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Jenna Sargent

Swallowing & Dysphagia: Research Paper


Fall 2015
Dysphagia in School Settings
Individuals, from infants to elders, can experience swallowing or feeding difficulties,
causing a need for treatment or management of dysphagia provided by a speech-language
pathologist (SLP). Treatment and management of dysphagia occurs in a variety of settings,
including schools. School-based SLPs provide services to students who were born prematurely
or have serious chronic illnesses and injuries, such as complex medical conditions, neurological
problems, craniofacial anomalies, or head injuries (Huffman & Owre, 2008; Lefton-Greif &
Arvedson, 2008). According to Lefton-Greif and Arvedson (2008), these children vary in their
manifestations of swallowing deficits and more generic feeding difficulties such as behaviorbased feeding problems, picky eating in the presence of adequate skills, and delayed
development of oral skills without true swallowing deficits (p. 237). In 2014, an American
Speech-Language-Hearing Association (ASHA) survey of school-based SLPs reported that 14%
of school-based clinicians provide services to students with dysphagia. SLPs have received the
appropriate education and experiences needed to treat and manage individuals with dysphagia.
A SLPs scope of practice includes providing services to individuals with dysphagia in
educational settings. This paper will examine the evaluation, management, and treatment of a
student with dysphagia by a SLP and dysphagia team within a school setting.
In regards to the treatment and management of dysphagia, SLPs are the most
knowledgeable profession within schools; therefore they should provide services to students with
dysphagia. Unfortunately, many school-based SLPs provide services in the absence of set
procedures or policies concerning the diagnosis of treatment of swallowing disorders in the
school setting (Homer, 2008, p. 177). Some professionals and school administrators believe

DYSPHAGIA IN SCHOOL SETTINGS


dysphagia is a medical issue rather than an educational one; therefore, the management and
treatment of it should not be the responsibility of a school system or carried out by a schoolbased SLP (Homer, 2008 & Bailey et al., 2008). According to ASHA (2010), IDEA supports
the need for dysphagia therapy when it affects educational performance. Conditions that
support the need for dysphagia management and treatment while at school include a) safety of
students while eating at school, b) adequate nourishment for students to attend to the curriculum,
c) students must be healthy to attend school, and d) the necessary skills to safely participate in
meals with peers and eat in a timely manner (ASHA, 2010).
While it is within the SLPs scope of practice to provide services regarding dysphagia in
the school system and it is supported by IDEA, several studies have found dysphagia
management in the schools to be complex and challenging for SLPs (Bailey et al., 2008 &
Homer, 2008). Research has suggested that SLPs have concerns about treating dysphagia in
schools due to limited knowledge, training, and experiences evaluating and treating children with
dysphagia (Bailey et al., 2008). Practicing without the knowledge and skills to provide services
to students with dysphagia in the school is a violation of AHSAs Code of Ethics; therefore,
SLPs should obtain the education and skills needed for pediatric dysphagia by attending
continuing education courses and observing experienced clinicians to become competent (Bailey
et al., 2008; Huffman & Owre, 2008).
School-based SLPs also feel they have little to no support to treat and manage dysphagia
from their schools administration, which is necessary for effective dysphagia management.
With administrative support, school districts should have a dysphagia protocol to follow, as well
as a service delivery model that emphasizes a team approach (Bailey et al., 2008). The team
approach should focus on the following goals: safe and effective eating methods across
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environments to promote generalization and adequate and safe nutrition and hydration while at
school (Bailey et al., 2008; Homer, 2008; Greif-Lefton & Arvedson, 2008).
To meet these goals, school districts need to develop procedures for dysphagia teams to
provide guidance in the identification and treatment of students with dysphagia. The guidelines
are meant for students with dysphagia to be fed safely and for team members to have the
knowledge and skills necessary to feed students with dysphagia in the school (Homer, 2008).
Communication and collaboration between school-based and medical-based teams is crucial so
that all health, development, and feeding issues are handled in ways that maximize each
students safety for oral [or tube] feeding and to facilitate the ability to participate fully in the
academic process (as cited in Huffman & Owre, 2008, p. 170; Lefton-Greif & Arvedson, 2008).
Both teams must work together for the student to swallow safely, because school-based teams do
not have access to medical instruments needed to determine if a child should be treated or not,
while hospital-based teams have limited access to their clients and must rely on school-based
teams to monitor the childs progress and report changes (Lefton-Greif & Arvedson, 2008).
School-based and medical-based teams must also constantly communicate with the childs
family. Addressing dysphagia in schools should be done through a system-supported
interdisciplinary team, such as a school-based team or system core team (Homer, 2008). The
model for a school system is chosen based on the number of students with dysphagia, the trained
professionals, and system policies (Homer, 2008).
The school-based team is made up of the following professionals: dysphagia-trained SLP,
occupational therapist, physical therapist, nurse, teacher, principle, paraprofessional, cafeteria
manager, and social worker. The SLP must be dysphagia-trained and competent in treating and
managing dysphagia in children, in order for a team to be school-based. Team members have the

