Identifying Swallowing and Feeding Disorders in the Schools
Addressing swallowing and feeding is becoming more common in school districts and so the question of how to evaluate any particular student is being asked. One of the challenges facing school-based SLPs is the large variety of cases that they are likely to encounter. In the schools there are children with true dysphagia (oral, pharyngeal and esophageal) with some having the signs and symptoms of aspiration, undernutrition, dehydration and choking risk. But there are also children that fit the broader category of “feeding disorders”. These students may have sensory or behavioral concerns that interfere with their ability to participate in mealtimes at school. The school-based SLP is responsible, along with the other school-based team members, for all of these students (Mabry-Price, 2015).
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Identifying children with swallowing and feeding disorders in the school setting may be approached in different ways. Each district will need to follow the guidelines of their individual state and local department of education. However, there are some procedures or components that are best practice and provide safe guards (ASHA, 2018). Let’s discuss these under the scope of identifying students with Down’s Syndrome.
General Information of Down’s Syndrome and Swallowing and Feeding
- 50-80% frequency of feeding issues in children with Down Syndrome (Pipes and Holm, 1980: Van Dyke et al, 1990)
- Common for them to have low muscle tone, respiratory problems, gastrointestinal disorders and cardiac issues.
- Often have oral motor deficits including: poor suck and lip closure, uncoordinated swallow leading to choking, gagging and coughing, underlying respiratory issues and chewing difficulties.
- Common behavioral feeding concerns include oral defensiveness, food avoidance and texture aversions, among others.
- Swallowing and feeding disorders with this population may include: aspiration which is often silent in children with Down’s Syndrome, recurrent pneumonia, chronic respiratory illness, poor nutrition, and failure to thrive.
As a result of the above, it is essential for students with Down’s Syndrome to have their swallowing and feeding skills thoroughly evaluated within the school setting utilizing a team approach and systematic procedure (Homer, 2016).
Similar to addressing swallowing and feeding in other settings, identification and treatment should be done using an interdisciplinary team approach. In the schools, most of these team members are already employed by the district. Primary team members include:
- School Nurse
- Classroom Teacher
In addition, the parents/guardians are part of the school team, as well as the student’s physicians. Communication with the physician(s), requiring a signed release from the parents/guardians is recommended. All members of the school-based team may be called upon to work collaboratively to identify and treat the student’s swallowing and feeding concerns.
The first step in identifying a student’s swallowing and feeding disorder is to complete a referral on the student indicating observed signs and symptoms. This serves as part of the screening process. Children with Down’s Syndrome have a high incidence of swallowing and feeding disorders so it is recommended that all children with Down’s Syndrome be referred to the school-based swallowing and feeding team for a screening to determine if the student has any signs or symptoms. The referral may be completed by the classroom teacher, SLP, OT, parent/guardian, etc. Once a referral is completed it is important to talk to the parents/guardians to gather information on the following:
- Medical History (including failure to thrive, intubation, aspiration, history of pneumonia, etc.)
- Current Feeding Practices (including food preferences, food textures, self-feeding, behaviors when eating such as choking, and so on).
- Parent’s/guardian’s level of concern
This process of interviewing the parents serves two purposes:
- To gather important information from the family on the student’s feeding habits at home and on their medical history as part of the screening and evaluation process.
- To immediately involve the parents as part of the team that will address the student’s swallowing and feeding at school.
Oral Mechanism Evaluation
Prior to the Interdisciplinary Observation a thorough oral mechanism evaluation should be conducted by the SLP and OT. This evaluation should include:
Oral Peripheral Examination
- Hard palate
- Soft palate
- Range of motion
- Sensitivity to touch, smell, temperature, color or sound.
Children with Down’s Syndrome commonly have the following which may affect swallowing and feeding skills:
- Low tone
- Open mouth at rest
- Misaligned bite
- Small jaw
- High arched palate
- Lax ligaments
- Larger tongue relative to mouth space (Baldwin and Rosebush, 2015)
Identifying dysphagia in the school setting is generally the same process that you would follow in the medical setting. Once you have gathered information on the student, determined that there is a concern and have completed the Oral Mechanism Examination, you conduct a clinical evaluation. This evaluation looks at how the student is currently eating. Remember that in the school setting, most students are not sick or recovering from an illness. They typically have been eating at home and school, playing on the playground and attending classes. The school team, SLP, OT, nurse, classroom teacher, paraprofessional, observe the student eating their typical school meal (either cafeteria or home provided meal).
Each child in the school system will require attention to their specific signs, symptoms, conditions and presenting concerns, so each child’s evaluation will be different.
