Dysphagia Team in the Public Schools

62 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 31 • 62–75 • January 2000 © American Speech-Language-Hearing Association

0161–1461/00/3101–0062

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LSHSS

Clinical Forum

ABSTRACT: This article describes the development of aschool-based dysphagia team (swallowing action team[SWAT]) within the St. Tammany Parish School Systemlocated in Covington, Louisiana. The team’s vision was toensure safe nutrition and hydration for students at risk forswallowing dysfunction during school hours. This articleaddresses how the team was initially formed, the processof identifying students who were exhibiting a swallowingdisorder, steps taken for staff development, and problemsencountered in seeking administrative approval. Thecurrent status of the dysphagia program, as well as futureplans for further implementation, are also presented.

KEY WORDS: pediatric dysphagia, interdisciplinaryteaming, IDEA, IEP, professional liability, nutrition,assessment

Development of an InterdisciplinaryDysphagia Team in the Public Schools

Emily M. HomerCheryl Bickerton

Sherry HillLisa Parham

Darlene TaylorSt. Tammany Parish Schools, Covington, LA

he role of the speech-language pathologist inthe public school is constantly changing. Asthe scope of practice in the field of speech-

language pathology has expanded to include dysphagia, theschool-based clinician’s recognition of students withpotential swallowing problems has increased (AmericanSpeech-Language-Hearing Association [ASHA], 1992).

Dysphagia, or dysfunctional swallowing, is common inchildren with severe cerebral palsy and multiple disabilities.It can also occur in at-risk neonates and children with avariety of neurological deficits and structural abnormalities.

Dysphagia may be characterized by dysfunction in oral,pharyngeal, and esophageal phases of the swallow. Duringoral feedings, children with dysphagia are at risk foraspiration, defined as the entry of material into the airwaybelow the level of the true vocal folds (Arvedson, Rogers,Buck, Smart, & Msall, 1994).

Medically fragile children are attending publicschools, resulting in the need to identify and treatassociated swallowing disorders. Because of expandingknowledge, speech-language pathologists and occupa-tional therapists in educational settings are now in theposition to identify students who exhibit swallowingdisorders, make appropriate medical referrals, and followthrough with subsequent interventions. Such interventionsmay include consultation, therapeutic techniques, andtraining of staff and caregivers.

As speech-language pathologists and occupationaltherapists in St. Tammany Parish Schools became moreinformed about the diagnosis and management ofswallowing disorders, the pattern emerged of a numberof students in the system displaying signs and symptomsof dysphagia. Because state guidelines for identifyingstudents eligible for special education and relatedservices do not specifically address dysphagia, thesestudents had not been previously evaluated for thisproblem. Written procedures needed to explain theidentification, screening, and evaluation of students hadnot yet been developed by the school system. Concomi-tant findings validated the urgency of the need to

Homer et al.: An Interdisciplinary Dysphagia Team 63

develop these procedures. For example, 50% of studentsunder 17 years of age who aspirate do so silently(Logemann, personal communication, March 27, 1998).This could indicate that some of our students werepossibly, and even probably, aspirating at school. Noclear guidelines currently existed as to the amount ofaspiration that could be tolerated by an adult or childbefore complications, such as aspiration pneumonia,arose (Logemann, 1998). Logemann further reported thatthe symptoms of dysphagia included, but were notlimited to: “the inability to recognize food; difficultyplacing food in the mouth; inability to control food orsaliva in the mouth; coughing before, during, and/or aftera swallow; frequent coughing toward the end or immedi-ately after a meal; recurring pneumonia; weight losswhen no other reason can be defined; and gurgly voicequality” (pp. 3–4).

In addition, optimal nutritional status is a vitalhealth requirement for all children, but is of specialconcern for those who exhibit neurologically based orphysiologically induced oral-motor deficits. Consistentprovision of adequate calories, protein, and fluid helpsto optimize growth and development of the child, whichis essential for the learning process to occur. Problemswith feeding or swallowing, if not recognized early,may rapidly result in malnutrition and growth failure(Arvedson & Brodsky, 1993). Therefore, the primaryconcerns within the school system include the mainte-nance of adequate nutrition and hydration, as well assafety of the student during oral feeding. Because allstudents eat at least one meal a day in school, andsometimes two, the concern for safe oral intake is asignificant component of these students’ school day.Prior to development of the swallowing team, there wasno set procedure for addressing these issues.

As a result of these concerns, the development of aschool-based swallowing team was felt to be crucial for theidentification and management of students at risk for oral-motor dysfunction and swallowing issues. The purpose ofthis article is to describe the evolution of the St. TammanyParish Dysphagia Program to serve as a potential model foradoption by other school systems.

VISION OF THE DYSPHAGIA TEAM

A team of professionals trained in dysphagia was formedto design procedures that would ensure safe nutrition andhydration for the students during school hours, whilesimultaneously protecting the professionals who work withthese students. The seven goals were to accomplish thefollowing: (a) identify students at risk, (b) refer parents tophysicians with specific recommendations, (c) immediatelyimplement an emergency plan for children who are “atrisk” for dysphagia, (d) evaluate the student, (e) participatein a modified barium swallow study (MBS), when recom-mended, (f) design and implement a treatment plan, and (g)develop compensatory strategies for safe swallowing whenappropriate.