DYSPHAGIA IN SCHOOL SETTINGS


benefit of frequently interacting with school staff and parents/guardians when needed, as well as
regularly monitoring students as they eat regular meals during school hours. The dysphagiatrained SLP of a school-based team will also work with the student to provide intervention to
improve oral motor skills and to teach the student compensatory strategies to aid in swallowing
(Homer, 2008).
A system core team, on the other hand, consists of a SLP, occupational therapist, and
nurse who specializes in dysphagia. These professionals travel to school sites to provide services
to students with dysphagia, because there is not a dysphagia-trained SLP already on site. This
team works in collaboration with school-based professionals and trains them how to follow the
swallowing and feeding plan and to report concerns and changes in the students skills related to
feeding and swallowing (Homer, 2008).
The dysphagia team works together to conduct an assessment within the school to
determine function and safety for oral feeding for a student (Lefton-Greif & Arvedson, 2008).
As cited in Homer (2008), the assessment and treatment of students with dysphagia in the
schools should address the primary physiological and sensory-motor issues as well as the
functional consequence of dysphagia (p. 183). The evaluation process begins with a review of
the students medical history, followed by observing the student during meal time to determine
signs of dysphagia, as well as to gain information on how to safely feed the student (Homer,
2008). School-based SLPs are at an advantage, as they are able to observe the student multiple
times eating and drinking in their typical everyday environment at school (Lefton-Greif &
Arvedson, 2008). While the student is eating, the dysphagia team should observe the following
a) the ability to perform the necessary components immediately before food enters the mouth, b)
the ability to adequately form a bolus, c) the ability to use the advanced skills of chewing,
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drinking, and self-feeding, d) the ability to initiate and complete a swallow for larger and more
viscous boluses, and e) the ability to manage a saliva bolus (Homer, 2008). A student may have
dysphagia if they present with rejection or limited intake of foods or liquids, increased
congestion while eating and drinking, coughing or choking during meals, a wet or gurgly voice
quality before or after swallowing, and excessive drooling (Lefton-Greif & Arvedson, 2008, p.
238). If the student does not appear to be safe while eating, student needs to be referred for an
instrumental evaluation to observe each swallowing phase: preparatory, oral, pharyngeal, and
esophageal. The results of a video-fluoroscopic swallow study (VFSS) will aid in the decision
making process and in developing appropriate intervention plans regarding the extent of oral
feeding, the appropriate textures and viscosity of foods and liquids, and appropriate
modifications in posture and position (Lefton-Greif & Arvedson, 2008).
Once the evaluation is completed, an IEP meeting is held to discuss a swallowing and
feeding plan to provide teachers and paraprofessionals with information needed to safely and
effectively feed the student. Following the plan, training in the management of eating and
drinking difficulties must be conducted with all team members, as well as staff members, who
will be involved in food preparation or feedings to ensure safety (Homer, 2008).
Intervention related to dysphagia may include providing information to the students and
their families about the nature of swallowing, communicating with medical providers throughout
treatment, training individuals on swallowing safety, and teaching the student, family members,
and school team members involved about the social-emotional relationship between dysphagia
and educational success (Lefton-Greif & Arvedson, 2008). All team members need to
understand how dysphagia affects a student in the school setting and how it affects their overall
attentiveness and participation in classes. Direct treatment and management will differ and need
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to be individualized for each student. Some students will benefit from therapy to improve oral
motor skills and work on compensatory strategies, while other students may only need to meet
once a week to monitor progress (Homer, 2008).
Swallowing and feeding difficulties can be experienced by the students on a SLPs
caseload in educational settings; therefore, a school-based SLP needs to know how dysphagia is
evaluated, managed, and treated in the schools. In 2014, 14% of school-based SLPs reported
they have a student with dysphagia on their caseload (ASHA, 2014). As this number continues
to grow, SLPs will need to be component and able to effectively manage students with dysphagia
on their caseload.

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Bibliography
American Speech-Language-Hearing Association. (2014). 2014 schools survey: caseload
characteristics. Available from http://www.asha.org/uploadedFiles/2014-Schools-SurveySLP-Caseload-Characteristics.pdf.
American Speech-Language-Hearing Association. (2010). Roles and responsibilities of speechlanguage pathologists in schools [Professional Issues Statement]. Available from
www.asha.org/policy.
Bailey, R., Stoner, J., Angell, M., & Fetzer, A. (2008) School-based speech-language
pathologists perspectives on dysphagia management in the schools. Language, Speech, and
Hearing Services in Schools. 39, 441-450. Doi: 10.1044/0161-1461(2008/07-0041).
Homer, E. (2008) Establishing a public school dysphagia program: a model for administration
and service provision. Language, Speech, and Hearing Services in Schools. 39, 177-191.
Doi: 10.1044/0161-1461(2008/018).
Huffman, N., & Owre, D. (2008) Ethical issues in providing services to schools to children with
swallowing and feeding disorders. Language, Speech, and Hearing Services in Schools. 39,
167-176. Doi: 10. 1044/0161-1461(2008/017).
Lefton-Greif, A., & Arvedson J. (2008) Schoolchildren with dysphagia associated with
medically complex conditions. Learning, Speech, and Hearing Services in Schools. 39, 237248. Doi: 10.1044/0161-1461(2008/023).

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