e. knowing when to complete each required work or school task, deadlines, etc.)
Appropriate social interactions with peers, customers and co-workers
Self advocating and requesting help when necessary
Explaining their disability and asking for additional accommodations if/when necessary
Social interactions in community settings (i.e. ordering at a restaurant, going bowling, getting a haircut, etc.)
SKILLS PHYSICAL THERAPISTS TARGET FOR TRANSITION INCLUDE:
Strength and mobility to complete daily tasks (i.e. mowing the lawn, shoveling, sports participation, etc.)
Having and maintaining good balance when completing tasks (i.e. standing on 1 leg for getting dressing, tipping head back to shower, safely navigating multi-surface environments, stairs, etc.)
Increasing endurance (i.e. vacuuming, household cleaning, folding laundry, working a shift, etc.)
Core strength (i.e. driving, seated posture, dressing, etc.)
Counseling can also be vital in transitional planning. Youth may require additional support for managing emotions. Families often benefit from counseling in an effort to manage many things at once. Counselors can also be instrumental in helping to identify additional community supports and resources.
If you’d like more information on transitional planning, please collaborate with your child’s therapist. You may also contact Family Voices of North Dakota at 701-527-2889 or their website: www.fvnd.org
By: Jessica Oswald, Therapy Coordinator
Insurance plans and policies are all different and can be so confusing! Let us give you some basic facts and terminology so that you are better able to understand the jargony language of insurance and third party payers. Keep in mind that therapy services (speech, occupational, and physical therapy) and counseling services are often handled by different departments and often have different rules.
Habilitative vs. Rehabilitative services
Rehabilitative: Services provided to help a person regain previously acquired skills that were lost due to an illness, accident, or injury. For example, therapy to help a child learn to walk again after a car accident would be rehabilitative services. Another example would be a child who experienced oxygen deprivation due to an accident in a pool. As a result, the child has lost motor and speaking skills and requires rehabilitative therapy to restore these skills previously mastered.
Habilitative: Services that help a person learn or acquire skills/milestones not previously mastered. An example of habilitative therapy would include teaching a child how to walk and improve their gait pattern or teaching a child a speech sound they haven’t used before.
Deductible: A determined amount of money to be paid out-of-pocket by the patient before insurance will begin covering the payment of services. This deductible amount varies depending on the type of coverage plan. When a deductible is “met,” insurance will begin paying some or all of the services. Deductibles can be tricky! Some companies are specific about what services are “eligible” for coverage as well as “eligible” for counting toward the deductible amount.
Co-insurance: Typically a percentage of the cost of services that you will start paying once your deductible has been met. For example, if you have an 80/20 plan, the insurance company will pay 80% and you will pay for 20% of the service.
Co-pay: Is a fixed amount you pay for a visit, typically due the day of service.
Visit limits: This refers to the number of services that can be used during a calendar year. Some policies that have no service limits as long a medical necessity is evident. Others are very limited. Some companies require providers to “make a case” for continued services while other companies will take a hard approach–what you get is what you get.
Hard visit limits: Maximum number of visit limits allowed in a certain period of time, typically a calendar year. These plans do not allow providers to “appeal” for additional visits.
Soft visit limits: The amount of visits initially allotted by an insurance company. Once the soft limit has been reached, providers are able to request additional visits based on documented problem areas and progress through medical necessity. Each company will determine the number of those additional visits. Providers are often able to complete multiple requests for additional visits within the calendar year.
What you can do?
If you or your child are beginning therapy or counseling services, there are a few things you will want to know about your policy. The best way to obtain this policy specific information is to call the member services number located on the back of your insurance card. To make the process easier, we have provided you a list of important questions to ask:
Does the plan require a pre-authorization or physician referral?
Is Rehabilitative therapy covered by this policy?
Is Habilitative therapy covered by this policy?
Does this policy have a deductible? If so, what is the deductible?
Is an in-network referral necessary?
Does this policy require a prior authorization?