PROGRAM DEVELOPMENT

Phase I: Team Formation

In spring 1997, the St. Tammany Parish Speech-Language-Hearing Program initiated discussions with theoccupational therapy department regarding formation of acommittee to address dysphagia in the schools. At thispoint, the occupational therapists were working withstudents who had feeding disorders and oral-motor prob-lems associated with feeding; however, they were notaddressing swallowing disorders. Both disciplines agreedthat our school system needed a structured program toaddress swallowing issues. The assistant coordinator of theSpeech-Language-Hearing Program discussed the need forprogram development with special education administrators.The administration was receptive and requested that a teamof speech-language pathologists, occupational therapists, andnurses collaborate to design a program and then submit awritten plan for approval to adopt system-wide. Personnelwho had experience in dysphagia were asked to volunteerfor this project. The committee, consisting of eight speech-language pathologists, three occupational therapists, and twonurses, adopted the name Swallowing Action Team (SWAT).

The first meeting was held in June 1997 to share ideas,concerns, and possible solutions among possible teammembers. Concerns were discussed at length and docu-mented. Table 1 outlines questions and issues pertaining tothe procedures, training, personnel, and liability issues thatwere identified during this meeting and later served asstepping stones for program development. The collaborativegoal for the summer months was to explore the Internetand professional journals in an effort to locate other schoolsystems that already had an established dysphagia programin operation that could be used as a model.

When the team reconvened in the fall of 1997, memberswere disheartened to learn that summer research had beenin vain. The team was unable to locate any school systemswith a dysphagia program in place. In fact, most of theschools contacted indicated that they were reluctant toventure into this area of service. It was decided to design aprogram, but to continue to investigate other sources forguidance and professional input. The assistant coordinatorof the Speech-Language-Hearing Program was designatedas the SWAT chairperson due to easy accessibility to higheradministration personnel. During the 1997–1998 schoolyear, the chairperson’s responsibilities included the follow-ing: (a) scheduling team meetings, (b) notifying principalsin writing that the SWAT members would be attendingthese meetings, (c) sending written reminders to the teammembers, (d) setting the agenda, (e) summarizing minutesfrom prior meetings, and (f) making revisions and copies offorms and guidelines between meetings.

SWAT met monthly for 2 hours at the same location.Team members formed subgroups and each subgroup wasassigned an area of concern from Table 1 to explore andcompile possible ideas or solutions. Each subsequentmeeting consisted of all team members analyzing thejudgements and findings of each subgroup and discussing

64 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 31 • 62–75 • January 2000

practical implementation for SWAT program development.Several specific issues were discussed during consecutivemeeting dates. These included legal responsibilities ofschool-based clinicians, criteria for requesting an MBSstudy, and the development of a protocol. Approval of ourrequest for an MBS study to be completed was critical.Results of the MBS study would serve to rule out aspira-tion and identify specific swallowing abnormalities in thestudents felt to be at risk. It would also provide informa-tion to determine whether modifications of texture, consis-tency, position, or oral stimulation could be used to protectthe airway, maintain oral feeding status, or facilitatedysphagia therapy.

Although more frequent planning sessions would havebeen a better scenario to expedite program development, itwas difficult to accommodate the schedules of all of thepersonnel involved. An agenda was prepared in advance sothat the team meetings were focused on the specified areas

to be addressed. Meeting dates were alternated betweenWednesday and Friday afternoons to conform with alreadyestablished planning times for speech-language pathologistsand occupational therapists, respectively. However, ifplanning conflicted with scheduled intervention assign-ments, team members were required to reschedule anystudent sessions canceled. Because it was already difficultto coordinate meetings with the three participating disci-plines, a decision was made that other related personnel,such as dietitians and social workers, would be consultedas needed throughout program development.

Phase II: Identification and InitialManagement of Students at Risk

The first goal was to establish a process to identifystudents at risk for swallowing disorders. To begin, we

Table 1. Concerns identified at the onset of dysphagia program development.

Procedural Personnel Training Liability

1. How can we identify potentialstudents at risk?

2. Swallowing diagnostic issues arenot currently part of the PupilAppraisal Services according toLouisiana guidelines.

3. Can students receive dysphagiaservices if they are ineligible forspeech and/or occupationaltherapy?

4. IEP objectives to address specifictreatment for dysphagia areneeded.

5. How can we obtain a neededmedical history regarding feedingand swallowing?

6. How can we obtain MBS referrals,when needed, from a physician?

7. Who will order the video studies?Who will pay for the studies?

8. What local facilities are equippedto perform studies and what is thecost?

9. What protocols are needed forreferrals, screening, evaluations,and tracking.

There is no professionalliability insurance.

There is a limited knowledgeof school board and unionsupport/coverage.

Physician orders are neededfor evaluation and treatment.

What personnel have adequatetraining?

Failure to recognize apotential swallowing problemand initiate appropriateintervention may result inliability issues.

Input from the school boardattorney is needed.

Does the school systemcontinue to feed a studentwhen aspiration is suspectedand the family refuses torelease medical information?

What are the criteria fordetermining sufficient trainingin dysphagia for school-basedclinicians?

Is the school system respon-sible for a student’s safety ifthe parents refuse recommen-dations?

There is a lack of dysphagiatraining in the school system.

How can we educate the schoolsystem on dysphagia and itsterminology?

