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Using Mixed Methods Research to Better Understand Pediatric Feeding Disorder

Kelsey L. Thompsona and Wanqing Zhangb

Purpose: Mixed methods research is a relatively new, but growing, research methodology with particular relevance to speech-language pathologists because of its utility in translating research into practice. Mixed methods research involves collection of both qualitative and quantitative data, which is integrated to gain a deeper understanding of a research question, particular population or intervention, or to develop a tool. In particular, pediatric feeding disorder (PFD) research stands to benefit from this methodology to comprehensively and holistically report on this population. Conclusions: This article focuses on introducing researchers new to mixed methods, as well as clinicians, to the four basic mixed methods study designs and considerations. To establish a foundational understanding, examples of

published work specific to PFD are incorporated and a framework for understanding mixed method study design is proposed. Then, the four designs are examined from the lens of critical appraisal, so that clinicians and researchers are well prepared to critically evaluate mixed methods studies. Finally, applications of mixed methods to PFD are explored, with a commentary on how published examples could be extended using mixed methods designs. This article provides researchers and clinicians with a basic understanding of mixed methods as well as a clear avenue for its application to PFD. Mixed methods has the potential to advance our understanding of the heterogenous population PFD impacts, improve our use of interdisciplinary teams, examine holistic interventions, and develop tools for clinical and research use.

The 2019 consensus definition of pediatric feedingdisorder (PFD) outlined four diagnostic compo-nents: medical, nutrition, feeding skill, and psycho- social (Goday et al., 2019), emphasizing the fact that PFD is a complex, multifaceted disorder. PFD stakeholders have increasingly recognized the need for interdisciplinary frameworks and evidence-based interventions that are easily translated into clinical practice (McComish et al., 2016). As such, PFD clinical practice stands to benefit from research that integrates these four diagnostic components (Goday et al., 2019), in order to advance our understanding of PFD and its impacts, as well as to develop evidence-based treatments that involve interdisciplinary collaboration.

While traditional quantitative and qualitative meth- odologies demonstrate strengths in the systematic study of

phenomena, they often lack the rich understanding neces- sary to extend findings to clinical practice (Robins et al., 2008). However, mixed methods research involves the col- lection and integration of both qualitative and quantitative data, which provides a richer understanding of research problems than quantitative or qualitative methods alone, encourages interdisciplinary work, and emphasizes the translation of research into evidence-based practice (Creswell & Plano Clark, 2011). As such, mixed methods research has been steadily growing in popularity in various fields, such as health services (Zhang & Creswell, 2013), physical ther- apy (Rauscher & Greenfield, 2009), and quality of life re- search (Ring et al., 2010) as well as in randomized control trials (Mertens & Hesse-Biber, 2013). Given its growing popularity, and particular utility in translating research to practice, it is important for clinicians and researchers to be both aware of mixed methods research and able to critically evaluate it in order to implement evidence-based practice.

Despite its strengths, the use of mixed methods re- search design has been limited in speech-language pathol- ogy, including PFD. However, mixed methods have the potential to holistically and systematically capture all four elements of PFD in a single research study. This integra- tion provides flexibility and depth of insight in order to

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aDivision of Speech & Hearing Sciences, University of North Carolina–Chapel Hill bDepartment of Allied Health Sciences, University of North Carolina–Chapel Hill

Correspondence to Kelsey L. Thompson: [email protected]

All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

Editor-in-Chief: Angela H. Ciccia Editor: Aneesha Virani

Received May 27, 2020 Revision received August 25, 2020 Accepted September 30, 2020 https://doi.org/10.1044/2020_PERSP-20-00119

Disclosures Financial: Kelsey L. Thompson has no relevant financial interests to disclose. Wanqing Zhang has no relevant financial interests to disclose. Nonfinancial: Kelsey L. Thompson has no relevant nonfinancial interests to disclose. Wanqing Zhang has no relevant nonfinancial interests to disclose.

Perspectives of the ASHA Special Interest Groups • Vol. 5 • 1623–1630 • December 2020 • Copyright © 2020 American Speech-Language-Hearing Association 1623

capture clinically significant data and dig deeper into this complex diagnosis, which could not be achieved by using either qualitative or quantitative methods alone. Although some PFD studies have used both qualitative and quantita- tive methods, they are unclear in their reasoning for this approach and are lacking in their use of mixed methods strat- egies, therefore limiting the utility of the research.