The SLP directs the feeder to modify the food when observing concerns, such as difficulty chewing, watery eyes, coughing, etc. A variety of foods and textures are attempted and documented on the form. The team also looks at liquids and makes modifications based on these observations and trials with alternative thickness. When evaluating a child with Down’s Syndrome in the school setting, the school team also looks at signs of sensory or behavioral concerns. These are documented on the Interdisciplinary Observation form (clinical evaluation) and is part of the school-based clinical evaluation. Classroom teachers and paraprofessionals often provide information on the student’s behaviors during mealtimes. This information, as well as, the information provided by the parents/guardians, is used to determine if a sensory/behavioral evaluation is indicated. The OT and possibly a Board Certified Behavioral Analyst (BCBA) may be involved in this portion of the clinical evaluation.
When the team observes concerns that suggest pharyngeal involvement or aspiration, or if the student is frequently sick with upper respiratory infections or pneumonia then the team may determine that a referral for an instrumental evaluation is indicated.
Instrumental Evaluation Referral
In some cases, the school team will determine that an instrumental evaluation, such as a Video Fluoroscopic Swallow Study (VFSS)/Modified Barium Swallow Study (MBSS) is recommended to complete the identification of the student’s swallowing and feeding disorder and to establish a safe feeding plan. Children with Down’s Syndrome have a high incidence of silent aspiration, frequent respiratory infections and recurrent pneumonia. In these cases, an instrumental evaluation would be recommended.
When do I refer for a VFSS/MBSS?
The school team will use the information gathered to decide whether the student needs a VFSS/MBSS. The team will want to consider the following when making a referral:
- Signs and symptoms of aspiration (gurgly voice, coughing, multiple swallows, and so on)
- History of pneumonia/chest congestion/wheezing
- Upper airway congestion after meals
- At risk for undernutrition and/or dehydration
- Previous history of aspiration
In order for the school district to receive a copy of the VFSS/MBSS report, the parents/guardians must sign a release of medical information form. Based on the information of the instrumental examination, the swallowing and feeding plan may be revised, classroom staff trained on the new plan and the revised safe plan implemented.
Establishing a Swallowing and Feeding Plan
Once the referral, parental interview and clinical evaluation have been completed a swallowing and feeding plan is written primarily by the SLP with input from other team members, that establishes safe feeding. The classroom staff is trained and the plan is implemented. The swallowing and feeding plan includes the following information:
- Identifying Information (DOB, Teacher, etc.)
- Brief History/Special Considerations/Student’s Condition
- Feeding recommendations:
- Diet/Food Preparation
- Feeding plan techniques/precautions
- Name/number of swallowing and feeding case manager
- Verification of classroom staff training on the plan recommendations
If the student is referred for an instrumental evaluation, then a revised swallowing and feeding may be indicated following the evaluation.
Goals Following Swallowing and Feeding Evaluation
The evaluation process is not complete when a safe swallowing and feeding plan is established. Students with Down’s Syndrome, as well as other students, are constantly growing and changing. The task of identifying swallowing and feeding disorders is ongoing throughout the time the student is attending school. The swallowing and feeding plan may need to be revised several times in one year or may remain the same for several years and then change. So the goal then becomes twofold:
- Maintaining safety with ongoing monitoring of the student during meals, collaboration with classroom staff and feeders, and revision of the plan when indicated.
- Improving oral and oral sensory motor skills through specific therapeutic intervention to improve functional eating skills.
This article has outlined the process for evaluating a student suspected of having a swallowing and feeding disorders in the school setting, with an emphasis on children with Down’s Syndrome. Each child in the school system will require attention to their specific signs, symptoms, conditions and presenting concerns, so each child’s evaluation will be different. However, the process will be similar for most students who are evaluated through the school system.
Links of Interest
- For more information on evaluating students for swallowing and feeding disorders in the school setting contact Emily Homer
- Emily’s New Book: Management of Swallowing and Feeding Disorders in Schools
American Speech-Language-Hearing Association. (2018). Clinical Topics/Pediatric Dysphagia. Retrieved 3/31/2018, from http://www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia
Arvedson, J. (2008). Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Developmental Disabilities Research Review, 14(2):118-27. doi: 10.1002/ddrr.17.
Baldwin, J. & Rosebush, R. (2015). Oral Motor Development in Down Syndrome: Impacts on Speech and Feeding. Down’s Syndrome Research Foundation. https://www.dsrf.org.
Homer, E. (2016). Management of Swallowing and Feeding Disorders in Schools. Homer, E. (2016). Management of Swallowing and Feeding in Schools. Plural Publishing, San Diego, 39 – 170.
Mabry-Price, L. (2015) Treating dysphagia in schools: making it easy to swallow. The ASHA Leader, 20, 36-37.
Pipes, P. & Holm, V. (1980). Feeding children with Down’s syndrome. Journal of American Diet Association, Sep;77(3):277-82.
Van Dyke, D. (Ed.). (1990). Clinical Perspectives in the Management of Down Syndrome. Springer-Verlag Berlin and Heidelberg GmbH & Co. K. DOI 10.1007/978-1-4613-9644-4