Essential personnel are nottrained in CPR.

Individualized emergency plansdo not address choking.

How can we train casemanagers on dysphagiaprocedures?

Who will organize and fund thetraining?

All school caregivers, such asclassroom teachers, paraprofes-sionals, and cafeteria monitors,need to be educated.

The responsibility for imple-mentation of the recommenda-tions is unclear to parents andteachers.

Who will educate family andschool-based personnel onstrategies and safety issues?

Role delineation of the speech-language pathologist andoccupational therapist.

Nursing involvement isneeded, although personnel aremore limited in number.

Swallowing issues are notincluded on the medical intakehistory.

Personnel are hesitant toaddress dysphagia.

Who will follow up on thereferrals that are received?

Who will attend the videostudies?

What is the referral criterionfor a video study?

Who might serve as the “datacoordinator?”

Who will initially contact theparents regarding swallowingconcerns addressed at school?


reviewed the Louisiana Department of Education, PupilAppraisal Handbook, Bulletin 1508 (Louisiana Departmentof Education, 1993). This publication describes the processused by pupil appraisal services in the State of Louisianato identify children eligible for special education andrelated services. Developed in compliance with the Louisi-ana legislation regarding the implementation of programsfor exceptional children, the handbook includes procedures,standards, criteria, and rights of students and parents.

Reviewing Bulletin 1508, the team found that neitherswallowing disorders nor dysphagia were specificallymentioned in the state guidelines. Because dysphagia is notconsidered as either an exceptionality or a criteria foreligibility of exceptionality, no state guideline or procedureexisted to identify students at risk. However, the teamrealized that students at risk for swallowing disorders mightexhibit characteristics of other impairments recognized inBulletin 1508, such as speech, language, and motor impair-ments. The decision was made, therefore, to survey speech-language pathologists and occupational therapists in theschool system regarding their present caseload of students.The purpose was to determine the number of students who,potentially, might be at risk for swallowing disorders.

To accomplish this task, a broad survey was developedconsisting of a checklist for clinical symptoms of dysph-agia. Each student on the caseload of a speech-languagepathologist or occupational therapist was observed for: poororal-motor functioning, pocketing of food after meals,coughing/choking during meals, history of swallowingproblems, weight loss or malnourishment, repeated respira-tory infections, and so forth (Appendix A). All 92 speech-language pathologists and 11 occupational therapists withinthe school system were surveyed. A SWAT meeting wasthen held to review the returned surveys. Results indicatedthat, of the 2,800 students receiving speech-languagetherapy or occupational therapy, 75 (3%) were identified tobe at risk for potential dysphagia or aspiration.

A speech-language pathologist or occupational therapistteam member was then designated as a case manager foreach identified student. Case managers were assigned fourto eight students to assess and determine informally if thesestudents were at risk for swallowing dysfunction. Atracking form was designed to facilitate follow-up ofstudents for all case managers. This form included thename of the student, school, and school-based clinician, aswell as the date and results of initial consultation.

Based on the information gathered from the surveys andobservations of the student by the case manager, the teamdecided that crisis management was needed for severalstudents immediately because they exhibited symptoms suchas weight loss, choking during meals, recurrent fever, andrespiratory infections, as well as significant oral-motordeficits. For these emergency students, the SWAT membersfelt that immediate action should be taken to ensure theirsafety even though our procedures were not yet fullydeveloped or approved by the administration.

Team members, including speech-language pathologists,occupational therapists, and nurses, maintained constantcontact with each other and the administration while slowlyworking through the process of: (a) establishing an emer-

gency plan, (b) informing parents of the concern and theneed to obtain a release of medical information, (c)conferencing with the students’ parents and physician, (d)attending the recommended MBS, and (e) designing atreatment plan specific to the individual needs.

There were at least four problems encountered by theSWAT members during crisis management.

• need to arrive at a determination of role delineationfor each discipline,

• need to inform partents of the expertise of school-based professionals to identify or address swallowingdysfunction,

• need to address parental denial that a swallowingproblem existed and the impact that dysfunctionalswallowing might have on the child, and

• need to reassure parents when an unfamiliar profes-sional is making decisions concerning their child.

Phase III: Development of Process, Protocol,and Documentation Methods

Through the interdisciplinary team approach—thecombined expertise of occupational therapists, speech-language pathologists, and nurses—the process of crisismanagement laid the groundwork for efficient programdevelopment regarding students in the school system whowere yet unidentified. Many modifications were necessarydue to working through the experience of crisis manage-ment, reviewing the issues and concerns identified on Table1, and considering the problems mentioned in Phase II.However, an outcome was a flowchart that considered allconcerns (see Figure 1).

The agreed-on process, outlined on the flowchart,requires that the referral form (Appendix A) be completedby the school-based clinician or occupational therapist onany student who exhibits swallowing difficulties. Then, asthe flowchart in Figure 1 displays, this referral is for-warded to the SWAT coordinator for assignment of a casemanager from the SWAT members. The school-basedclinician or occupational therapist then notifies the parentsof their concern and the request for a consultation with aSWAT member and inquires into feeding and swallowingconcerns at home. The school-based clinician usually hasalready established rapport with the parents. This relation-ship seems to be preferable in contrast to someone whomay be unfamiliar to the parents. The case manager thenschedules and completes an interdisciplinary consultationwith the school-based clinician and occupational therapist.This is a “hands-off” observation of the student’s behaviorsduring eating, drinking, and routine swallowing at school(see Appendix B). Based on the findings of the consulta-tion, the school administration (principal) is contacted andmade aware of the concerns.