Given the growth of mixed methods research, and its potential to advance the study of PFD, it is important that both clinicians and researchers working with this popula- tion are well informed about this methodology. While guide- lines for using mixed methods research designs exist for pediatric researchers in several fields, such as pediatric psy- chology (Wu et al., 2019) and pediatric oncology nursing re- search (Wilkins & Woodgate, 2008), there has not been any explicit guidance for conducting mixed methods research in the field of PFD. The purpose of this article is to provide a practical guide to conducting mixed methods research in PFD. This article serves as an introduction to mixed methods research purpose, design, and critical appraisal, with specific examples of how it has and can be, used in the context of PFD. In particular, this article aims to (a) introduce re- searchers new to mixed methods to basic design and consid- erations in addressing their research questions and (b) help clinicians understand the appropriate use and limitations of this methodology, as well as its potential clinical implications.

Mixed Methods Research Design In order to be considered mixed methods, a study

must meet three criteria (Creswell & Plano Clark, 2011): (a) At least one qualitative and one quantitative

method are combined. (b) Each method is used rigorously according to

the standard of that research methodology. (c) The study must be carried out by using a mixed

methods design, which includes integration of the quantita- tive and qualitative data.

There are four primary research designs used in mixed methods, described below, all of which meet the aforemen- tioned criteria (see Table 1).

Concurrent Triangulation/Convergent Parallel Design The concurrent triangulation, or convergent parallel,

research design involves collection of both quantitative and qualitative data in the same, single phase (Creswell & Plano Clark, 2011). The purpose of this design is to merge the quantitative and qualitative data during interpretation in or- der to combine the results and gain a richer understanding of the phenomenon being studied. These studies are efficient and may be more intuitive to a researcher who is new to mixed methods, but still require knowledge and expertise in both quantitative and qualitative methods. Additionally, it may be difficult to directly relate the two data types, par- ticularly if they have conflicting results.

A general question that could be answered using a concurrent triangulation design might be, “To what extent do the qualitative results confirm the quantitative results?”

For example, a study of the psychological well-being and medical guidance provided to parents of children with cleft palate, specifically related to feeding problems, concurrently measured parents’ well-being with questionnaires (quantita- tive), and engaged parents in semistructured interviews (qualitative; Mauriën et al., 2019). These researchers found that quantitative and qualitative results confirmed that pa- rental self-esteem was not impacted by the child’s feeding problems but reported divergent results about stress and depression.

Sequential Explanatory Design A sequential explanatory design involves collecting

data in two or more phases, first quantitative data and then qualitative data (Schoonenboom & Johnson, 2017). The purpose of this design is to use the qualitative data collec- tion to follow up on a quantitative finding of interest, con- necting the first phase to the second to better explain or interpret the quantitative findings (Creswell & Plano Clark, 2011). This design is relatively straightforward and easier to implement for traditionally quantitative researchers but is more time consuming than concurrent designs because it in- volves two phases of research.

A question that could be answered using a sequential explanatory design might be, “How does the qualitative data explain these specific quantitative results (i.e., signifi- cant or outlier results, specific population of interest?)” For example, a study of children who have undergone intesti- nal transplant (Mancell et al., 2020) first administered par- ent report questionnaires and collected 3-day food diaries (quantitative). Then, they followed up with semistructured interviews with a subset of parents (qualitative) to clarify information found in the quantitative phase and explore caregiver perceptions about the children’s eating behaviors and nutritional intake, as well as the influencing factors in these outcomes.

Sequential Exploratory Design A sequential exploratory design involves collecting

data in two or more phases, first qualitative data and then quantitative. The purpose of this design is to use the quali- tative data to inform or build a tool to be tested in the quantitative phase (Creswell & Plano Clark, 2011). This design has similar advantages and disadvantages as the sequential explanatory design described above. That is, it offers the relative simplicity of only collecting one type of data in each phase but can be time consuming due to the use of two or more research phases.

