Promoting student safety and adequate nutritional intake are always the primary goals of a school-based dysphagia management program. Clinicians must be mindful that safety and nutrition should not be compromised in the pursuit of therapeutic advancement. It is also important, however, that practitioners have an understanding of therapeutic strategies, methods, and instructional tools for facilitating improvement in eating and swallowing skills. It is critical that SLPs obtain adequate education and training in evaluation and treatment of pediatric dysphagia in order to provide competent services in this area.

Service Delivery and Systems Change

Most practitioners are aware that dysphagia therapies traditionally have been provided in medical settings. For many SLPs, the required paradigm shift from provision of dysphagia services within a medical system to an educational system is a difficult adjustment to make. Educational settings offer unique challenges for SLPs, particularly for those whose prior dysphagia practice has been in medical settings. It is clear that comparatively fewer environmental supports, such as opportunities for consistent collaboration with medically trained experts and access to technical instrumentation, are available to SLPs providing school-based dysphagia services. This more limited support is one more reason why SLPs' education and training in pediatric dysphagia is so important. Therapeutic strategies, methods, and instructional tools chosen for individual students must also be practical for use in school environments.

Simple Strategies

The implementation of some simple and practically applicable strategies may increase the effectiveness of school-based dysphagia management programs. Descriptions of these strategies are based on the limited amount of available evidence related to school-based practice in dysphagia management and the authors' experiences in developing and managing school-based therapeutic programs for students with dysphagia. Most of these interventions are intended for use with students who are unable to follow the directions required for many of the skilled therapies often used with adults in medical settings (e.g., swallowing maneuvers). Instead, the focus is on simple interventions that may be implemented for students with severe and/or multiple disabilities who have limited ability to follow directions. Additional strategies, such as skilled dysphagia therapies and evidence-based instructional strategies, have been described elsewhere (e.g., Alberto & Troutman, 2005; Arvedson, 2000; Logemann, 2000; Wolery, Ault, & Doyle, 1992).

These strategies are offered as a broad overview, and are not applicable for use with every student. As in every aspect of educational or therapeutic programming, there is no single program that works for all students with dysphagia. A thorough assessment should be completed for each student by knowledgeable, trained clinicians and individualized therapeutic programs developed in collaboration with team members. Additionally, changes in programming must be made gradually, with careful monitoring of the effect(s) of a program change on each student's abilities and overall functioning.

Typically, a clinician should make one change at a time to a student's treatment programming to determine the effect of individual interventions. The outcomes associated with programming changes should be systematically observed and documented. Further recommendations for collaboration with team members to determine individualized school-based programs and implement program changes have been recently published (ASHA, 2007).

Sensory Enhancement Procedures

Sensory enhancement procedures have been reported as effective compensatory strategies for dysphagia treatment (Bisch, Logemann, Rademaker, Kahrilas, & Lazarus, 1994; Lazarus et al., 1993; Lazzara, Lazarus, & Logemann, 1986; Siktberg & Bantz, 1999) and are often included as one component of a therapeutic program for students with dysphagia. These simple modifications have been reported as effective in improving swallow physiology, specifically in improving awareness of the bolus and in decreasing oral onset and pharyngeal delay times.

The purpose of sensory enhancement procedures is to heighten awareness or alert the cortex and brainstem that a swallow is needed. Heightened awareness serves to facilitate the initiation of the oral swallow and the triggering of the pharyngeal swallow. Both the brainstem and the cortex are "sensory motor integration points, that is, moments when sensory information sent to the cortex and brainstem is recognized in the central nervous system (CNS) as a swallow stimulus and the resulting motor action is initiated" (Logemann, 2000, p. 51).

Sensory enhancement procedures (see sidebar above left) include activities such as heightening the taste, temperature, and viscosity of a bolus [for information related to modification of federally funded school nutrition programs see USDA Guidance Manual: Guidance for Accommodating Children with Special Dietary Needs in School Nutrition Programs [PDF] (2001)].

Self-Feeding

The importance of self-feeding to the development of improved oral-sensory and oral-motor skills has been suggested in recent literature. For example, Logemann (2000) explained that "the child's own hand-to-mouth coordination involved in bringing the food to the mouth also alerts the CNS to initiate oral activity for a swallow in response to the placement of food in the mouth" (p. 51). Arvedson (2000) also indicated the importance of self-feeding skills, stating, "Children who demonstrate sufficient postural support and hand-to-mouth skills to be self-feeders usually, but not always, have better coordination for safe swallow production" (p. 30).

Collaboration with occupational and physical therapy team members may be particularly helpful in developing programming to assist students with sufficient physical and cognitive abilities in progressing from dependent feeding to more independent self-feeding. If children fail to advance to self-feeding, guiding their hand movements to assist as needed may be helpful. Clinicians can provide daily practice with assisted self-feeding, using instructional strategies that have been shown to be effective for diverse learners along with positive reinforcement methods to encourage skill development. The amount of assistance can then be gradually reduced to help students advance in self-feeding.