The SWAT member then informs the teacher to schedulean individualized education plan (IEP) conference. Thisconference includes the teacher, speech-language patholo-gist, occupational therapist, nurse, parent, and schooladministrator. At this meeting, the emergency plan is


reviewed and signed by the parent (see Appendix C).Medical information is requested from the parents in orderfor the team members to have access to or analyze anyprevious swallowing diagnostic information (Appendix D).Permission to send and receive medical information isobtained, and an MBS study, special diet, and positionalrecommendations are then discussed. A feeding andswallowing plan is written on the IEP for immediateimplementation for those students considered to be at risk.This is a temporary plan pending the results of a bedsideevaluation or MBS. School personnel are then trained inimplementing emergency and treatment procedures.

Following the IEP meeting, the student’s physician isfaxed or mailed a copy of the release of information along

with a physician’s letter and input form to be completed(Appendices E and F). These forms are used to inform thephysician of the purpose of SWAT and the specific signsand symptoms that were observed during the consultationwith recommendations for further medical input. Theserecommendations may include a swallow study or specificchanges in diet consistency.

The administration asked SWAT members to revise thephysician input form. In the revision, the team wasrequested to simply state that a problem was observed andto ask the physician what, if any, recommendations wereindicated. The dysphagia team met again and the proposedrevisions were discussed. The team members felt stronglyabout the necessity of making specific recommendations to

Figure 1. Swallowing disorders procedure.

Referral form is completed by the school-based speech-language pathologist/occupational therapistand is sent to the dysphagia coordinator for assignment of a case manager.

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The school-based speech-language pathologist informs the parent of the concern and that a dysphagia team member will be consulted.

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Interdisciplinary consultation, which is a “hands-off” observation of student’s feeding and swallowing behaviors, is conducted.

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An IEP meeting is scheduled and conducted; includes teacher, speech-language pathologist,occupational therapist, nurse, parents, and school administrator.

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An emergency plan is discussed and signed.

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A release to send and receive medical information is signed by the parent at the meeting.

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MBS, special diet, and positional recommendations are discussed.

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A feeding/swallowing plan is written for immediate implementation; once the MBS is completed, the plan may need to be adjusted.

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Following the IEP, school personnel are trained on the emergency and treatment plans.

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Medical information is requested and an input letter and form are sent to the physician.

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Bedside evaluation is completed at the school (if ordered by physician).

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MBS is set up (if requested by physician); case manager attends the study.

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The school dietician is notified and diet orders are implemented.

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Therapy feeding guidelines and a swallowing treatment plan are developed.

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The IEP is developed based on the revised feeding/treatment plan.

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School personnel and parents are trained in the feeding/treatment plan.

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The feeding/treatment plan is initiated.

▼

The dysphagia team monitors the case on a monthly basis.


the physician. The administrators did not understand thedisorder and the role that the speech-language pathologistor occupational therapist played in diagnosing dysphagia inmedical and clinical settings. The main concern was that,without these written recommendations on the form, thephysician may not have understood the risk involved withthe students, resulting in inadequate orders for follow-upevaluation and treatment. The form was revised; however,not all requested changes were made. A compromise wasreached that was agreeable to both administrators andSWAT members (Appendix F).

The team understood that initially, physicians in the areamight need to become educated in the new process ofdysphagia identification within the school system; however,the team believed that, once this process had been in effect,physicians would come to understand the service beingprovided by the interdisciplinary dysphagia team in theschools and would feel comfortable making referrals basedon the observations of the school-based speech-languagepathologist, occupational therapist, and nurses.

Once the physician orders the MBS study, a SWATmember accompanies the student to the procedure. Whenall needed information is obtained, such as from a bedsideevaluation or an MBS study, a comprehensive treatmentprogram is designed using input from the school-basedclinician, occupational therapist, SWAT member, hospital-based speech-language pathologist, parent, and physician.This program may include changes such as positioning,postural, diet consistency, or compensatory strategies toensure safe nutrition and hydration intake. A qualifiedSWAT member trains all staff and family in appropriatetechniques (ASHA, 1990). In cases where the prognosis forsafe oral feeding is poor and the physician advises that apercutaneous endoscopic gastrostromy (PEG) tube beplaced, the school nurse will train the speech-languagepathologist, other team members, or family as necessary inaccord with the physician’s orders. Finally, the IEP isrevisited, updating the general student information sectionand adding goals and objectives for therapeutic interventionregarding swallowing dysfunction.

Phase IV: Inservice Education

To implement a child-specific treatment plan, theresponsibility would need to shift from the district-wideSWAT to school-based staff. Because many of the speech-language pathologists, occupational therapists, and nurses inthe school system had little or no knowledge about orexperience with swallowing disorders, it was evident thatthe system would need to provide education in this area.