A sequential exploratory design can be used to help develop an instrument or new intervention protocol or iden- tify categories or a taxonomy for follow-up. For example, this design is being used by a research team examining the role of different diets for children who are gastronomy tube fed (Taylor et al., 2019). In Phase 1, they will complete semistructured interviews with parents and focus groups with health professionals (qualitative) to determine appro- priate outcome measures. In Phase 2, they will use the stan- dardized measures and questionnaires developed in Phase 1

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to collect data from parents, children, and clinicians (quan- titative) to compare home-blended and formula groups.

Embedded Design or Intervention Design An embedded, or intervention, design involves one

or two phases of data collection, with either quantitative or qualitative data serving as the primary data, while the other acts as supporting data (Creswell & Plano Clark, 2011). The purpose of this design is to enhance traditional intervention designs by collecting additional information about the inter- vention (Palinkas et al., 2011). This design is more efficient and may be more natural to traditionally quantitative re- searchers. However, this design needs to be thoughtfully implemented with a clear rationale for collecting the sup- plemental data and awareness of the possibility of treatment bias. That is, qualitative data collection often involves having individuals reflect on their experiences, and this reflection

in itself may alter their engagement in and response to the intervention being tested.

An embedded design is primarily used for enhancing intervention trials and can enhance the interpretation of the outcomes and feasibility. For example, this design has been used with students to evaluate the benefits of an in- tensive dysphagia clinical placement (Cocks et al., 2014) as well as changes in student attitudes toward breastfeeding (Mahurin-Smith, 2018). Both of these studies captured pre– and post–quantitative and qualitative data to measure con- structs such as knowledge gained, change in attitude, and general feedback.

Other Considerations When designing mixed methods research studies, re-

searchers must also consider design decisions such as:

Table 1. Framework for mixed methods research design.

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• Timing: Whether data collection will occur concurrently, sequentially, or both (see Table 2).

• Weighting: Whether either the quantitative or quali- tative data be given more weight, or if both will be given equal weight in analysis (see Table 2).

• Mixing: When the two types of data will be mixed— during design, at analysis, or to connect one phase to another.

• Sampling: Whether the researcher will collect quanti- tative and qualitative data from the same group, a subset of the larger group, or two different groups.

• Sample Size: This will follow traditional methodology for each sample, with quantitative sample size based on statistical sample size calculation and qualitative based on thematic saturation.

• Rigor: Mixed methods studies should still meet the same standards of quality and rigor for both qualita- tive and quantitative methodology, collection, analysis, and interpretation (Zhang & Creswell, 2013). These four basic designs are not mutually exclusive

and can be combined in any given study. We suggest that researchers, particularly those new to designing and con- ducting mixed methods studies, consider starting with these four basic types of mixed methods designs. As researchers gain more experiences with mixed methods, they are more able to effectively design their studies using a more advanced mixed methods approach.

Critical Appraisal of Mixed Methods Research The critical appraisal of research is an important skill

for both clinicians and researchers. Appraisal of research re- quires careful consideration of various elements, specific to that methodology, that impact the study’s quality. While no study is perfect, it is important that the authors have ad- dressed these areas adequately and appropriately. The fol- lowing critical appraisal questions are based on the Mixed Methods Appraisal Tool (Version 2018; Hong et al., 2018) to assist clinicians and researchers new to mixed methods in assessing the quality of mixed methods research.

1. Is it mixed methods? The use of the term mixed methods is relatively recent.

Earlier studies may use terminology like qualitative and quantitative study or in their abstract discuss collecting both quantitative and qualitative data. While these are not labeled

mixed methods, many of them certainly meet the criteria outlined earlier. Readers should consider the following:

• Do the researchers collect both qualitative and quan- titative data?

• Does the study design fit one of the four mixed methods designs?

The reader can typically determine if the study is mixed methods by examining the abstract, although they may have to read further into the methods to determine if it truly meets the necessary standards.

2. Does the chosen mixed methods design match the research questions, and does the author provide a rationale for this choice?

