Our SLPs Share 4 Of Their Favorite Treatment Activities

At Pediatric Therapeutics, our Speech-Language Pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children. We work very closely with family members and frequently collaborate with physicians, school personnel and other health professionals to provide a unified approach to treatment. In asking our SLPs to share one of their favorite treatment activities, the responses are all varied and interesting with one common thread. Can you guess each therapist’s choice?

1. This therapist says one of her favorites is the Curious George Beach Discovery Game! All the kids enjoy it. She loves the versatility—she uses it to assist with multiple skills including articulation activities, memory skills, vocabulary building, turn taking, sequencing, direction-following and answering questions.

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2. This therapist enjoys using her iPad with communication therapy apps. Among her favorites are those which allow the child to create something unique such as a story which they can then illustrate. There are apps with animation, sounds and visual input to assist with sound production skills and social stories which assist with social communication skills. She loves that her clients are empowered by the use of technology while staying focused on the goals of the session.

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3. This therapist says Balloon Lagoon is one of her many favorites! The four stations allow for practice of a variety of skills including turn taking, vocabulary, matching, sorting, phonemic awareness, articulation, and much, much more. She and her friends can focus on any one or a combination of many skills. Kids love it because it’s just plain FUN!

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4. This therapist prefers toys where the emphasis is on eye contact, attention, interaction and reciprocity. Blocks are a favorite for their myriad uses in building skills and practice for every treatment goal. Whether improving vocabulary, listening skills, counting, articulation or verbal elaboration, building all kinds of structures requires a combination of skill and interaction. Versatility and FUN remain a common thread among us all!!

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ANSWER KEY:
1. Karen Betheil
2. Maureen Harper
3. Terri Jones
4. Anne Toolajian

–Anne Toolajian, MA, CCC-SLP

Why are swings used in therapy?

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Question:
Why are swings used in therapy?

When a person enters therapy it’s usually because something needs to change. Something is not occurring in response to the stimulation of everyday life and environments are as it should be; there’s a desired change that is in need of specialized help. A therapist helps create and hold the space for change, and orchestrates the specialized intervention that is needed to stimulate the desired change over a course of time.

Since movement is an essential part of life, it’s an essential consideration of therapy in one way or another. While the use of suspension equipment/swings in pediatric therapy was initially unique to sensory integration therapy, we now know enough about sensory integration and the value of movement to recognize that swings are useful in most types of pediatric therapy. Intentionally provided movement experiences can contribute to sensory, physical, emotional, cognitive, language and social changes that lead to improved function.

Swings are a primary way of providing intentional movement, or movement that is being provided with an express purpose. We sense our bodies moving whether we’re being moved passively, we’re moving ourselves, we’re moving movable objects, or we’re actually moving to move objects that move us. And we’re able to sense stillness. Sensation of movement or lack thereof, can come to our conscious awareness or can be processed subconsciously. The versatility of swings, and of certain swings in particular, is priceless when it comes to treatment planning, as most swings can be used in many ways in order to offer the desired type of movement. In fact, when each of the Pediatric Therapeutics OTs were asked about their “Big Room Favorite” (favorite piece of equipment in our sensory gym), each named a swing and mentioned versatility as a reason for their choice. Missy and Carrie both mentioned the many positions possible when swinging on the glider swing, even when weakness or lack of confidence may be an issue. Liz mentioned the endless possibilities for using the hammock (“superman”) swing for varied activities, from calming to intensively stimulating, working on weightbearing, strengthening, visual motor skills, directionality, and fine motor skills, while engaged in linear or rotational movement. Anne mentioned various aspects of postural control that can be addressed with the long cylindrical shape of the bolster or “horse” swing.

Our movement and position in space, and in relation to the pull of gravity is received by a part of the ear called the vestibular system, but the vestibular system is not the only system that gives us information about where we are, how we’re positioned and how/where we’re moving. Information from our muscles, joints, eyes, hearing part of the ears, skin, and nose also contribute to our awareness of our bodies in space. When we’re using swings we are able to easily and creatively incorporate other types of sensory input to increase awareness and discrimination related. The movement and positional information offered by swings can support our abilities to regulate our physical and emotional selves and to do what we need/want to do.