To support development of self-feeding skills, clinicians can:

• Collaborate with physical and occupational therapists to determine the level of independence that students can safely achieve when eating and to determine optimal support strategies (e.g., verbal support, type and amount of physical support, or use of adaptive equipment). Occupational and physical therapists often provide additional individualized interventions toward improving hand-to-mouth, gross motor, and fine motor skills outside of mealtime that may also positively impact development of self-feeding skills.
• Use evidence-based instructional strategies for diverse learners with and without positive reinforcement strategies to systematically teach new skills (Wolery, Ault, & Doyle, 1992):
• Constant Time Delay is an instructional strategy for use with diverse learners. It involves a response-prompting procedure in which the clinician presents a target stimulus (i.e., holds spoon within a student's visual field and reach and provides a verbal cue, "Take"), then waits for a fixed amount of time before providing a controlling prompt (e.g., hand-over-hand assistance to take spoon and scoop food from a bowl). Clinician begins instruction with no time delay between stimulus and controlling prompt, then systematically increases the amount of time before the controlling prompt is delivered.
• Antecedent Prompt and Fade is a response-prompting procedure in which a prompt is presented (e.g., clinician holds picture of spoon and provides a verbal cue "take spoon"). If the student does not take the spoon, the clinician provides maximal assistance. As desired responses increase, cues are gradually faded at the clinician's discretion until the target stimulus (picture) initiates an independent response.
• A system of Most-to-Least Prompts provides maximal assistance and reduces assistance to the learner in a systematic way (based on learner response) until minimal to no assistance is given.
• Positive reinforcement of desired responses (verbal and/or sensory reinforcement that is gradually faded as evidence of learning is observed) should be used with these instructional strategies. Positive reinforcement often serves to increase the rate of skill acquisition.

Changing Feeding Patterns

When dependent feeding is necessary, an effective programming change may be to change the student's typical feeding patterns. Adjustments can be made in the presentation of foods and liquids to maximize students' strengths, avoid abnormal reflexes, facilitate improved oral movement patterns, and compensate for identified weaknesses. When chosen and implemented properly, these methods can optimize oral-sensory awareness and increase oral-motor control to maximize students' eating efficiency and swallowing skills.

Strategies for changing feeding patterns should be determined individually, based on an SLP's evaluation and feeding experiences with students.

An SLP could:

• Pace the meal. Use smaller meals but more frequent snacks for students who fatigue easily.
• Use a rhythmic (predictable) but slow rate of bite/sip presentation.
• Give a verbal cue to alert the student that the bite is being presented.
• Slow or alter the rate of food presentation to match the student's abilities.
• Use extra pressure to the tongue with spooning to increase sensory awareness and encourage muscle movement.
• Present the food on alternating sides, or on a specific side to improve acceptance, sensory awareness, or oral-motor skills.
• Present the food to the tongue without extra pressure, but wait for the lips to move around the spoon before withdrawing. This may facilitate improved lip closure and may decrease the presence of a bite reflex by avoiding stimulation of the jaw with spooning.
• Encourage occasional "dry" swallows to clear residue by icing a spoon to make it cold and presenting it empty with a verbal directive to swallow.

Postural Changes and/or Supports

Proper positioning and body stability are important to support a coordinated, stable swallowing mechanism. Typical eating positions have been described as upright at approximately a 90-degree sitting position with hips, knees, and ankles flexed and feet flat on a stable surface. The head is typically in midline of the body with the chin slightly flexed during feeding (Siktberg & Bantz, 1999). The arms and hands should be free to participate in self-feeding (Rosenthal, Sheppard, & Lotze, 1995).

It is important to stress, however, that no single position works best for all students. Individualized assessments should be completed in collaboration with physical and occupational therapists to determine each student's optimal position for eating. Assistive and adaptive positioning equipment may be used to maintain positioning at mealtimes. Straightforward and often inexpensive modifications can often be made for students using pillows, head rests, towel rolls, cushions, splints, and support straps.

Changes to position, which should be made incrementally and with careful documentation of their effect, may include:

• Use head supports or pillows to promote neutral chin or chin-tuck position. Chin-down position tends to narrow the entrance to the airway and may support safer swallowing.
• Provide a stable base of support at mealtimes. When possible, elbows should be supported to allow participation in self-feeding. Feet should be stable.
• Use adaptive positioning equipment such as shoulder straps, H-straps, butterfly harness, vest harness, head rests, positioning wedges, towel rolls, and/or pillows to stabilize optimal head and body positioning per assessment results.

It is often necessary to modify the interactions that occur between caregivers, students, and the school environment during mealtimes, as each of these interactions has a positive, neutral, or negative effect on outcomes. Efforts should be made to modify caregiver-student interactions and the environment as needed (see sidebar at right) to support students' optimal eating and swallowing skills.

Management of dysphagia is an educational priority because it threatens the academic, social, and emotional well-being of students with disabilities. Dysphagia can cause impaired health and nutrition, which clearly have an effect on a learner's ability to attend to instruction and participate in the learning process. It is critical that SLPs involved with school-based dysphagia management obtain adequate education and training in pediatric dysphagia.

A thorough, individualized therapeutic program should be developed for each student by knowledgeable, trained SLPs in collaboration with team members. Additionally, school personnel involved in management of students with dysphagia should actively engage students in the learning process and apply well-established instructional procedures that have been shown to be effective for teaching diverse learners.