Pediatric Dysphagia Assessment: Evaluating Clinical Tools

Introduction

It’s that time of year again- back to school and back to frequent testing for school age children.  Tests are meant to measure skills or knowledge in a particular area.  Dysphagia clinicians use tests all the time too to measure many different components of oropharyngeal swallowing, including strength and range of motion of the articulators, variety and sufficiency of diet, efficiency and coordination of oral intake, growth, sensory processing, and feeding behaviors.

While instrumental assessment is necessary to verify airway compromise during the swallow and accurately identify the contributing factors to that airway compromise, it is not usually the first step in the dysphagia evaluation.  Most clinicians depend on a clinical assessment as the first piece in the diagnostic puzzle.  However, the information from a clinical assessment is only as useful as the instruments we choose to use.  The quality of the clinical assessment establishes the reliability and validity of the information gained from the assessment.

Elements of a Quality Assessment

There are three basic elements of quality for any assessment:

1. Reliability
2. Validity
3. Standardization.

Reliability is the measure of an assessment’s consistency and there are four types to consider:

1. inter-rater reliability: measure of agreement between different raters describing/scoring the same instrument
2. test-retest reliability: measure of a test’s consistency when given at two different points in time
3. parallel-forms reliability: measure of a test’s consistency as compared to another measure designed to test the same construct(s)
4. internal consistency reliability: measure of the consistency of items within a test

Validity is a measure of an assessment’s usefulness.  There are two types of validity to consider for test measures:

1. content-related: establishes that the assessment has appropriate content with face validity (the assessment measures what it says it measures) and construct validity (the assessment relates to underlying theoretical concepts)
2. criterion related: establishes the assessments relationship to similar measures, if other measures exist.

Finally, standardization provides a mean (average) and standard deviation (spread) of assessment scores for the target population.  For the clinical assessment to be meaningful, clinicians must use tools that provide reliable and valid results, which necessitate administering the assessment in a standardized way.

Experts in pediatric dysphagia have reported on the basic elements of a clinical assessment.  These include medical, developmental, and feeding history, parent/child interactions during meals, child positioning during feeding, use of specialized feeding equipment, child’s level of alertness and communication during mealtimes, signs/symptoms of oropharyngeal dysphagia, assessment of oral structure and function, cranial nerve exam, oral feeding skills, and food selection/preferences (Arvedson, 2008; Bell & Alper, 2007; Dodrill & Gosa, 2015; Piazza, 2004).  However, selecting the specific clinical test/tool that may be used to evaluate any of these elements is up to the individual clinician and there are a myriad of tools available.  Two recent systematic reviews identify and describe the psychometric rigor of common clinical assessment tools for pediatric dysphagia assessment (Benfer, Weir, & Boyd, 2012; Heckathorn, Speyer, Taylor, & Cordier, 2016).

State of Current Clinical Assessments

In a review of clinical measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities, nine oropharyngeal dysphagia assessments tools were identified (Benfer et al., 2012).  Of those nine tools, The Schedule for Oral Motor Assessment (SOMA) and the Dysphagia Disorders Survey were found to be the most comprehensive measures with good clinical utility and strong psychometric evidence of reliability and validity (Benfer et al., 2012).  The SOMA is an observation-based assessment for infants and children 0-2 years of age that requires formal training for appropriate use.  The DDS is also an observation-based assessment for children with developmental disability aged 2-21 years that requires formal training for appropriate use.  The SOMA is no longer in publication and training is no longer being offered for this tool.  In contrast, investigation continues into the psychometric properties and clinical usefulness of the DDS and it is recognized as reliable and valid tool for identifying and describing swallowing and feeding disorders in individuals with developmental disabilities (including cerebral palsy) from 2-21 years of age (Sheppard, Hochman, & Baer, 2014).  Training for use of the DDS is offered periodically through Nutritional Management Associates.

In a second, systematic review of clinical swallowing and feeding assessments for use with pediatric populations, not just children with cerebral palsy, authors identified 30 assessments that are published or described in the literature as clinical, pediatric swallowing and feeding assessments (Heckathorn et al., 2016).  Of the 30 identified assessments, instruction for scoring and interpreting the assessment was available for only 20% (6) of them.  The six assessments that provided instructions for scoring were the Mealtime Behavior Questionnaire (MBQ), the Oral Motor Assessment Scale (OMAS), the Pre-Speech Assessment Scale (PSAS), the Pediatric Assessment Scale for Severe Feeding Problems (PASSFP), the Schedule of Oral Motor Assessment (SOMA), and the Screening Tool of Feeding Problems, modified for children (STEP-Child).  A summary of the clinical features of these tools is provided in Table 1.

Table 1

This systematic review did not assess the psychometric rigor of the reported instruments, but it did note the apparent lack of information regarding reliability, validity, and standardization of the majority of clinical assessment tools available for clinically assessing pediatric feeding and swallowing problems (Heckathorn et al., 2016).  Of the instruments reported above, there was at least initial psychometric information reported on the MBQ, OMAS, PASSFP, SOMA, and STEP-Child (Berlin et al., 2010; Crist, Dobbelsteyn, Brousseau, & Napier-Phillips, 2004; De Oliveira Lira Ortega, Ciamponi, Mendes, & Santos, 2009; Seiverling, Hendy, & Williams, 2011; Skuse, Stevenson, Reilly, & Mathisen, 1995).