10 reasons we use swings:
1. Swings provide an opportunity for shared steady beat/rhythm that helps therapist and child, or one child and others, sync up with one another.
2. Swings are a way of enhancing positional and movement stimulation.
3. Swings can be easily adapted to meet sensory processing patterns and needs.
4. Swing movement can help activate muscles and muscle groups.
5. The rhythms of swing movement can be used to affect internal rhythms.
6. Swings can be used to work on timing.
7. Swings can be used to support the working relationships of midline, and the right and left sides of the body
8. Swing choice/use can be graded for working on balance.
9. Swings lend themselves to imaginative play and creative processes.
10.Movement stimulates vocalizing/speech and language.

Swinging can be fun! Ask to try out a swing in our Big Room…you’ll see why we use them all the time!

–Sheila Allen, MA, OT

It’s Time For a Pet. What Now?

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We’ve decided it’s time to get a pet. What can you tell me about assistance dogs?

You’ve made the decision to get a pet! As if it’s not hard enough to decide upon what kind of animal would be the best pet for your child and your family, whether you want a specific breed or mix, and whether you want to establish a relationship with a breeder or go the rescue route, you also have the consideration of the specific role the pet will play in your child’s and family’s life and how official you’d like that role to be.

Most pet owners would agree that most pets have a therapeutic effect them and their loved ones. They would agree that their pets support & enrich their lives immeasurably. Yet most pets are not officially designated as “assistance”, “service” “companion”, “emotional support” or “therapy” pets. And to add to the mix (no pun intended!), there’s a distinct difference between registering and training these working animals. An assistance pet is one who provides some sort of assistance (i.e. service, companionship/emotional support) and a therapy pet or “pet therapist” is is an animal used in animal-assisted therapy or other activities to help a person work toward therapeutic goals. Animal training, if available, is strongly encouraged and often absolutely required.

To help you get started with your exploration of assistance pets, we have provided you with some resources. As you will see, as you begin your exploration, there is a good deal of information to review. Assistance Dogs International, www.assistancedogsinternational.org, has been involved with setting standards for assistance dogs since 1987. This website provides a thorough review related to access and other laws. Certapet, www.certapet.com, provides a nice review of laws related to emotional support animals, a group of assistance animals for which regulations seem less clear and training is generally not required.

When it comes to assistance pets, the organization we know best and regularly recommend is Canine Companions for Independence. Founded in 1975, Canine Companions for Independence® is a non-profit organization that enhances the lives of people with disabilities by providing highly trained assistance dogs free of charge and offering ongoing support to ensure quality partnerships. Learn more about Canine Companions and the four types of assistance dogs they raise, train and partner – service, hearing, facility and skilled companion dogs, at www.cci.org.

Canine Partners for Life (CPL) is a another non-profit 501©(3) organization dedicated to training service dogs, home companion dogs, and residential companion dogs to assist individuals who have a wide range of physical and cognitive disabilities. In operation for over twenty years, Canine Partners for Life (CPL) envisions that the lives of those they serve will be forever changed through the opportunities and independence afforded by a steadfast relationship with a service or companion dog. They also provide seizure alert, diabetes alert and cardiac alert dogs. A suggested donation, on a sliding scale, is requested as part of partnership arrangements. Visit www.k94life.org to find out more.

The Seeing Eye, www.seeingeye.org, is a philanthropic organization whose mission is to enhance the independence, dignity, and self-confidence of blind people through the use of Seeing Eye®dogs. While the Seeing Eye is specific in its service to the blind, this organization may be of interest to you because of their adoption program for their puppies who do not go on to actually becoming full fledged Seeing Eye dogs.

Pet therapy is a desirable alternative for those whose families cannot have pets but would like to have their children develop a relationship with an animal that is loving and therapeutic in nature. Therapy Dogs International, www.tdi-dog.org, is a volunteer organization dedicated to regulating, testing and registration of therapy dogs and their volunteer handlers for the purpose of visiting those in need. Home visits can be arranged through TDI. Creature Comfort Pet Therapy, www.ccpettherapy.org is a similar organization that provides facility-based visits. In addition to dogs, CCPT also works with other animals including cats and rabbits for animal assisted activities; a mini-horse has also been a part of their group.