The research questions should be a good fit for a mixed methods study and should not be able to be better answered using qualitative or quantitative methods alone. There should typically be at least three aims—one aimed at the quantitative information, one aimed at the qualitative information, and one aimed at integrating the two (Sadan, 2014). Addition- ally, if a mixed methods study is appropriate, the research questions should guide the choice of design, not the other way around. The design type should be explicitly stated in the abstract and purpose statement. With the four possible designs in mind, the reader should consider the following:

• Are there separate aims for, at a minimum, the quan- titative and qualitative research questions?

• Do the quantitative and qualitative portions each seem to provide additional information to the study, or could this question be answered with only one data source?

• Of the four mixed methods designs, is there a differ- ent design that could provide more information about this question?

These questions can be answered by examining the study aims and/or the author’s rationale for choosing this design, which usually is found near the purpose statement in the introduction to the article. The purpose statement should include qualitative and quantitative purpose state- ments and the rationale for using mixed methods.

3. Are both the quantitative and qualitative data col- lection and analysis methods sufficiently rigorous, consistent with disciplinary standards for each of those methodological approaches?

While collection of both quantitative and qualitative data can be laborious, it does not mean the quality standards are relaxed. Both the quantitative and qualitative portions of the study should meet the quality standards of those method- ologies. Both sections should have appropriate recruitment strategies and sampling, data collection, robust data analysis, ethical considerations, and sufficient reliability, validity, and rigor. The reader should keep in mind the expectations of quantitative and qualitative research and consider those standards for both the quantitative and qualitative portions:

• Do the authors explain their recruitment and sam- pling strategies for both? Are these valid procedures for the study?

Table 2. Timing and weighting of mixed methods designs.

Variable Concurrent Sequential

Equal weighting QUAN+QUAL QUAN → QUAL QUAL → QUAN

Dominant weighting QUAN+qual QUAL+quan

QUAN → qual Quan → QUAL QUAL → quan Qual → QUAN

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• Do the authors describe data collection and analysis for both? Are these valid and rigorous procedures for this type of data?

• Do the authors describe methods and measures that provide confidence in the validity and reliability for both types of data?

• If one were to look at the quantitative and qualitative portions of this study as stand-alone studies, would they judge each portion to reflect high-quality research?

These questions can be answered by examining the Method section of the study, which will include both quan- titative and qualitative methods.

4. Are the Quantitative and Qualitative Components of the Study Integrated or Mixed Effectively in Order to Answer the Research Question(s)?

Mixed methods research stands out because of this key component—mixing of quantitative and qualitative data. In concurrent studies, qualitative and quantitative data collection and analysis often occur in parallel and indepen- dently from each other. The separate results are merged dur- ing the interpretation part of the study (Zhang & Creswell, 2013). Sometimes, either qualitative or quantitative data can be transformed in order to be directly comparable. In sequential studies, the results of data analysis from the first phase, whether this is quantitative or qualitative, should then inform the next phase of data analysis (Zhang & Creswell, 2013). For example, a tool may be developed using quali- tative measures in Phase 1 and then evaluated or used in quantitative Phase 2, or Phase 1 may analyze quantitative data, and based on that data, researchers may follow up with a population who had a surprising or interesting result using qualitative methods. Authors must be explicit about how they mix data and must do it effectively to answer their research question(s). They should also describe how they weighted each data set, that is, how they decided which type of data they would prioritize or give more emphasis to when interpreting their results. The reader should keep in mind the different methods of mixing and consider the following:

• Do the authors explain when they mixed their data?

• Are they explicit about how they mixed the data?

• Do they describe the joint picture the mixed data pro- vides and how this relates to the study aims?

• Do the mixed results demonstrate the value added by using both quantitative and qualitative data?

These questions can be answered by looking at the Method, Results, and Discussion sections. Many authors will provide visuals showing how the data were integrated.

5. Are the findings interpreted accurately and meaningfully?

The goal of all research is to report accurate and meaningful findings. The authors should use all of the data collected to come to some conclusions about the aims they set out for. This should be thoughtfully described and con- sidered. Connections to prior research, acknowledgement

of limitations of the study, and suggestions about clinical implications and/or future directions should be included. When examining the results, the reader should consider the following questions:

• Do the conclusions drawn match the data presented?

• Are the conclusions meaningful and specific?

• Does the author explain the results in the context of other research?

• Is the author forthcoming in their acknowledgement of the potential impact of study limitations?

