1. GUIDELINES FOR SPEECH LANGUAGE PATHOLOGISTS PROVIDING DYSPHAGIA SERVICES IN SCHOOLS

2. Definitions  Dysphagia - are feeding and swallowing disorders that occur in the mouth, pharynx, larynx and/or esophagus, indicating a delay and/or disorder in the development of eating/drinking skills. This includes difficulty with ingestion of food and liquid, saliva management, and taking oral medications  MBSS - Modified Barium Swallow Study (also known as Videofluoroscopy)-A radiographic evaluation(x-ray) where graduated thickened/textures are given orally, mixed with barium to provide visual information on swallowing competency.

3. ASHA Scope of Practice  ASHA (American Speech/Hearing Association) position statement 2001 of Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders SLPs play a primary role in the evaluation and treatment of infants, children, and adults with swallowing and feeding disorders Appropriate roles:  Clinical feeding and swallowing evals

4. Roles of SLPs related to feeding/swallowing disorders (ASHA)  Clinical feeding and swallowing evals  Instrumental assessments delineating structures and dynamic functions of swallowing  Defining abnormal swallowing anatomy and physiology  ID additional disorders in the upper aerodigestive tract and making referrals to med personnel  Recommendations about mgmt of swallowing/feeding disorders  Developing treatment plans  Providing treatment, documenting progress and determines approp dismissal criteria  Teaching/counseling individuals/careproviders on swallowing  Educating other professional  Advocating for services  Advancing the knowledge base through research

5. DYSPHAGIA IN THE SCHOOLS Draft guidelines from Division 13/16 (ASHA)  Due to changes in revisions of IDEA (2004) and Rehabilitation Act of 1973 (Section 504)- mandates services for health-related disorders that affect the ability of the child to access educational programs and participate fully.  Educational goal for children with special needs is to facilitate each child’s developmental potential, while maintaining adequate nutrition, hydration, and health to benefit the educational program

6. Working document (cont)  Children must receive nourishment and hydration, as well as medications, in a safe and timely manner.  Children who are undernourished due to swallowing and feeding problems cannot attend adequately to the learning environment, and consequently their performance at school could suffer.  Children will swallowing/feeding disorders may miss school more frequently than other children due to related health issues (repeated URI or pulmonary problems related to aspiration)

7. Working Document (cont)  Children who have difficulty managing saliva or resist toothbrushing due to sensory based disorders or autism spectrum disorders may have poor oral hygiene.  Children need to be efficient during regular educational meal/snack times – 30 minutes or less. Prolonged mealtimes are red flags. These mealtimes should be unstressful and pleasurable for the child and adult.

8. WHO IS A RISK?  Children with neurological deficits (e.g. cerebral palsy, MD, cranial nerve dysfunctions, TBI)  Children with cleft palate w/ or w/out cleft lip  Congenital  Enlarged tonsils/adenoids  Esophageal stricture/stenosis  Tracheostomy  Primary Global delays  MR/PDD  Behavioral issues  Complex medical issues  Gastrointestinal tract  Metabolic dysfunction  Renal disease

9. AT RISK COMPONENTS  A continuum of severity-all related to primary diagnosis, age and ability  Prognosis designators  Physiological  Behavioral

10. GENERALIZED PROBLEMS ASSOCIATED WITH FEEDING/SWALLOWING DISORDERS  Prolonged/stressful mealtimes  Coughing and throat clearing on saliva or when eating/drinking  Wet breath sounds or gurgly voice quality  Spillage of food and liquid from mouth  Drooling  Pocketing food  Swallowing solid food without chewing  Inability to drink from a cup  Multiple swallow per bite of food or sip of liquid  Effortful swallowing  Vomiting associated with eating and drinking

11. CONSEQUENCES FROM FEEDING/SWALLING DISORDER  Weight loss or lack of weight gain for age  Frequent respiratory illness resulting in reduced school attendence  Constipation/diarrhea/other gastrointestinal tract problems  Need for special strategies or distractions at mealtimes.

12. ANATOMY OF A SCHOOL BASED TEAM  ASHA states that the individual needs to hold the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) and abide by ASHA Code of Ethics incl. Principle of Ethics II, rule B, which states that “individuals shall engage in only those aspects of the profession that are within the scope of the competence, considering their level of education, training, and experience”

13. SCHOOL TEAM (CONT)  Survey conducted by ASHA indicated the 3 most frequently reported barriers to dysphagia management were: -liability concerns Proving educational relevance Self-reported lack of experience in dysphagia.  -not all programs address dysphagia in their curriculum-particularly in degrees conferred earlier  Observation and participation were not emphasized at many programs—therefore many CCC-SLPs do not have adequate instruction and experience in dealing with dysphagia

14. SLP REQUIREMENTS  ASHA’s Code of Ethics mandates SLPs must be competent in any area of service that they deliver (2003) Assessment/mgmt of swallowing and feeding disorders in children are sufficiently different from adult dysphagia to warrant different practice patterns and additional knowledge and skills. SLPs who manage swallowing and feeding in the schools are ethically bound to achieve and maintain confidence in this area of practice.

15. SCHOOL TEAM APPROACH  It is recommended that the school based team be comprised of a core team SLP-dysphagia case manager Parent nurse, OT or PT School administrator Cafeteria personnel

16. SCHOOL TEAM CONT)  Medical professionals outside the school system Physicians (pediatrician, gastroenterologist, neurologist, pulmonologist, physiatrist, ENT, radiologist SLP Dietition/nutritionist Psychologist OT/or PT

17. Recommended School Dysphagia Team Protocol  Optimum delivery of school-based services Referral process Parental notification and involvement IEP or 504 plan Individualized swallowing/feeding plan Individualized health plan (IHP) Process of securing physician clearance for clinical evaluation, diet, and prescriptive recommendations for instrumental and other medical assessments Therapeutic intervention Monitoring of feeding/swallowing status

18. Who pays for all this?  If recommended at ARD, the school district is required  Basic cost analysis (approximate) Radiographic study (MBSS) $79.00 Contracted SLP to administer and interpret results $125.00 Cost of food Medicaid is free Sometimes only a co-pay

19. RESPONSIBILITIES  SLPs do not have to feed the student every day. They can train others to implement the diet consistency and presentation.  SLPs need to train school personnel and caregivers on overall safe feeding and eating and how to look for signs of unsafe swallowing as well as how to safely feed

20. SCHOOL BASED TEAM RECOMMENDATIONS  Currently, Comal ISD has 3 trained and experienced SLPs in feeding and swallowing. Two others have had the education, but has not practiced or kept up with current information.  There are a total of eight CCC-SLPs in the district.  Training with professionals and continuing education is recommended by ASHA and Division 13.

21. Legal Requirements  Children are identified under the OHI eligibility due to the condition results in the child’s “limited strengths, vitality or alertness”  However, an IEP must be developed to address the plan  TSHA and Tx Dept of Health does not directly address this through their information, but refers to ASHA.  A malpractice can be filed due to misdiagnosis, incorrect or inadequate treatment, injuries from equipment, failure to refer and failure to obtain informed consent. However, it must be proven that an SLP failed to exercise a reasonable standard of care in his or her duties to the student.