While most of us are not likely to be able to have a horse at home as a pet, hippotherapy and equine assisted activities can meet a host of therapy objectives while also offering the opportunity to relate and care for a horse. Health and Recreation Through Horses, www.hrhofnj.org is a useful resource for equine organizations/stables/facilities. Rocking Horse Rehab, www.rockinghorserehab.com, is a pediatric rehabilitation and family wellness center located within an equestrian center. It specializes in equine assisted therapies along with alternative and traditional therapeutic programs. Over the years many children who receive Occupational, physical or speech/language therapy at Pediatric Therapeutics have been successfully involved in riding and other activities at Rocking Horse Rehab.

How many times have you heard somebody say that his/her pet makes him/her a better person? Given how often this is said, it’s a comment worthy of our attention, particularly when we’re looking for positive changes in one way or another! Your decision to get a pet and/or to explore various options that suit the needs of your child/family may very well be one of the best decisions you’ll ever make.

–Sheila Allen, MA, OT

Haiti Thoughts

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How is it possible that I can be blessed with a roof over my head, relatively healthy children, parents and siblings? Why was I so lucky to come into this world never worrying that I’d have shoes on my feet and clean water to drink? What did I do to deserve to be able to make simple choices all day long based on what I WANT not on what I may or may not NEED?

These are some of the many questions that ran through my head during my time volunteering in Haiti with STAND (Sustainable Therapy and New Development) The Haiti Project, a nonprofit organization, dedicated to establishing permanent access to orthopedic rehabilitative services for Haitian adults and children in need through direct patient care and clinical training of its citizens. I landed in Haiti with 20 other STAND volunteers from around the US. We were primarily PTs but a nurse and a physician assistant were with us as well. As soon as we passed through customs in the airport there was a small band playing music on empty buckets and pans – what a welcome! The Haitian people are lovely.

We piled into a bus to begin our journey to Port de Paix, told that it could take anywhere from 6-16 hours. The road was paved for the first half of the trip, but for the second it was not. There didn’t appear to be any rules of the road. Our bus driver would quickly accelerate passing overloaded motos (mopeds) carrying up to four people (no helmets, I might add!), trucks packed tightly full of 20-30 people, other buses and pedestrians. There were vehicles driving in both directions on all sides of the road. To my American eyes, it appeared to be chaos. I later learned from the adult therapists that a large number of the patients they treated came in complaining of pain/injury from moto or vehicle accidents.

The condition of the unpaved road is indescribable. I have been on plenty of dirt roads in our country in VT, CO and AK. I have never seen roads like these. There were huge (2-3’ in diameter) boulders obstructing the roads. There were large gulleys in the middle of the roads. There was evidence that at some point road construction had been started, but nothing was complete.

The view from the bus windows: women carrying, by estimate, 40-50 pound bags of potatoes on their heads, children bathing in the river, babies squeezed in between adults on overcrowded motos, children walking donkeys loaded down with fruits and vegetables, goats with triangular wooden frames around their necks. En route to the clinic we got a flat tire, a noticeably common occurrence.

We arrived at the STAND clinic in Port de Paix at 9pm. Dinner was waiting. For me dinner, and lunch and breakfast, consisted of fried plantains, fried breadfruit and fried bread with Haitian peanut butter. I set up my mattress outside on the balcony with mosquito netting hanging from above. The waves crashing below me, I slept on and off through the night. When I woke up the next morning, I could not believe the view. It was a million dollar scene.

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In the clinic, I saw children with diagnoses that are obsolete in the United States because of vitamins. Rickets, for example, is a disease where your bones become soft due to lack of Vitamin D and Calcium. This results in bowed legs. I saw children with seizure disorders who are not on medication having five-six uncontrolled seizures daily. I saw children with Zika virus resulting in microcephaly. I saw children with cerebral palsy who were dependent for all daily activities.

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For these children, we built standers, walkers and chairs out of PVC pipes, foam and duct tape. We modified old orthotics we brought from home to fit these children’s feet as best we could. We taught families stretches and strengthening activities. We gave families shoes for their children so their feet would be protected and supported. We used donated Bumbo chairs so that infants who could not sit independently were safe and well positioned when they were not being held. We fabricated wrist splints.

There is an obvious huge difference between healthcare in the States and Haiti. In the Haitian system, only the wealthiest of families can afford healthcare. The way I saw this play out is that a child, for example, with microcephaly, in the States would be followed by MDs, PTs, OTs, STs and other medical and developmental professionals from birth. However, in Haiti, this is not the case. A child with a severe medical condition and disability is not given proper care early on, so his/her growth and development is stunted more than a similar child with the same diagnosis here in the States.