How many visits are allowed per year for each discipline (i.e. OT, ST, PT, Counseling)?
Is the evaluation included in the allowed visits?
Are these hard or soft visit limits?
Is there a copayment? If so, what is the copayment amount per visit?
Is there coinsurance? If so, what is the coinsurance percentage per visit?
Many clinics offer a private pay rate if your insurance plan does not cover these specific services. The billing department at Red Door is very knowledgeable and are happy to host any questions you may have about insurance policies and related coverage: 701-222-3175.
Why do some infants need PT and how do I know if my child is one of them?
By: Laura Kendall, DPT
How do you know your child is meeting motor development skills on time? How do you know if your infant needs Physical Therapy (PT)? Difficulties in infancy can be tricky to identify! Many parents are overwhelmed by the other life changes that come with having an infant and identifying missed milestones can be hard to do. This blog article aims to help by sharing common reasons physical therapy is beneficial in infancy and help parents determine if their child is missing milestones.
The term “developmental delay” covers a multitude of “not yet mastered” skills in children of all ages. In infancy, early gross motor milestones include rolling, crawling, and walking skills. When children do not develop these skills on time, physical therapy helps develop those skills so kids can continue to explore their environment. Physical therapy works through play by practicing these difficult skills in a fun an innovative way. PT helps children strengthen muscles that may have remained weak and to learn new movement patterns necessary to meet motor milestones. When looking at typical child development, children should be able to roll over by 5 months, independently sit by 6 months, crawl by 8 months, stand at 11 months, and walk at 12 months. Delays in one or more of these areas can interrupt a child’s development in the areas of strength, coordination, and balance causing difficulties in all areas of mobility.
Difficult labor and delivery can also cause infants to require the services of a Physical Therapist. During a difficult vaginal delivery, an infant’s neck can get stretched during the process. This causes damage to a large bundle of nerves that travel into the shoulder causing weakness of the infant’s arm. In more severe cases, the infant may receive a fracture to the collarbone. This type of injury is called a brachial plexus injury. This injury becomes obvious when the infant is not using one arm. In these cases, a physical therapist will work with parents and the infant to promote strength and use of the injured arm by providing exercises for parents to complete at home.
While neglecting to use one arm is a more obvious symptom of torticollis, there are more subtle symptoms that can indicate a problem. If an infant looks predominantly in one direction, a tight neck muscle could be the culprit. When this happens, the baby will demonstrate a preference with the direction they look and/or rotate towards that side while also holding their head in a tilted position. Physical therapy works on stretching, massage, and positioning techniques to help them improve muscle mobility and allow them to look both directions. When these techniques are not implemented, changes to the child’s head shape will become apparent (plagiocephaly). PTs identify and track progress by measuring a child’s head and watch for changes in head shape. These measurements are used to determine positioning strategies that improve the symmetry of the head in order to prevent long term effects. When plagiocephaly is severe enough children may be required to wear orthotic helmets.
Here are some commonly used techniques that can be used to help promote physical development:
Working on improving neck range of motion by tracking toys, lights, or sounds
Football hold working on strengthening neck muscles
By: Laura Kendall, DPT
Exploration of the world starts in infancy. Some infants, however, have limited motion, specifically with their neck. This is often due to a tight neck muscle, typically the sternocleidomastoid, and is called torticollis. Torticollis is a condition that occurs in infants and can be diagnosed shortly after birth. Torticollis can also be identified in the first few months of life. Torticollis is observed when an infant rotates his or her head one direction and tilts the head, bringing one ear towards the shoulder; this is an abnormal pattern that results in the head being “stuck” or not being able to move in the opposite direction.
There can be different reasons for the development of this abnormal pattern. One reason can be a large birth weigh. Decreased space in the womb can limit movement for the infant. Another cause of torticollis may be positioning and posture due to how parents hold/carry the child.