To initiate the educational process, the Speech-Lan-guage-Hearing Program hosted an inservice workshoppresented by a nationally recognized authority on pediatricdysphagia. This workshop was mandatory for all speech-language pathologists in the school system. In addition, alloccupational therapists, physical therapists, and nurseswithin the system were invited to attend. To increaseregional awareness of swallowing disorders in children andour school system’s commitment to serve these childrenmore effectively, registration was open to all speech-

language pathologists and occupational therapists within thestate, as well as local pediatricians. This effort drew 100professionals from other work settings in the area andnetted funds for the purchase of needed equipment andsupplies for all students in the school system with specialneeds.

SWAT members were designated to attend two intensivecourses in New Orleans, Louisiana on the management ofdysphagia and the interpretation of radiographic swallowstudies given by a nationally recognized expert. Followingthe courses, SWAT members attending the courses sharedresearch findings and treatment techniques about dysphagiain the pediatric population. To educate the other staff,nurses participating on SWAT initiated sessions with otherschool nurses on the implementation of the new emergencyplan for choking.

Phase V: Seeking Administrative Approval

The chairperson of the SWAT committee met with thespecial education administrators to present the proposedprocess, protocol, and methods of documentation. Docu-mentation was presented for the definition of dysphagia,initial concerns, proposed solutions, and the team’s vision.The roles of the speech-language pathologists, occupationaltherapists, and physician in the diagnosis and treatment ofdysphagia were included. The administrators expressedenthusiasm about the development of this new program, butthey also had some questions and concerns for the schoolsystem’s attorney to answer. Primary concerns werewhether the school system was required by the Individualswith Disabilities Education Act (IDEA) to address swallow-ing disorders (or was swallowing strictly a medical issue)and whether the school system would incur the medicalcost of the MBS study. One administrator conveyed hershock that the team had the “audacity” to tell a physicianwhat tests were indicated.

Based on the dialogue with the administrators, sixquestions were prepared for the school system’s attorney toaddress.

1. Is the school system required by IDEA to addressswallowing problems?

2. If dysphagia has not been diagnosed, does a schoolsystem with knowledgeable professionals have aresponsibility to make the necessary referral fordiagnosis to ensure safe eating?

3. Is the school system financially responsible for anMBS study if it is determined that this medical test isnecessary?

4. If parents refuse to send a child for the MBS studyor, if the physician will not give the orders, then isthe system correct in not addressing the swallowing atschool, even though it has been determined that thechild may be at risk for aspiration? If not addressed,the student would then maintain the existing diet andthe dysphagia problem would not be included intherapeutic goals. If choking occurs at school or ifcomplications develop from recurring aspiration, areschool personnel liable?


5. If the physician agrees with diet recommendationsmade by the speech-language pathologist, but theparents do not agree, which options are thenappropriate?

a. Use recommended diet.

b. Use diet requested by parents.

c. Request that the parent feed the student at school.

6. How will the school board support the SWAT mem-bers regarding liability?

On September 22, 1998, the supervisor of specialeducation received a letter from the school board attorneystating that it was his legal opinion that school systemshave an obligation to evaluate all children with disabilitieswho are in need of special education and related services.Medical services and school health services are included asrelated services according to IDEA. Therefore, if a schoolsystem suspects that a child has a swallowing problem,which is a disability requiring special education and relatedservices, it is obligated to conduct an appropriate assess-ment, or to arrange for an assessment by an individual whois trained and qualified to do the assessment. When it isdetermined that an MBS study is necessary, then the schoolsystem would be responsible for payment or services wouldhave to be secured from another public agency thatallocates funds for such diagnostic services to children,such as the parish (county) or state Department of Health.

In the opinion of the school board attorney, whenparents refuse to follow through on recommendations of thedysphagia case manager, subsequent actions would need tobe decided on a case-by-case basis; however, the schoolsystem has an obligation to respond in the interest of thechild. School personnel must make reasonable and docu-mented attempts to secure parental cooperation. Reports ofhealth- or life-threatening situations should be directed tothe proper authorities. These steps ensure that the schoolsystem has taken appropriate steps to minimize the risk tothe child and, as a result, has reduced the system’s expo-sure to liability. The school system has an obligation todefend school personnel against lawsuits, which are basedon actions or omissions occurring during the proper courseand scope of their duties. (It should be noted that theresponses to these questions were based on the opinion ofone attorney and on Louisiana State guidelines, andregulations may differ from state to state.)

The response by the school board attorney gave theSWAT members the clearance they needed to proceed withthe execution of the established process and procedures. Inaddition to affirming the team’s vision, the attorney statedin the last paragraph of his letter that he commended theteam for its “innovative and proactive” approach taken indealing with the issue of swallowing disorders in theschools.

Phase VI: Plans for the Future

Developing plans and procedures for a dysphagiaprogram in the schools required an entire school year. Theyear focused on the development of the team, as well as

policies and procedures for addressing students potentiallyat risk for dysphagia. In the 1998–1999 school year,utilization of the flowchart procedures shown in Figure 1was initiated. SWAT continues to meet regularly to problemsolve, evaluate, and revise procedures and to providetraining for school personnel and parents. They offerdiagnostic and therapeutic support for the school-basedspeech-language pathologist and occupational therapist. Themembers of the team also serve as case managers and havedirect contact with both the speech-language pathologists inthe school and the students.