These questions can be answered by examining the discussion section of the article, which typically includes a discussion of results, limitations, and future directions or implications.

6. Are any divergences or inconsistencies between the quantitative and qualitative components addressed appropriately?

The potential benefit, and challenge, of using both quantitative and qualitative methods is that quantitative and qualitative results may not line up. This can be useful in providing an opportunity for critical reflection on study design and findings, as well as informative for future research. While divergences or inconsistencies in the data do not make it a poor study, they do need to be addressed and explained by the author. For example, the author may treat the results as complementary (Moffatt et al., 2006) or take steps to explore the data in different ways (Pluye et al., 2009).

The readers should consider the methods for explain- ing divergence and consider the following:

• Are there divergences or inconsistencies in the quanti- tative and qualitative results?

• Does the author acknowledge and explain these in- stances appropriately and thoroughly?

These questions can be answered by looking at the Discussion section, which should acknowledge conflicting results and explain possibilities for their cause.

Potential Use of Mixed Methods in Pediatric Feeding Disorder Research

In the introduction to the article, we highlighted some challenges in understanding PFD that might be productively addressed through the use of mixed methods research de- signs. Having provided an introduction to these approaches and quality indicators for mixed methods research, we now will provide specific examples of the application of these approaches to PFD research questions and aims. In particu- lar, mixed methods research design allows for research that focuses on (a) understanding attitudes, preferences, and knowledge; (b) exploring predictors, outliers, and specific demographics; (c) developing tools; and (d) evaluating inter- ventions (Creswell & Plano Clark, 2011). All four of these areas are greatly needed in the PFD literature and to advance clinical practice.

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Understanding Attitudes, Preferences, and Knowledge

Traditionally associated with qualitative research, mixed methods offer an opportunity to explore attitudes, preferences, and the knowledge of key stakeholders from multiple per- spectives. This may include parents, children, speech-lan- guage pathologists (SLPs), nurses, occupational therapists, gastroenterologists, and other related professionals. For ex- ample, Simione et al. interviewed parents of children with PFD and found themes such as impacts on daily life and social participation, desires by parents for the health and quality of life of their children, facilitators and barriers of desired outcomes, and preference for family-centered treat- ment approaches (Simione et al., 2020). They could have extended this study by including a quantitative measure of quality of life, such as the PedsQL Measurement Model (Varni et al., 1999), to support their findings. Similarly, a qualitative study of occupational therapists’ knowledge of infant feeding assessments could have been extended with a concurrent quantitative measure of knowledge, to determine how the practitioners’ reflections on assessment integrated with standard measures of knowledge, such as those commonly used in clinical education (Subramaniam & Reid, 2003). In such instances, mixed methods design can integrate survey, in-depth interviews, and/or focus group discussions to better understand the individual, social, and clinical factors associated with PFD. This advanced understanding can aid clinicians and researchers in developing specialized interventions for sub- populations of PFD and in facilitating stakeholder buy-in to intervention.

Exploring Predictors, Outliers, and Specific Demographics

Mixed methods research offers an opportunity to take traditional quantitative research one step further, by allow- ing the researcher to immediately follow up on interesting results. The sequential explanatory design produces a richer description of the data and can answer questions about out- liers, statistically significant results, key predictors, and spe- cific demographics, rather than having to theorize based on other studies. For example, a study of children with and with- out feeding problems in Thailand found that the first child of a family was more likely to have feeding problems and could have explored this finding further by interviewing families of first children with feeding problems (Benjasuwantep et al., 2013). A study of longitudinal changes in feeding in children with cerebral palsy found that most children’s skills were stable over time and could have extended their findings by conducting interviews with the parents of those children whose skills were variable over time to better understand that subset of the population (Clancy & Hustad, 2011). These extended findings could unearth implications for the diagnosis and treatment of PFD.

Developing Tools Tools that are reliable, valid, and feasible can be de-

veloped to near completion with a mixed methods design.