Torticollis is often associated with plagiocephaly or brachycephaly. Plagiocephaly refers to the asymmetrical change in head shape. Often one side of the child’s head is flatter. This can also have an effect on how the ears are shaped. Brachycephaly is a condition in which the back of the head is flat. Flattening on the sides or back of the head is caused by increased pressure to the head. This happens when infants spend a lot of time laying on their backs, sitting in car seats, or other carrying devices where their head is in contact with a firm surface for long periods of time.
Torticollis, plagiocephaly, and brachycephaly are all issues that Physical Therapy addresses. Muscle lengthening and movement are key factors in promoting age appropriate development. Physical therapy works on providing stretching and strengthening exercises to promote head and neck movement in both directions. Massage can often assist with gaining full neck movement. Positioning advice and techniques are provided to promote sustained stretching within a pain free range. All of this leads to cranial reshaping which subsequently leads to a symmetrical head shape!
Physical therapy for torticollis and head shape abnormalities are best combated with early intervention and home programming. Though torticollis is an issue affecting the neck musculature and range of motion, it can lead to limitations with motor milestones by creating compensatory movements. Physical therapy works to alleviate the torticollis and ensure appropriate movement patterns for overall gross motor development. The sooner an infant is able to start physical therapy for torticollis, the quicker their range of motion and developmental motor milestones will progress.
By: Mandy Griffin, MS, CCC-SLP
Parents seek the advice of Speech Language Pathologists (SLPs) when there is concern that their child isn’t talking. There are several early communication skills that SLPs observe well before a child’s first words appear. These skills emerge shortly after birth and continue to develop beyond their first birthday.
What skills should emerge in the early phases of development?
Eye contact is one of the earliest forms of communication. An infant uses eye contact as a greeting and as a means to interact. When a baby makes eye contact, we should always respond with a smile, verbal greeting, funny face, or other reciprocal gesture.
Joint attention occurs when you and your child share the same interest in an object either by interacting with the object or looking at the object. Books are a great example.
Social referencing occurs when your child wants you to watch them play or or perform. This may occur when a child hears a loud noise and looks at you for a reaction or for an emotional response.
Turn taking is an essential skill that will lead to the development of conversation. Turn taking begins with taking turns during play and eventually taking turns while talking.
Motor imitation happens when children learn to imitate physical movement (waving, shaking head no, “so big”). Motor imitation improves eye contact and overall social interaction.
Initiating social games occurs when a child attempts to start a game or interaction. An example would be the game of “peek a boo.” A child covers up his/her face with a blanket and waits for the parent to remove the blanket.
Gesture is when a child uses their body to tell us what they want. For example, pointing to their cup to tell you they want more milk, waving to indicate “bye,” raising their arms to be picked up.
Sound imitation a precursor to imitating words. During play, see if your child can imitate blowing raspberries, making animal or car sounds, or creating silly noises with their mouths.
Early sounds begin with babbling. Repetitive syllables like “dada” tend to show up first. Soon, they are followed by varying syllables like “daddy.” The earliest sounds to emerge are typically: /p, b, m, n, w, h/
First words generally emerge around 12-18 months. Children understand more language than they can produce. When children say their first words, the productions will be an approximation of the real word (“mo” for “more,” or “ba” for “ball”).
How can these skill be facilitated?
Talk to your kiddo throughout the day and describe what you are doing during activities of daily life (i.e., “time to change your diaper, let’s wash your hands, I see daddy!”)
Avoid screen time!
What if these early communication skills aren’t emerging?
Visit with your primary care physician or other developmental specialist
Contact Red Door Pediatric Therapy for a free screen at 701-222-3175
The Speech Room News
Super Duper Publications
By: Mandy Griffin, MS CCC-SLP
We typically see /s/ emerge around the age three, though kids often use it during play and in babble much earlier than that. The production of /s/ is made using the sides of the tongue to elevate and meet the palate (roof of the mouth). The middle of the tongue is down, making a groove for air to move through. Some kids make /s/ with the middle of the tongue bunched up, with air flows down the sides (think Sid from Ice Age!), this is called a “lateral s.” This type of /s/ is always considered developmentally atypical and you should seek treatment around three years of age if you notice your child exhibit this error. Some kids make /s/ with a forward tongue placement (think Daffy Duck!) when /s/ is made between the teeth, this is called a “frontal s.” This type of /s/ is considered a typical part of development and is observed through the age of three. A “good” /s/ is made by placing the tongue behind the teeth and should be fully developed by the time a child turns four years old.
