According to ASHA (2006), 1 in 10 public school speech-language pathologists have a student with dysphagia. I have to be honest; this is a struggle for me. Here’s why: while I have extensive dysphagia experience in medical and private home-based settings, I have difficulty defining my role as an SLP who provides dysphagia therapy in school.
Identifying the obstacles
ASHA has a fairly clear document describing the role of the school-based SLP in schools. However, the perceived obstacles can be daunting (Miller, 2008). The top 4 obstacles consistently come across are: Scheduling and environment, training staff, keeping the lines of communication open between family, staff and outside therapists, and getting student buy-in.
Removing the obstacles
Miller (2008) urges collaboration in treating students with dysphagia. I have the good fortune to work with many talented special educators, nurses, behavior specialists. While I bring the knowledge of dysphagia to the table (bad pun), recognizing the daily demands upon the child requires team-based attention. The following strategies may help balance your student’s dysphagia issues within the context of the school day:
Examine/modify the child’s schedule. Students have very little time to eat. Snack is usually 15 minutes (if at all) and lunch is about the same with recess either before or after. This means students risk missing academic time, social time, recess. Suddenly speech is the no fun allowed zone; staff/students become worried that therapy cuts into these activities.
To help with this let the child start eating in the cafeteria before everyone else arrives, use calming strategies such as music with headphones, or a favorite book for the child to read while he/she is eating. Bring a lunch buddy if it helps. Gradually set limits around how much music she/he can listen to. If a child is too overstimulated during lunch time (elementary cafeterias are quite an experience), have the student eat early and let them read a book or chat with friends. This allows mealtimes to be associated with positive feelings.
Training staff. Many students have a paraprofessional, who also needs to eat their lunch, but guess when their student may need the most support? During lunch, of course. Keep clear instructions and provide hands-on training for staff, give a copy to the school nurse. If there is a change in staffing, make sure the change is with a familiar person who also has training. I have staff sit in on times that are not during their break or lunch. I also encourage the student’s paraprofessional to eat with the student as to “normalize” the experience and to provide role-modeling around food. We have Fun Friday where everyone eats together and we do a fun food play activity. Again, create positive associations with eating (for staff and students!). Staff need consistent access to strategies that will keep the student calm, like this cue card, created by my colleague and co-author of The Behavior Code:
Communicate closely with families. Eating is a cultural and emotional experience. Ongoing communication with family members provides insight as to when everyone is ready to move to the next step. Clearly communicate that safety is the most important factor in the decisions related to their child’s eating. Encourage parents to come in, or take pictures and video. Use a home-communication journal so notes can go between school and home, highlighting what they ate, how much they ate, and any events that may have affected their eating.
Communicating with outside SLPs. OK, so here’s the deal. Expertise exists across settings. If I don’t do VFSS on a daily basis, I recognize that I am not an expert in that assessment tool. But if I have a background in dysphagia, have worked in schools for 11 years, have seen this student 3 times a week in their school setting for three years, guess what? I have expertise as well. I can (and should) make a referral for a VFSS by an SLP who has the skill and equipment. Likewise, private SLPs should confer with the school-based SLPs perspectives on eating. Speech-language pathologists need to reach out to one another and value these differences. These differences are a good thing (stepping off of my soapbox now….).
Make the child a part of the process. Keep it low pressure, and rewarding. Take picture of their successes and make a book about it together. Have them review the book before they eat, so they remember their successes and eating strategies. Here’s a rather crude (but effective) example of a page I wrote with my student:
Last but not least, set aside your own assumptions of what tastes/feels/smells good….these kids experience food much differently than you do. Remember, eating involves developing trust; it is not a forced process. The end goal is to make eating pleasurable and safe so that mealtime becomes enjoyable for everyone.
Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are my own and do not represent those of my employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.