Action: School Services

Dysphagia Services in the Schools

Kathleen Whitmire

Originally published in "Action: School Services," by Kathleen Whitmire, 2000, Language, Speech, and Hearing Services in Schools, 31, pp. 99-101.  

This issue of Language, Speech, and Hearing Services in Schools (LSHSS) offers us the opportunity to examine the relationship of the schoolbased speech-language pathologist with children who have feeding and swallowing disorders. The juxtaposition of educational focus and medical needs, coupled with the relative recency of swallowing issues as a domain of our profession, has created uncertainty and confusion for many school-based speech-language pathologists regarding their role with these children, as well as concern about lack of training and preparation for dealing with these disorders.

The articles in this issue's clinical forum provide some excellent guidelines for developing and implementing school-based dysphagia services within the framework of federal and state educational laws and regulations. As a supplement to these articles, I have asked the American Speech-Language-Hearing Association's (ASHA's) Special Interest Division 13, Swallowing and Swallowing Disorders, to provide comments on dysphagia services in the schools. Following are thoughts from Rona Alexander and Joan Arvedson, members of DIV 13's steering committee who are also pediatric and childhood swallowing experts.

School-Based Services for Children With Feeding and Swallowing Problems

This issue of LSHSS gives school-based speech-language pathologists information that should be useful as they examine their roles in service to children with feeding and swallowing problems. As more and more of these children are attending public schools in integrated settings, speech-language pathologists are receiving requests from teachers, administrators, nurses, and others to assist with mealtime guidance.

It is likely that many children are being followed regularly for swallowing and feeding intervention. It is important that issues like scope of practice and knowledge base are all taken into consideration when speech-language pathologists are establishing their caseloads.

Scope of Practice

The Scope of Practice in Speech-Language Pathology states that the speech-language pathologist can provide screening, identification, assessment, diagnostic, treatment, intervention, and follow-up services for a variety of disorders (ASHA, 1996, p. 18). Swallowing and swallowing disorders are included as one of the areas of focus by practicing speech-language pathologists. However, as stated within the Scope of Practice, "It may not be possible for speech-language pathologists to practice in all areas of the field" (p. 16). An individual speech-language pathologist's competency in the area of swallowing and swallowing disorders, as well as limitations placed on practice in this area by state laws and other environment requirements/restrictions, could lead to the decision not to practice in a specific area within the field of speech-language pathology.

Individuals with Disabilities Education Act

The Individuals with Disabilities Education Act (IDEA) discusses speech-language pathology as both a related service and within special education. As a related service, speech-language pathology includes "developmental, corrective, and other supportive services ... as may be required to assist a child with a disability to benefit from special education ... and includes the early identification and assessment of disabling conditions in children" (section 602.22).

As part of special education, speech-language pathology services consist of "specially designed instruction, at no cost to the parents to meet the unique needs of a child with a disability, including instruction conducted in the classroom, in the home ... and in other settings" (section 300.26). The individualized educational program (IEP) team must decide, on an individual basis, (a) needs resulting from a disability that must be met to facilitate participation in the general curriculum, and (b) other needs resulting from the disability that must also be met. Therefore, a child with a diagnosis of feeding and swallowing disorders may require intervention for feeding and swallowing in order to participate in a public school setting where lunch is a typical activity. In that case, appropriate goals and objectives should appear on the IEP, with speech-language as one of the related services to address that need.

Early Intervention

Within early intervention programs, children from birth to 3 years of age with communication or swallowing disorders and delays can be receiving services from speech-language pathologists (ASHA, 1999, p. 5). This is supported by Part C of IDEA, in which early intervention services are defined as being "designed to meet the developmental needs of an infant or toddler with a disability in any one or more of the following areas: physical, cognitive, communication, social or emotional and adaptive development" [section 632(c)].