Next, a system will be established for tracking childrenwho need to be screened as well as those with knownswallowing problems. IEPs will be developed for childrenwith dysphagia and will include information relating to theuse of compensatory techniques, oral exercises, dietaryrestrictions, and use of adaptive equipment (Langley &Lombardino, 1991). Materials and supplies needed for oralmotor therapy and feeding will be purchased, such astoothettes, tongue depressors, nuk brushes, blow toys,rubber gloves, adaptive feeding equipment, food thickeners,and positioning equipment. School-based speech-languagepathologists and occupational therapists will providedysphagia therapy. Using an apprenticeship model, clini-cians with minimal training will be assisted by those whoare experienced.

Parents and school personnel will require child-specificinstruction and training on all precautions, compensatorytechniques, and use of adapted equipment to assist the childin safe and efficient eating. Some training proceduresrecommended by the team include actual demonstrations ofthe compensatory feeding techniques, written directions forboth parents and staff, as well as viewing of videotapedand narrated samples from MBS studies, depicting aspira-tion and therapeutic interventions, if possible. Theseprocedures will help parents and school-based personnel tounderstand the disorder more completely and the implica-tions of intervention. The more educated the caregivers areon swallowing disorders and treatment, the more successfulthe treatment may be.

Continued professional growth opportunities for allspeech-language pathologists in St. Tammany ParishSchools, featuring information on the diagnosis of swallow-ing disorders, therapeutic techniques, ethical issues, andcounseling of caregivers, will be available throughout theschool year. In conjunction with Southeastern LouisianaUniversity, a graduate-level course on dysphagia wasoffered within our school district in the fall of 1998 for allinterested school speech-language pathologists. The systemis in the process of working on plans for providingmembers of the school staff with training on cardiacpulmonary resuscitation.

As mentioned previously, Louisiana State Bulletin 1508currently does not include dysphagia as an exceptionality.This bulletin is being revised to reflect changes resultingfrom IDEA. The St. Tammany parish coordinator andassistant coordinators of the Speech-Language-HearingProgram will work with state department officials toincorporate dysphagia evaluation and service eligibilitycriteria into the revisions.


CONCLUSIONS

The St. Tammany Parish SWAT members have accom-plished much thus far; however, there is more work to bedone. Implementation of a successful dysphagia program isensuring that children will receive safe, adequate nutritionallowing them to make developmental and academic gains,thereby fulfilling their potential. Several of the studentstargeted for emergency intervention for swallowing prob-lems are now, as a result of intervention, stronger andbetter able to participate in their academic program due toincreased nutrition. Considering whether to adopt a SWATprogram within a school system is a challenging endeavor.The following seven suggestions may facilitate the processof adoption.

1. Do not assume that anyone knows what you aretalking about.

2. Maintain your vision, but be prepared to compromise.

3. Use the question “Is it best for children?” as a guideto decision-making.

4. Follow your system’s chain of command whenpresenting the concept of establishing a dysphagiateam. Prepare the following, written in lay person’sterms:

• definition of dysphagia

• summary of the concern/problem

• outline of the solutions

5. Have an idea of what this model will cost thesystem—but be ready to point out that this mayprevent future due process hearing.

6. Consider cost issues, such as:

• Personnel: Can the model be adopted with thepersonnel currently in the system?

• Training: How much will it cost to train personnelcurrently in the system?

• Videoflouroscopy/MBS: The school system will beresponsible for some of these tests. Medicaid orprivate insurance should cover the cost for most ofthese assessments.

• Materials for evaluation/therapy: Minimal costs willbe incurred for materials, such as toothettes, tonguedepressors, mirrors, and so forth.

7. Keep everyone involved informed throughout theprocess.

ACKNOWLEDGMENTS

The authors would like to express appreciation to the supervi-sors, administrators, and principals of St. Tammany Parish Schoolsfor their cooperation during the process of addressing the issues ofdysphagia in the schools. Appreciation is expressed to JudeyanneCoudrain, Elizabeth Duncan, Pamela Gaden, Maureen Larsen,Carol Negrotto, Donna Thomas, Roberta Torman, and SandyZeringue for their assistance with this project. The authors wouldlike to extend a special thanks to Jeri Logemann for her invaluablesupport and encouragement during the drafting of this manuscript.

REFERENCES

American Speech-Language-Hearing Association. (1990, April).Knowledge and skills needed by the speech-language patholo-gist providing services to dysphagic patients/clients. Asha,32(5), 7–12.

American Speech-Language-Hearing Association. (1992, March).Instrumental diagnostic procedures for swallowing. Asha,34(Suppl. 7), 25–33.

Arvedson, J., & Brodsky, L. (1993). Nutrition. In J. Arvedson &L. Brodsky (Eds.), Pediatric swallowing and feeding: Assessmentand management (pp. 157–208). San Diego, CA: Singular.

Arvedson, J., Rogers, B., Buck, G., Smart, P., & Msall, M.(1994). Silent aspiration prominent in children with dysphagia.International Journal of Pediatric Otorhinolaryngology, 28,173–181.

Langley, M. B., & Lombardino, L. J. (Eds.). (1991). Neuro-developmental strategies for managing communication disordersin children with severe motor dysfunction. Austin, TX: PRO-ED.

Logemann, J. (1998). Evaluation and treatment of swallowingdisorders (rev. ed.). Austin, TX: PRO-ED.

Louisiana Department of Education. (1993). Pupil appraisalhandbook [Louisiana State Bulletin 1508]. Baton Rouge, LA.Author.

