Collaboration Corner: Surviving Dysphagia in Schools

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(photo credit)

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:

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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:

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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.

Collaboration Corner: Rethinking the IEP: Making Language the Foundation of Academics

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Collaboration Corner is a new monthly column written for ASHAsphere by Kerry J. Davis, E.d.D, CCC/SLP.  Kerry will focus on different themes that involve collaborating with colleagues and other disciplines. Thank you Kerry for sharing your ideas with the ASHA community!

We welcome guest bloggers and columnists; if you’d like to write for ASHAsphere, please fill out a blogger application here.

I work in a totally inclusive school district as an inclusion speech-language pathologist. My caseload consists of the neediest students in the district. Those kids are simply fascinating to me. I work with the soup-to-nuts kids; kids with severe learning challenges, kids with social-emotional disabilities, kids who are nonverbal. You know the kids where you try and crawl inside their neurology and figure out how they perceive the world? These students push me to be a better clinician. More importantly, they make me want to think creatively on how to make public school and inclusion work for them.

All of my students participate in a general education classroom. Students attend their neighborhood schools and access their day with a host of academic supports. All of my students have goals that allow meaningful access to math, language arts, science and social studies. And here’s the funny part, while all of my students have communication disorders, I am working to eliminate the designated “speech and language” section of many students’ IEPs.

Imagine taking the speech and language section off of the IEP! I can sense the collective raising of eyebrows….

But here’s the deal. I believe that one of the best parts of being a speech-language pathologist is that opportunities for learning are never-ending. Language is everywhere. Bruner (1996) discussed the need to connect learning through meaningful interaction. People learn when they can relate new information with old information. Semantic-connections allow for learning. Language is the vehicle for that connection.

So let’s back up to the IEP. Why do we tend to compartmentalize language and communication to a single goal area? It is unnecessary, and dare I say…inappropriate.

Collaborative goal-writing

So perhaps we should rethink our approach. A student’s IEP is based upon the team’s recommendations.

Integrating language-based goals throughout the IEP also encourages team ownership. Distributing language-based objectives throughout the IEP underscores the connection between language and academics. For students who need extra repetition and meaningful practice across contexts, these collaborative efforts foster skill generalization. So how does that look in an IEP? Here are some ideas my school-based teams have used (as a part of measurable objectives of course):

Math:

  • Develop the concepts of less, more, some
  • Answering wh-questions related to quantity
  • Following directions in a recipe, including gathering appropriate tools and materials

Science:

  • Provide similarities and differences(feature/function/class) between target vocabulary words
    • simple machines
    • animals and habitats
    • weather
    • states of matter
  • Using temporal markers, will demonstrate understanding of  a plant/animal life cycle
  • Answering wh-questions related to non-fiction text and picture books

Social studies/geography:

  • Matching clothing with seasons
  • Using attributes to describe the weather
  • Identifying and answering personal and biographical information (town, street, school)
  • From a book or activity, answer who, where, what doing, and when questions related to other countries and communities

English Language Arts:

  • Answering wh-questions related to character, setting and supporting events
  • Using temporal markers to create a personal narrative from a photograph
  • Use a home journal template to retell a two activities of the day
  • From a photo, use adjectives to describe an event or activity
  • Sequence pictures representing events from a picture book

Independence:

  • Communicating self-advocacy,
  • Asking clarifying questions,
  • Following checklists related to daily routines,
  • Following 2-step group directions

Some words of advice

I’ve used these ideas with children who have a variety of skill abilities. I use these ideas with children who have moderate to severe cognitive and communication challenges. Many use high-tech assistive technology tools, to accomplish these goals. Others use fill-in-the-blank cut and paste activities. The key is to scaffold the concepts in a way that will be meaningful. This does not mean lowering the bar for learning, these means thinking about how to embed naturalistically these ideas throughout the school day. Checklists can be used as part of getting ready in the morning. Narrative writing may include templates and photographs, or writing a letter home at the end of the day. Sequencing can be used in “how-to” books, or describing the life cycle of a frog. Comparisons can be drawn between a student’s home, and the Native American Wetu. All of these examples connect language concepts and learning in a meaningful way.

Gather the expertise in your team members and make the IEP work for those students that challenge you; you will be better practitioner for it. Not every team will be ready for this change. Through thoughtful discussion, creative planning and patience, the shift may not be as hard as you think.

References:

Bruner, J. (1996). The culture of education. Cambridge, MA: Harvard University Press.

Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her area of interest includes augmentative alternative communication, and working with children with multiple disabilities and learning challenges. I welcome various perspectives and lively dialogue. 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.