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The question I keep being asked since back in the states is “What kind of impact do you think you really had on these people?” And, that was exactly what I was most reluctant about prior to my trip. To that, I answer, “I know that I had an impact on these families and these children”. I saw so many smiles after children spent time in our clinic. There were so many simple, small things that I did while I was in Haiti that were so impactful.

I am so thankful for my husband, Jeff, and our children, Harper and Talia, who managed everything while I was away, and for my extended family and friends who helped as well. I am grateful for the support I received from my own family, Pediatric Therapeutics families, my friends, and colleagues. I am grateful for the choices I have every day of my life. I am grateful for my health, the clothes on my body and the sound roof over my head. I am grateful for the extremely patient Haitian children and their parents who allowed me to help them.

Miriam Cohen, PT, DPT, PCS

Does Feeding Therapy Really Work?

Mealtimes with my picky eater can be so stressful.  Does feeding therapy really work?

The short answer is YES! The longer answer is still yes, but it takes time, patience and a consistent approach. Trying new foods is a process and for many children it is fraught with anxiety, uncomfortable sensations, mixed expectations and feelings of a lack of control. At Pediatric Therapeutics, we combine several methods and techniques to assist our clients with gaining confidence, oralmotor skill and tolerance for new foods. Each child is different and so is their treatment plan.

Depending upon the comprehensive history taken and specific needs discovered, we can begin to formulate an approach where the child feels safe FIRST and then we can begin the process of setting the expectation, specific treatment goals and ways to follow through at home. Parent involvement is critical and paramount to success outside of the treatment room. How a child “works” in therapy and bonds with their therapist is different than what typically happens at home. The first and obviously most important bond around food occurs with parents and their children. It is an emotional experience for parents and when mealtimes become less pleasurable and more stressful, the emotions run even higher. Our children sense the importance of this so consist use of language, consistent expectations and consistent follow through are critical to the success of any feeding therapy session, whether inpatient or outpatient, daily, weekly or just periodically.

As with any intervention, progress isn’t always linear. The trajectory changes. Sometimes we need other professional guidance in addition to feeding therapy. There is no magic bullet but there is plenty of hope, plenty of tools to achieve the goals we set, and plenty of literature that supports the positive outcomes of feeding therapy. Would you guess that six months ago, Nicolina, an adorable 5 year old, was an extremely selective eater? With persistence and hard work, Nicolina is expanding the foods she tolerates, the foods she enjoys and the foods she will attempt. Trying something new can be empowering!!

–Anne Toolajian, MA, CCC-SLP

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The Art and Design of Out-of-the-Cart Shopping

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Shopping with your kids may fall into the category of unavoidable things you’d rather not do. Or, perhaps you’ve found you really enjoy it! Enjoy it, or not, shopping raises well-documented safety issues, especially related to shopping carts. For examples, a study done in 2014 found that every 22 minutes a child in the United States experiences an injury related to a shopping cart. 90% of shopping cart related injuries occur with a parent present. In fact, the American Association of Pediatrics has advised keeping children out of and off shopping carts (or leaving them home, or bringing along another adult) whenever possible, attributing most injuries to falls. As a reminder, seats in shopping carts are intended for kids (strapped in) from 6 months to 4 years and the cart itself is intended for objects, not for people. Shopping with your child out of the cart raises its own safety and logistical considerations.

So, what should you be doing when you bring your child along for some out-of-the-cart shopping? And what if your child just happens to experience extra challenges that compromise her ability to control herself? Here are some suggestions for out-of-the-cart grocery shopping with all kids , especially those who easily become out-of-control:

Know when your child’s ready (emotionally, sensorily, motorically, communicatively and cognitively) to make the trip to the supermarket, and wait until he/she is (if possible!). Consider both your child’s abilities & responses to stimulation and the characteristics of the store you plan to visit. As guidelines, your child should be able to pay attention to you in a distracting, variable environment for at least 15 minutes and follow your simple directions. He/she should be demonstrating comfort and cooperation in small shops. He/she should be able to maintain an appropriate activity level in his/her stroller or walk holding your hand through the parking lot, for at least one aisle and the check out, and back to the car. Not sure? If you think you’re close, try it…and try it with the mindset that you want to see how your child is going to handle the store visit, rather than intending to bring home a load of groceries!