What causes trouble with /s/?
It is often not possible to determine the exact cause of an articulation impairment, but the cause may be structure related (i.e., a forward jaw/underbite), motor based (i.e., apraxia), or sensory related (i.e., hearing impairment). There are several other factors that impact how a child learns to make /s/, like a family history of speech sound disorders or prolonged oral habits like a pacifier or extended sippy cup use.
How to we fix it?!
The child first needs to discover the sound which we do via auditory bombardment (heavy modeling of the correct production) and discrimination (telling the difference between good and poor productions) tasks. Once the child can hear and discriminate the sound, we start talking about the tongue in order to help the child discover the tip and sides of the tongue. Sometimes we need to work on things like jaw stability or moving the tongue separate from the jaw, before a child can imitate /s/. Once we have all of these things worked out, we can work on shaping the sound. Some children can imitate quickly from a model and for other children we make an /s/ by building it off of other sounds, like making a “long t” (t-t-t-ts-ts-tsss), then eventually omitting the /t/. Once a child can make /s/ by itself we drill and drill until they are consistently successful. Therapist will work through a hierarchy of syllables, words, phrases, sentences, and structured conversation, until the sound emerges within the child’s spontaneous speech. It is important that the child be able to self-monitor, meaning they need know when they are making the sound correctly or incorrectly so they can adjust it accordingly during practice and eventually use the sound correctly during normal conversation.
If you have specific questions or notice that your child demonstrates this type of error, please be sure to consult a Speech Language Pathologist near you.
By: Jorden Beckman, MS CCC-SLP
There may be a variety of reasons why your child is not yet talking, but one reason may be that you already anticipate their wants and needs before they have to communicate with you. It is important to let your child take the lead to promote communication with you and to help develop those words – remember to “OWL” (Observe what he/she is interested in – Wait to see what he/she will do – Listen to what he/she is trying to tell you). Waiting is so HARD, try counting to 10 in your head to help you.
If your child is thirsty she may want some milk and walk to the fridge and stand there. Instead of getting it out for her, WAIT and LISTEN for her to communicate. She may look at you, point to the fridge, take you to the fridge, or vocalize (i.e., grunt, babble). You can then model appropriate vocabulary “milk, you want milk, milk” and get the milk for her.
You may be playing blocks with your child, but she does not seem interested anymore. Ask her “What do you want to play?” OBSERVE her actions (she may go get a different toy or she may just look at you). If nothing happens, you can choose another activity or two and present them to her (bubbles, cars, etc.) WAIT and LISTEN (she may reach for her preferred activity and vocalize “da” or babble “bababa”). Then you can model the name of the activity she chose and repeat repeat repeat (“bubbles, you want bubbles, bubbles, blow bubbles, etc.”).
Other ideas to get your child communicating – we call these “communication temptations”:
Put a motivating toy or object where they can see it, but not reach it (cars, ball popper, bubbles, sippy cup, snack cup)
Only give your child 1 or 2 of something and wait to see what they do next – “withholding” (goldfish, fruit snacks, puzzle pieces, stickers, sip of juice)
Give your child an activity she needs your assistance with (blowing bubbles, something with an on/off switch, something fun in a container they cannot open)
Give two choices of something they like (cars or trains, trampoline or swing, milk or juice, crackers or fruit snacks)
Play repetitive games, then immediately stop and wait (Tickle, chase/tag, swing)
Use fun sounds and words in play (environmental noises such as transportation and animal sounds)
After you OWL using one of these strategies – it is important to provide a model of what you expect from your child. Often times, if they are not using words, we teach sign language to show there is a cause and effect in communication (i.e., when you sign – you get what you want)
You gave your child 2 fruit snacks and now she pointed at the bag because she wants more. You can show her how to sign “more” by doing it yourself and saying “more.”