The sequential exploratory design allows for qualitative methods, such as interviews, focus groups, or expert panels, to lead to the development of measurement tools that are meaningful to the target population, which can then be vali- dated with quantitative measures. For example, a qualitative study of factors that impact school-based management of pediatric dysphagia (Angell et al., 2008) could have used their findings to develop and test a parent satisfaction tool related to school-based management. Alternatively, the au- thors of the Ability for Basic Feeding and Swallowing Scale for Children (Kamide et al., 2015) could have first used an expert panel to reach consensus on the items included in the scale before then testing its reliability and validity. The addi- tion of stakeholder perspectives can make the tool more meaningful for the target population.

Evaluating Interventions The use of mixed methods approach enables better

understanding of whether and how an intervention works (Palinkas et al., 2011). Intervention research in the field of PFD is much needed, particularly for children under three and their families. An embedded research design would al- low for an examination of not only the quantitative effects of treatment but could also use qualitative methods to ex- amine the feasibility of the intervention for families or SLPs. This design can capture meaningful intervention outcome data that is not easily assessed with quantitative methods, such as how family dynamics change around mealtimes, how a child’s mood changes with positive interventions, or the impact on the dyad across daily living activities. For example, in a study of the effects of oral motor stimulation on feeding outcomes in infants with univentricle anatomy (Coker-Bolt et al., 2013), the authors could have extended the study by collecting pre– and post–qualitative data from the therapists implementing the intervention to assess feasi- bility. Similarly, a study of a pacing intervention for pre- term infants could have conducted qualitative interviews with the nurses who implemented the study to assess feasi- bility and acceptability of the intervention (Law-Morstatt et al., 2003). These additions can improve the development of effective, feasible interventions.

Implications for Interdisciplinary Work in Pediatric Feeding Disorder Research

Mixed methods research offers a way of conducting research that meets the needs of interdisciplinary research in PFD, particularly important given the growing acknowl- edgement that PFD must be assessed and treated with an interdisciplinary lens. Mixed methods lend itself well to in- terdisciplinary teams, as it allows for different methods of research to focus on different aspects of the same phenom- enon (Bowers et al., 2013). For example, an interdisciplinary team could participate in an embedded design and examine medical, nutrition, feeding skill, and psychosocial outcomes using qualitative and quantitative measures. An interdisci- plinary team could also use a sequential exploratory design

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to develop an appropriate outcome measure that integrates medical, feeding skill, nutrition, and psychosocial outcomes.

Interdisciplinary teams are also advantageous in mixed methods design for implementation of a rigorous study (Bowers et al., 2013). An interdisciplinary team with diverse experiences is critical because mixed methods research necessitates inclusion of qualitative and quantitative re- searchers for proper implementation. While potentially more labor intensive than traditional single methodologies, the information gained from these studies can be rich when properly implemented, and team collaboration can ease the burden on individual researchers or practitioners. Clini- cians involved in clinical research may find this methodology particularly exciting, as it allows for multiple perspectives on a single phenomenon, such as understanding the SLPs’ or parents’ perspectives in addition to those of the re- searchers. Additionally, mixed methods research design could enhance the feasibility of implementing the interven- tion into clinical practice, bridging research and clinical practice more smoothly (Palinkas et al., 2011). Mixed methods research design helps us answer whether an intervention works (or not) and why (or why not), as well as assess its fidelity of implementation (how it is being delivered).

Conclusions This article highlights the benefits of mixed methods

research in the area of PFD, as this methodology holds po- tential to advance our understanding of the heterogenous populations PFD impacts, improve our use of interdisci- plinary teams, examine holistic interventions, and develop tools for clinical and research use that capture all four com- ponents of PFD in a meaningful and feasible way. To aid readers in considering applying mixed methods research to PFD, we have described the necessary components for rigorous mixed methods research and its critical appraisal. Mixed methods research has much potential for exploring phenomenon of interest in PFD. The application of mixed methods designs results in deeper and broader information about the subject of study that can enhance our under- standing and measurement of phenomenon or interven- tions, which makes it well suited to the interdisciplinary nature of PFD research.

Author Contributions Kelsey L. Thompson: Conceptualization (Equal),

Investigation (Lead), Writing – Original Draft (Lead), Writing – Review & Editing (Supporting). Wanqing Zhang: Conceptualization (Equal), Writing – Review & Editing (Lead).

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1630 Perspectives of the ASHA Special Interest Groups • Vol. 5 • 1623–1630 • December 2020

SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

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