Application to Current Clinical Practice

So, what is a clinician to do in the face of limited clinical assessments, many of which may not be appropriate for the feature of oropharyngeal feeding and swallowing skill that a clinician may be interested in and/or have not been validated on the population of children seen in a practice?  First thing to do, consider the clinical populations served by the facility where you work.  What are the age ranges served and what are the diagnoses (prematurity, cerebral palsy, etc…) most common amongst the clients served?  Then, take inventory of how the facility currently performs clinical feeding and swallowing assessments.  Do all of the clinicians in the facility use the same tools?  Are the tools used reliable, valid, and/or standardized for the age ranges and clinical populations served by the practice?  If not, then go to the literature to determine if there are psychometrically validated tools available.

A search within PubMed is free and will provide at least a summary (abstract) of the articles of interest.  If you work within a medical teaching facility, you might have access to a medical library and can request the full version of the articles of interest.  Similarly, if you serve as a clinical supervisor for students, the student can access the article of interest through their library.  In addition to the systematic reviews referenced in this article, there are three others that offer insight into currently available oral motor feeding assessments, infant oral motor feeding assessments, and assessment tools for oral feeding in infants younger than six months (Barton, Bickell, & Fucile, 2017; Bickell, Barton, Dow, & Fucile, 2017; Pados, Park, Estrem, & Awotwi, 2016).  If no tool with psychometric rigor is available, then consider the untested tools currently used in your facility and begin to document the reliability and validity of those tools.  Consider incorporating a quality improvement process within your facility to standardize the way in which clinical feeding and swallowing assessments are conducted to ensure a consistent standard of care within the facility.

Finally, when presented with new clinical assessment tools, evaluate them critically.  Ask questions—what is the evidence of reliability and validity for the tool you are learning about?  What age ranges and populations was the tool tested with and does this match the age ranges and populations served by your facility?  Once you know the answer to these questions, then you can make an informed decision about whether to incorporate it into practice.  In this way, clinicians will be assured that they are providing pediatric clinical swallowing and feeding assessments that are of the highest quality available to them and that their assessments provide accurate and useful information about potential swallowing and feeding disorders in our youngest patients.

References

Arvedson, J. C. (2008). Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev, 14(2), 118-127. doi:10.1002/ddrr.17

Barton, C., Bickell, M., & Fucile, S. (2017). Pediatric Oral Motor Feeding Assessments: A Systematic Review. Physical & Occupational Therapy in Pediatrics, 1-20.

Bell, H. R., & Alper, B. S. (2007). Assessment and intervention for dysphagia in infants and children: beyond the neonatal intensive care unit. Semin Speech Lang, 28(3), 213-222. doi:10.1055/s-2007-984727

Benfer, K. A., Weir, K. A., & Boyd, R. N. (2012). Clinimetrics of measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities: a systematic review. Developmental Medicine & Child Neurology, 54(9), 784-795.

Berlin, K. S., Davies, W. H., Silverman, A. H., Woods, D. W., Fischer, E. A., & Rudolph, C. D. (2010). Assessing children’s mealtime problems with the Mealtime Behavior Questionnaire. Children’s Health Care, 39(2), 142-156.

Bickell, M., Barton, C., Dow, K., & Fucile, S. (2017). A systematic review of clinical and psychometric properties of infant oral motor feeding assessments. Dev Neurorehabil, 1-11.

Crist, W., Dobbelsteyn, C., Brousseau, A. M., & Napier-Phillips, A. (2004). Pediatric assessment scale for severe feeding problems: validity and reliability of a new scale for tube-fed children. Nutr Clin Pract, 19(4), 403-408.

De Oliveira Lira Ortega, A., Ciamponi, A., Mendes, F., & Santos, M. (2009). Assessment scale of the oral motor performance of children and adolescents with neurological damages. J Oral Rehabil, 36(9), 653-659.

Dodrill, P., & Gosa, M. M. (2015). Pediatric Dysphagia: Physiology, Assessment, and Management. Ann Nutr Metab, 66 Suppl 5, 24-31. doi:10.1159/000381372

Heckathorn, D.-E., Speyer, R., Taylor, J., & Cordier, R. (2016). Systematic review: non-instrumental swallowing and feeding assessments in pediatrics. Dysphagia, 31(1), 1-23.

Pados, B. F., Park, J., Estrem, H., & Awotwi, A. (2016). Assessment Tools for Evaluation of Oral Feeding in Infants Less than Six Months Old. Advances in neonatal care: official journal of the National Association of Neonatal Nurses, 16(2), 143.

Piazza, C. C. C.-H., T.A. (2004). Assessment and Treatment of Pediatric Feeding Disorders Encyclopedia on Early Childhood Development (pp. 1-7). Montreal, Quebec: Centre of Excellence for Early Childhood Development (CEECD).

Seiverling, L., Hendy, H. M., & Williams, K. (2011). The screening tool of feeding problems applied to children (STEP-CHILD): Psychometric characteristics and associations with child and parent variables. Res Dev Disabil, 32(3), 1122-1129.

Sheppard, J. J., Hochman, R., & Baer, C. (2014). The dysphagia disorder survey: validation of an assessment for swallowing and feeding function in developmental disability. Res Dev Disabil, 35(5), 929-942.

Skuse, D., Stevenson, J., Reilly, S., & Mathisen, B. (1995). Schedule for oral-motor assessment (SOMA): methods of validation. Dysphagia, 10(3), 192-202.