Schools

The Guidelines for the Roles and Responsibilities of the School-Based Speech-Language Pathologist have recently become available as a document from ASHA (1999). According to these guidelines, intervention for swallowing disorders may include the following activities:

• Provide information and guidance to students, families, and caretakers regarding the nature of swallowing and swallowing disorders.
• Consult and collaborate with medical providers throughout planning and intervention.
• Train caregivers and educational staff on safe eating and swallowing techniques.
• Instruct families, caregivers, and educators on the social-emotional relationship between feeding/swallowing and educational success.
• Facilitate the student's ability to efficiently chew and swallow more safely and more efficiently.
• Integrate swallowing function intervention with communication function intervention.

Although it is clearly stated that swallowing function as it is integrated with communication function is a primary focus for school-based speech-language pathologists, the guidelines do not suggest that speech-language pathologists in the schools should necessarily be conducting ongoing swallowing therapy, whether it is in terms of oral-motor practice for swallowing or other swallowing therapy techniques. The school-based speech-language pathologist will need to have a sufficient base of knowledge in feeding and swallowing to perform those responsibilities.

Knowledge Base

The school-based speech-language pathologist must have a foundation of knowledge in the areas of feeding and swallowing, as in all areas in which one practices. The Code of Ethics states that "individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience." (ASHA, 1994). That knowledge base allows speech-language pathologists to determine whether adequate clinical and, in some instances, instrumental assessments have been carried out appropriately for a child so that interpretation of the child's intervention needs in feeding and swallowing have been determined properly.

The foundation on which judgments regarding adequacy of assessment are made includes extensive knowledge and experience in multiple areas related to infants and young children in regard to their abilities to swallow safely. These areas of assessment include anatomy and physiology, development of oral motor and swallowing skills, cognitive and communication status, gross and fine motor development, related health issues (e.g., airway and gastrointestinal status), nutrition, and posture and positioning.

The school-based speech-language pathologist who questions the adequacy of prior swallowing and feeding assessments can request or conduct additional assessments to determine the safety of the child's current status. A comprehensive assessment of the child's function needs to be completed prior to determination of future intervention procedures. The safety of a child's swallowing function and/or the procedures needed to make feeding and swallowing safe for that child within the school setting must be delineated clearly. This is most important in relationship to the child who will be receiving lunch or snacks during the school day.

Roles in Training and Intervention

The school-based speech-language pathologist is not providing swallowing function treatment solely for the sake of feeding, but rather as a foundation integrated within communication function intervention. ASHA's Guidelines for the Roles and Responsibilities of the School-Based Speech-Language Pathologist make it clear that the speech-language pathologist must recognize the role that is to be played in training caregivers and staff for techniques to be used for safe eating and drinking during mealtime presentations.

The school-based speech-language pathologist may arrange for training those persons who will be feeding a child (e.g., classroom aides, teachers, and other trained staff members) regarding required procedures. The school-based speech-language pathologist will also need to be in close communication with the child's physician or medically based feeding clinic as well as the medical center or community-based speech-language pathologist who may be providing more specific medically based feeding and swallowing treatment intervention.

Children with feeding and swallowing problems have medically based problems in feeding and swallowing that transcend environments. The challenges to the speech-language pathologist vary in relation to settings in which services are provided for a specific child. Community-based speech-language pathologists, who a medical model in providing services, focus on the specific goals and strategies required to modify the child's feeding and swallowing function. They also assist in the development of appropriate mealtime strategies that do not interfere with nutritional intake, while supporting that intake is provided in the safest manner possible.

School-based speech-language pathologists play a very important role in integrating these needs into the child's educational setting, especially for meals provided during the day or at any time in which swallowing function interferes with or must be integrated with communication. We all have important roles to play in ensuring that a child is receiving the services that he or she needs when feeding and swallowing problems exist.

References

American Speech-Language-Hearing Association. (1994, March). Code of Ethics. Asha, 36(Suppl. 13), 1-2.

American Speech-Language-Hearing Association. (1996, Spring). Scope of Practice in Speech-Language Pathology. Asha, 38(Suppl. 16), 16-20.

American Speech-Language-Hearing Association Ad Hoc Committee on the Roles and Responsibilities of the School-Based Speech-Language Pathologist. (1999). Guidelines for the Roles and Responsibilities of the School-Based Speech-Language Pathologist. Rockville, MD:Author.