After you model it, WAIT and see if your child will do it herself. If not, you can help her sign, you say “more,” and then give her one or two more fruit snacks. Continue this process until she is no longer interested in the snack. Then model “all done”
WAIT and see if your child will do it herself. If not, you can help her sign, you say “all done”
Once your child can sign “more” independently, you can give her a cue on her lips to show her you also want her to use words/sound. In my therapy sessions, I model by placing my thumb over both my lips for “mmmmmmm” and then removing my thumb from my lips, finish the word. Then I give the child the same cue to show the expectation of a sound/word
This works across a variety of different activities and use of signs – help, please, all done, open, close, etc. For more information on how to make these signs visit:
Manolson, H. A., & Hanen Centre. (1992). It takes two to talk. Toronto: Hanen Centre/
Sussman, Fern (1992). More than words. Toronto: Hanen Centre.
By: Kelli Ellenbaum, MS, CCC-SLP
Parents often find themselves spending a lot of time in the car. Whether this includes running errands, driving kids to school or appointments, or transporting children to activities, a parent’s vehicle be the vessel that contains many things. It can be a place of meals/snacks, a daily recap conversations, some ongoing learning, a therapy session, a homework study hall, or even a place for mini concerts. Here are a few ways to use this time to your advantage and help your child learn and grow!
For toddlers through preschool age, their worlds are ever-expanding. Once they are able to see the world in front of them, they can see the same things out the window that their parents can see. Language enrichment opportunities are everywhere!
I spy with my little eye: This game affords the opportunity to connect vocabulary words with what is seen. The game can be expanded to include teaching the function of objects, describing words that detail what an object looks like, or determining the groups with which the object belongs. For example, “I spy with my little eye a TRAIN. A train is a vehicle. It has many cars. It is long. It can go fast or slow. This train is green. What do trains say?”
Early math skills can be introduced. Counting objects such as trees or stop signs can help kids with rote tasks and understanding early concepts. The same can be applied to labeling the shapes of objects.
Letter development through sight. Finding different letters on signs and making it into a turn-taking game can be very beneficial in teaching children what symbols are letters and what symbols are pictures.
Exposure to music can help kids to further develop their brain and provide an opportunity to learn social skills. Some of these skills can include dancing, taking turns singing, pairing physical actions with song, and following directions.
Teaching sensory awareness in the car can be taught in a variety of ways. Parents can talk about temperature (heat vs AC) and how that feels when the car fan is turned on. Going through the car wash can teach kids about unexpected noise and visual input in an environment where their parent can old their hand. Discussion about feelings (as they related to emotions) during that experience (ex loud and scary) can help children have a word for their feeling.
Dressing skills such as teaching kids how to put on their coats, shoes, and socks during transitions in and out of the car pop up more frequently than we would like!
Physical development can also be targeted when children practice using their muscles to climb in and out of the vehicle. This provides both muscle building and coordination development.
For kids of elementary age, the same games and activities can take place by increasing the level of difficulty with which they are delivered. For example:
I spy can be expanded to follow an alphabetical rule where kids have to find objects in the environment that follow the sequence of the alphabet.
Math can be addressed with discussions of speed limits, mile markers, distance to destination, or anything to help kids answer their own questions (such as “are we there yet?”).
Skill building in the areas of memory and attention to details can be addressed with games such as “Going on a camping trip.”
This age group is well versed in questions related to “what if” and “why.” Use this opportunity to answer their questions (even when you’ve answered 50 of them already). It is a great way to prepare your child for situations they will encounter as they grow. When you get repeated questions; turn the question around and see if they can recall your answer.