Plan for success and make it special. Schedule grocery shopping trips as special events and go to the same store repeatedly, initially avoiding grouping grocery shopping with a long list of errands you need to run. Begin with small grocers. Think about where you ‘ll park (i.e. close by, so there’s little time and space between car and store, or farther away so you and your child have some movement prior to entering). Have a simple plan (re: what you’re going to look for to buy, a logical, direct navigation and how your child is going to help, what happens at checkout and in bringing items back to the car and home) and discuss it with your child. Talk about your plan as you’re carrying it out. Reinforce good behavior along the way with frequent, immediate verbal acknowledgement and praise (“I like the way you’re holding my hand .” “You just spotted the turkey in the deli case.” “You were really listening to the man at the check. I could tell he liked to talk with you.”), a small treat from home, a special item on the grocery list that he/she gets to enjoy at the end. Avoid reacting to a negative behavior (i.e. screaming, whining, running away, noncompliance, grabbing things) with something positive (an immediate treat). Prepping your kids for what will be happening as they strike out for that special time with you, reinforcing the sequence of events, talking about it later, and repeating the activity as a familiar event soon thereafter is very helpful.

Give her your attention, the entire time. This does not mean you always need to be talking to your child, but he/she needs to know from you, though your eye contact, verbalizations, physical contact and visual regard for his/her activity, that you are there for him/her. Save your conversations with a friend you haven’t seen for ages, your time- consuming search for something you just thought of, and your talk on your phone for later. Your attention means everything!

Give her a hand. Yours! Shop only for what you can handle knowing that you will need to hold your child’s hand, at least in the beginning (and likely, for some time to come). Gentle rhythmic hand squeezes can be calming and help your child focus on you. Varied squeezes can be fun.

Give her a job. Fortunately grocery shopping involves all sorts of opportunities. From the grounding influence of “heavy work” (such as reaching for, placing and carrying objects), to the focused attention needed for visual search, perceptual-motor skills for bagging, and cognitive/language stimulation such as sequencing and categorizing, shopping for groceries offers meaningful, purposeful activities for many ages and levels of ability. Think about what your child likes and likes to do and what he/she may need to do to help with appropriate behavior as the foundations for what you will be identifying as his/her job. Reinforce a job well done (on your part as well as your child’s).

Identify the learning opportunities each visit to the grocery store has provided. What worked? What didn’t? What would you do differently – proactively add or eliminate sensory input? simplify or increase complexity? reinforce desirable behavior another way? or modify the amount of your support (physical, sensory, verbal, emotional)?

Each of us knows the feeling of being overwhelmed by a shopping experience and coming home feeling either tired and drained, highly excitable, or perhaps irritable. Kids of all ages feel this too. Yet many of us love to shop, and love to shop with kids. Why? Shopping can be safe, fun…and therapeutic! From small town grocers to huge supermarkets, local shops and boutiques to immense department stores, out-of-the-cart opportunities can be deliberated crafted with loving care for positive experiences to be built upon throughout childhood.

–Sheila Allen, MA, OT

How can I coax my child to try new foods, especially if he is finicky?

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So much about the holidays seems to include food! Looking for ways to encourage your “picky eater” to try new things? Every baby and child is unique and there are a multitude of reasons for why a child refuses certain foods. While many toddlers and early school-age children experience some mealtime difficulties, there is a subset of children, many of whom have complex medical histories, who refuse most or all foods presented at meals. For these children, intervention with a multidisciplinary approach is critical and may require more specialized care.

For all of our kids, however, the primary goal is to assist them with developing a positive relationship with food. Try these beginning basics to coax your child to participate in learning about new foods while demystifying the process:

1. Encourage your child to help you at the grocery store by choosing some fresh fruits or vegetables and placing them in bags.

2. Ask for a helper at home to wash and dry fresh produce and place in a bowl.

3. Children usually LOVE to assist with food preparation…peeling, mashing and cutting with supervision. Take this time to discuss the properties of the food you are handling. What color is it? How does it smell? How does it feel? How does it change when we peel it, slice it or mash it?