Received September 21, 1998Accepted September 27, 1999

Contact author: Emily M. Homer, Assistant Coordinator Speech-Language-Hearing Therapy Programs, St. Tammany Parish Schools,Covington, LA 70433. Email: [email protected]


APPENDIX A. CASELOAD SURVEY/REFERRAL FORM

Please complete this form. If you have any students with the following characteristics, complete one form perstudent by checking the characteristics that apply. Note that if you do not have any students with thesecharacteristics, check the last statement on this list.

Student: _________________________________ School: ______________________ Teacher: ______________

Date of Birth: _________ Referral Source: __________________________________ Date: ________________

_____ Poor upper body control_____ Repeated respiratory infections/history of recurring pneumonia_____ Poor oral motor functioning_____ Receives nutrition through tube feeding_____ Maintains open mouth posture_____ Vocal cord paralysis_____ Drooling_____ Nasal regurgitation_____ Cleft palate_____ Food remains in mouth after meals (pocketing)_____ Coughing/choking during meals_____ Eyes watering/tearing during mealtime_____ Unusual head/neck posturing during eating_____ Requires special diet or diet modification (i.e. baby foods, thickener, soft food only)_____ Hypersensitive gag reflex_____ Reported medical history of swallowing problems_____ Weight loss/failure to thrive_____ Refusal to eat_____ History of head injury_____ Food and/or drink escaping from trach tube_____ Reflux (spitting up or vomiting)_____ Slurred speech

_____ I do not have any students with these characteristics on my caseload.

Additional Information or Comments:__________________________________________________________________________________________________

___________________________________________________________________________________________________

APPENDIX B. INTERDISCIPLINARY CONSULTATION

Student:_________________________________ Age:________ Date of Birth:__________________________Consultation Date:________________ Physician:___________________________________________________Diagnosis:________________ Exceptionality:_____________________ Case Manager:__________________Medical History:______________________________________________________________________________Present Diet:__________________________________________________________________________________Present positioning during meal:_________________________________________________________________School:_____________________________ SLP/OT:_________________________________________________

Intake questionnaire Yes No Unknown

Current nutritional intake adequateAlert and orientedVoluntary swallowing (on command)Cough, choking, gagging during mealIncreased time to eat“Wet” sound, cough/voice/breathGag reflexSpecific food avoidance behaviorsDiagnosed Oral Apraxia/vocal cord path.Hx frequent URI, pneumonia, BPDHx of cleftHx of dysarthriaChronic low grade feverMedical history of aspiration


Intake questionnaire Yes No Unknown

Hx prolonged intubation/tracheostomyNeurological impairmentPrevious hx of non-oral feedsFood allergiesTracheostomyPEG tube

General Observations

Behavior: ____ Cooperative _____ ResistantAlertness: _____ No Deficit _____ Partial Deficit _____Moderate Deficit _____ Severe DeficitFollows directions: _____ Verbal _____ Gestural _____ None ____ 1 Step _____ 2 StepVision: _____ No Deficit _____ Partial Deficit _____ Moderate Deficit _____ Severe Deficit

General Physical Observations

Abnormal reflexes: ____________________________________________________________________Trunk: ____Excessive Extension _____Dystonia _____Scoliosis _____Kyphotic _____ AsymmetricHead control: _____ Adequate _____ Poor_____ Receives external positioning _____Receives manual positioning_____ Reflexive position patterns _____ Excessive head/neck hyper extensionFacial: _____Asymmetrical _____Contortions _____Jaw extension _____ Grimaces/tics

_____ Open mouth posture _____ Increase tone _____ Decrease toneBreathing Patterns: _____ Mouth Breather _____ Audible inhalation

Observation of Feeding

Indicate functioning by checking (+) for adequate and (–) for inadequate for each food texture.

Liquid Puree Soft Solid+ – + – + – + –

AcceptLip ClosureTongue MovementJaw MovementSwallowCough

During this assessment, patient was fed _________________ by whom ___________Positioning _____________________Equipment _______________________Observation:_____ Drooling _____ Excessive oral secretions _____ Cued Swallow_____ Poor oral hygiene _____ Residual food in oral cavity _____ Hoarse/wet voice_____ Food remnants on lips _____ Bites tongue/lips _____ Poor jaw control_____ Tongue thrust _____ Oral apraxia _____ Fatigues easily_____ Gagging _____ Coughing (>2x) _____ Delayed swallow_____ Increase clearing throat _____ Absence tongue lateralization

Comments:____________________________________________________________________________________________________________________________________________________________

Recommendations:

_____ 1. Parent Consult (Phone conference) _____ 3. Physician Contact_____ 2. Nursing Consult _____ 4. Received Physician recommendations _____ 5. Other: _________________________

Signature_________________________________________ __________________________________________Speech-Language Pathologist CCC-SLP Speech-Language Pathologist CCC-SLP

_________________________________________ __________________________________________Occupational Therapist (SWAT) Occupational Therapist (SWAT)


APPENDIX C. INDIVIDUALIZED HEALTH SERVICES PLAN FORSTUDENTS WITH SPECIAL HEALTH CARE NEEDS

Emergency Plan for School Year _____

Name of Student _________________________________________ DOB ____________Date _____________

Parent/Guardian _____________________________________________ Home Phone ____________________