20 Questions is a great game that teaches children how to take a different perspective, use categories and details, follow specific rules (ex. must be a yes/no question), and learn the basics of honesty and sportsmanship.
Once kids move on to middle school, the games and skill building become less motivating. However, these times offer opportunities to engage in higher level conversations and emotional development. Often, in our busy lives, the car may be one of the only places we get the undivided attention or our teens. Use this time to:
Ask your teen about current events and what their developing perspectives are on world matters.
Check in with your teen about their emotional state or the functions of their peer groups.
Tackle problem solving skills as they relate to academics or social interactions.
Help your teen become more responsible of their own schedules.
Teach the rules of the road and other important driving skills and laws.
Have your teen give you directions to a destination and see if their navigation skills are developing.
By: Geena Schmidt, OTR/L, Mary Dahly, OTR/L & Lindsay Jolley, COTA
The mealtime routine is important for families in order to encourage healthy habits, communication, and to deepen family connections. Children especially benefit from mealtime because of the abundant opportunities to learn life long skills. Some of these lifelong skills include: meal preparation, responsibilities, manners, establishing healthy routines, and relating to other people. Here are some ways to involve your child in mealtime routines!
Involve your child
Have “Taco Tuesday” at home, or let your child pick 1-2 meals they want to eat each week
Make a list of ingredients and take them grocery shopping
Let them help prepare the meal
Have them gather items for mealtime and bring to the table
Have them set and clear the table
Wash dishes or load dishwasher
Prepare your child for mealtime
Give your child a 5 minute warning that meal time will be starting soon to help avoid meltdowns before mealtime. This could include a verbal warning or a visual timer showing how much time is left
Wash hands before eating
State your behavioral expectations for the meal (holding fork correctly, remaining seated, waiting until others are done talking before sharing a topic)
Eat with your child
Sit together at the table as a family
Increase attention by removing distractions, such as cell phones, ipads, television, loud music, and pets
Encourage proper seating; older children should be able to comfortably touch the floor with their feet (placing a small stool under their feet can be helpful)
Encourage communication by serving the meal family style; this increases social skills (making requests, asking questions)
Teach portion control by encouraging them to take only what they are able to eat
Broaden their repertoire of food by encouraging then to take at least one bite of a new food each mealtime
Improve the relationship with your child during mealtimes; ask your child about their day, ask about their recess activity, or find out what they had for lunch
Teach manners by having children ask to be excused from the table before leaving, using please and thank you, and helping with the cleanup
Make mealtimes a routine; if you can’t eat together everyday, make a point to share a meal at least twice a week
Try to be consistent with your expectations; but be flexible enough to know that not every evening will go according to plan
CDC Nutrition for Infants and Toddlers: Mealtime Tips and Routines
AOTA Children and Youth Mealtime
By: Amber Fox, MS, CCC-SLP
Gather your team- make sure all caregivers are on board and following the same plan- consistency is key!
Start early- straw cups can be introduced as early at 6-9 months and can help transition away from bottles and sippy cups.
Make a firm decision and stick with it, lean on your team for support!
For Pacifier: eliminate gradually in the following sequence: eliminate during day/waking hours, eliminate at nap time, eliminate at bed time, gradually cut down the tips, give away pacifiers to family or friends who may be expecting.
For Thumbsucking or Fingersucking: Provide a toy/fidget to keep hands busy, get a special ring to wear; teach that the ring is a reminder to keep hands out of the mouth, place a sticker, bandage, or tape on the thumb/finger; wear gloves at bed time, paint nail(s), apply lotion on hands/fingers several times a day
For both: create a “no suck” zone, use a reward chart (positive reinforcement can go a long way), work with a speech therapist or occupational therapist to help with additional ideas
Oral habits such as thumb or finger sucking and prolonged pacifire use can be very tricky to extinguish! Here are some helpful tips in tackling these unwanted oral habits.
Source: How to Stop Thumbsucking (and Other Oral Habits): Practical Solutions for Home and Therapy, by Pam Marshalla