4. Have your child help with clean up. They can discard the refuse by picking up and placing scraps in the garbage. “Pop” the garbage with your lips, blow the pieces with your mouth or drop the scraps with your fingers.

5. Family meal time – whenever possible, sit at the table for meals as a family unit. Solidarity sends a positive and powerful message.

6. Serve family style – passing food from person to person while serving allows the sights and smells of new foods to be part of the experience.

7. Encourage “playing” with food. Arrange foods to make smiley faces or letters, numbers or shapes. Avoid placing too many things on the plate. Start with one food and clear that before adding another. This keeps the plate visually interesting but not overwhelming.

Remember to have fun with food! Use positive dialogue such as “You can lick the peach!” rather than asking “Can you lick the peach?” Get messy! Interact, explore, manipulate and participate! With the emphasis on increasing interest and acceptance rather than eating, tastes, licks and nibbles often result. Good Luck!

–Anne Toolajian, MA, CCC-SLP

Sheila Allen’s Spinach Balls (Thanksgiving Recipe Series)

My daughters, who are now in their mid-twenties, began eating these spinach balls (nearly everyday!) as babies and still love them! A perfect recipe for kids to help make!

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• 2 10-ounce packages frozen, chopped spinach
• 2 cups crushed Pepperidge Farm stuffing
• 1 medium onion , finely chopped
• 1 cup grated Parmesan cheese (or ½ cup grated Parmesan and ½ cup grated or finely shredded mozzarella or cheddar cheese)
• 4 eggs, lightly beaten
• ½ cup butter, softened
• pinch garlic salt
• pinch ground thyme

Preheat oven to 350 degrees.
Defrost spinach and squeeze dry.
Mix all ingredients.
Form into balls 1½ inches in diameter.
Place balls on a cookie sheet.
Bake 15 minutes on top rack of oven. For lightly browned tops, broil (with oven door open) for 1 minute, watching carefully.
May be made ahead and reheated, or immediately frozen prior to baking.

Makes 60 balls .

To make this recipe gluten free, substitute 1½ cups crushed Corn Chex cereal and 3 tablespoons gluten free flour for the 2 cups stuffing.

–Sheila Allen

Liz Platt’s Cajun Cheese Dip (Thanksgiving Recipe Series)

If you’re looking for new dip, try this. It’s different and so TASTY!

• 2 cloves of garlic, grated
• ½ cup thinly sliced scallions, divided
• 1 tablespoon butter
• 1 lb. crawfish tail or lump crabmeat, drained and rinsed
• 1 (1 lb.) block of processed cheese (Velveeta)
• 2 (10 oz.) cans diced tomatoes with green chilies, drained
• Kosher salt
• Freshly ground black pepper

In a medium pot over medium-high heat, saute garlic and white parts of scallions in butter until slightly tender.
Mix in crawfish or crab and cook for about 5 minutes on low.
Pour mixture into a bowl and set aside.
Add cheese and tomatoes to empty pot and cook over medium-low heat until melted and combined.
Stir in reserved scallion mixture.
Heat on low until well blended and very warm.
Season with salt and pepper to taste.
Garnish with sliced green scallions.
Serve with seeded or seasoned crackers.

–Liz Platt

Miriam Cohen’s Chipotle Shrimp Wontons (Thanksgiving Recipe Series)

These are DELICIOUS! This is my husband’s go-to recipe that he’s made many a time over the years.

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• olive oil
• 1 16 oz package wonton skins
• ½ pound shrimp, cooked, peeled, deveined and coarsley chopped
• 1 yellow bell pepper, roasted, peeled and chopped
• 1 red bell pepper, roasted, peeled and chopped
• ½ cup chopped cilantro
• 1 chipotle pepper in adobo sauce, drained and finely chopped
• 8 ounces fontina cheese, shredded

Preheat oven to 350.
Brush mini-muffin tins w/olive oil.
Press 1 wonton skin into each cup.
Bake wonton skins10 min until tops are golden brown.
Remove from oven and cool slightly.
In large bowl, combine shrimp, roasted peppers, cilantro, chipotle pepper and cheese.
Remove cooled skins from muffin pan and place on baking sheet.
Fill each skin with reserved shrimp mixture.
Bake 7-10 min or until cheese is melted.

*Can be spicy so adjust with chipotle as needed.

–Miriam Cohen