Address ____________________________________________________________________________________

Emergency Numbers:

Parents/Guardian

Home ________________ Work __________________Car ___________________ Beeper _________________

Name/Phone Number _________________________________________ Relative? _______________________

Name/Phone Number _______________________________________ Relative? _______________________

Doctors _________________________________ # ___________________ Specialty _______________

_________________________________ # ___________________ Specialty _______________

Medical Conditions: _____________________________________________________________

Allergies: ______________________________________________________________________

Medications: (including those taken at home) _________________________________________

Major side effects: _______________________________________________________________

Emergency Plan for Choking

1. Difficulty noted: eyes watering, reddened face, difficulty vocalizing, hand to throat. Attempt Heimlichmaneuver if unable to cough. If still in distress, repeat. Observe results. If foreign object (food) seen inmouth, carefully do a finger swipe. If standing, mouth should face the floor if lying down, turn on side.TAKE EXTRA CARE NOT TO FURTHER LODGE FOOD IN THROAT!

2. Respiratory distress: bluish color around lips and nail beds. Loss of consciousness. Alert staff member tocall 911. Perform abdominal thrust, scan mouth, then attempt to ventilate. If unsuccessful, repeat.

REPORT CHOKING INCIDENT TO PARENT/GUARDIAN, DOCUMENT.

Parental Agreement

“I agree to the guidelines for emergency care stated above. If necessary, the school principal or alternate, orbus driver may have my child transported to the emergency room at __________________________hospitalor the nearest hospital and that I will be responsible for payment of emergency transport and care given.”

Signature of Parent/Guardian Signature of WitnessDate:_________________ Date:_________________


APPENDIX D. MEDICAL SERVICES

SHORT MEDICAL HISTORY

Name: ________________________________________________ Date: _______________________

Diagnosis: _____________________________________________________________________________

Allergies:

Medications (including reason for taking them and side effects):

Surgeries:

Diet:

Eating Disorder:

Swallowing/Choking Problem:

Has there been any previous testing as a result of suspected aspiration or swallowing difficulties?YES NO (Please include a copy of results of swallow study.)

Videofluoroscopy? YES NO If so, when?

Check medical treatments required:

Catheterization Tube or Button Feeding Tracheostomy Tube

Ventilator IV Therapy Seizure Monitoring

Developing/Motor Concerns:

Speech Concerns:

Brief medical history:

Date of Next Visit: ________________________

Physician’s Name (Please Print!):


APPENDIX E. SAMPLE PHYSICIAN’S LETTER

Date: ________________

Dear Dr. _________________,

Your patient _________________ was seen on consult for a possible swallowing disorder by the St. TammanyParish School Interdisciplinary Swallowing Team. This team consists of speech-language pathologists,occupational therapists, and registered nurses who work cooperatively to assess and devise treatment plans forparish students referred for swallowing concerns.

Your patient has been observed during school. Although a formal swallowing evaluation has not been done,we have enclosed the “Physician Input Form,” which highlights symptoms of possible aspiration found inyour patient. As a precautionary procedure we have, when appropriate, placed the student on an emergencyrestricted diet. Please review these concerns and your recommendations as indicated.

We are also requesting that you complete the enclosed medical history form that we will use as part of ourevaluation should an evaluation be indicated. It should be mailed along with a copy of the signed PhysicianInput Form to the case manager.

Thank you for your assistance. If you have any questions or would like to discuss this case further, pleasefeel free to contact the case manager at the number listed below.

______________________________Case Manager

______________________________Phone Number

__________________________________________________________________________________________Address


APPENDIX F. PHYSICIAN INPUT FORM

Date:____________________________ School: _________________________________________________

Student’s Name:______________________________________ Date of Birth:________________________

Dear Dr. ___________________,

Your patient was observed during speech and/or occupational therapy on __________ due to feeding andswallowing concerns. The clinical indication(s) of possible aspiration included:

_____ Changes in respiration rate _____ Reddening of the face_____ Coughing _____ Audible breathing_____ Oral residue _____ Gurgled vocal quality_____ Facial grimacing _____ Chronic low grade fever_____ Gagging _____ Pneumonia or history of it_____ Refusal to eat _____ Chronic, copious, clear secretions_____ Delay in swallowing _____ Questionable nutritional intake_____ Other: ___________________________

To ensure safe and adequate nutrition and hydration during school, we suggest a medical evaluation toinvestigate the need for a special diet, a “bedside” swallowing evaluation, a Modified Barium SwallowingStudy (Videoflouroscopy), etc. For further information, please contact the therapist(s) below.

Sincerely:

______________________________________ ________________________________________Speech-Language Pathologist CCC-SLP Occupational Therapist

_______________________ _______________________Phone # Phone #

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I recommend the following:

_____ Modified Barium Swallow/Videofluoroscopy_____ Interdisciplinary Swallowing Evaluation_____ Special Diet: _________________________________________________________________ Other: ______________________________________________________________________ Impressions: _________________________________________________________________ No recommendations at this time.

Physician’s Signature:__________________________________ Date: ___________________

2000;31;62-75 Lang Speech Hear Serv Sch Emily M. Homer, Cheryl Bickerton, Sherry Hill, Lisa Parham, and Darlene Taylor

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Dysphagia Team in the Public Schools