“Michael” is entering the public school system at four years old with a diagnosis of spastic, diplegic cerebral palsy. Fortunately, the school district he is entering already has a plan in place for addressing its students’ swallowing and feeding needs.
Watch how the six steps of the district’s plan come together for an example of a comprehensive system-wide procedure you can implement in your own school district.
1. Review the Referral
Michael has very specific dietary requirements, such as pureed food that he does not need to chew. He drinks his liquids from a sippy cup or bottle. After a helper scoops his food on to a spoon, he is able to bring it to his mouth. He closes his lips when he swallows, and he also shows food preferences.
Michael’s referral form highlights the signs and symptoms of a swallowing and feeding disorder, which include:
- Weight loss/undernutrition
- Special diet modification
- Poor upper body control
- Poor oral motor functioning
- Unusual head/neck posturing during eating
- Slurred speech
- Mealtime lengths of more than 30 minutes
The swallowing and feeding team leader or case manager (frequently the speech-language pathologist) reviews the referral form. Upon review, the SLP identifies the following team members and includes them in establishing Michael’s plan:
- The SLP will address the oral dysphagia.
- The occupational therapist will address scooping and hand to mouth behaviors.
- The physical therapist will address head, neck, and upper body positioning during meals.
- The school nurse will monitor nutrition and weight changes.
Additionally, Michael’s classroom teacher, his paraprofessionals, the school administration, and the cafeteria staff are all part of the district’s “Students Eat Safely: Follow the Forms” team and will have their own parts to play in assisting Michael.
2. Involve Parents from the Beginning
Once the referral is complete, the school team has the task of gathering the necessary information to determine how to safely feed Michael at school. During this process, he will continue to eat the pureed diet that his mother packs for him.
Parents are essential team members in establishing safe feeding at school. The district team may not always agree with how the student is fed at home, so developing a good working relationship with the child’s parents or guardians from the beginning is important.
The SLP sends home the Parent Interview Form and sets up a time to discuss it with the parents. This interview provides important medical information and home-feeding practices. It also establishes a collaborative relationship with Michael’s parents.
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3. Information Gathering: The Interdisciplinary Observation
The team arranges a time to observe Michael eating his typical packed lunch. They also bring dissolvable textured foods such as saltine or graham crackers and yogurt melts to observe Michael’s chewing skills. This will help them determine the safest texture for Michael to eat at school that will be as close to a normal diet as possible. The team also observes Michael as he drinks the juice his mother provides and water.
From their observations, the team determines that Michael is beginning to develop some chewing skills. They find that he would benefit from a soft and moist (IDDSI) diet at school and that this diet would be safe. This diet modification and advancement is determined by the trial on the crackers and melts, foods that have minimal texture but require some chewing skills. Thin liquids are also determined to be safe.
Next, the team works to put the plan in place. The PT adjusts Michael’s position in his chair so that he is upright and supported during meals and fits him for head supports. The OT determines that Michael can drink safely and efficiently from a straw, resulting in increased intake of fluids at school. The OT also recommends an adapted spoon and scoop bowl to encourage Michael to self-feed.
4. Write the Swallowing and Feeding Plan
The SLP team leader writes Michael’s swallowing and feeding plan, including the recommendations of the district team following the referral, parent interview, and interdisciplinary observation.
Included in the plan are:
- Concerns regarding Michael’s swallowing and feeding
- Specific, clear, and brief information on his diet and food preparation, including the soft and moist diet with thin liquids
- Wheelchair positioning requirements such as head and side supports
- Required equipment, such as a curved toddler-sized spoon, scooping bowl, and straw
- One-on-one monitoring during all meals
- Bite pacing and the need to cue Michael to swallow before taking a new bite
5. Train Classroom Staff
Once Michael’s plan is established, the school team trains those who will be assisting Michael on how to safely feed him according to his swallowing and feeding plan. This includes his classroom teacher, his paraprofessional, and two back-ups, ensuring that there will always be someone on campus who is trained and familiar with Michael’s plan.
6. Develop an Ongoing Monitoring Schedule
Once Michael has a safe swallowing and feeding plan, his SLP sets up a bi-weekly monitoring schedule to:
- Talk to classroom staff and answer questions about Michael’s feeding
- Observe Michael eating at lunch, looking for any changes or concerns as well as proper implementation of the plan
- Share information about swallowing and feeding in general and Michael’s skills specifically
Since Michael is now beginning to develop self-feeding skills and lateralization when chewing, the SLP and OT assign therapy to work on functional feeding skills such as hand to mouth, scooping, tongue lateralization, and chewing. His feeding therapy is incorporated into his speech and OT therapy.
Thanks to this plan and all the clinicians and school staff involved, Michael is off to a great start in his school career. The adaptations made allow Michael to eat a diet that is more similar to his peers and better meets the nutritional needs of a growing child. Because the district already had an overall plan in place, developing Michael’s specific plan went smoothly, reducing stress and the possibility of mistakes, missteps, or missed opportunities.
- American Speech-Language-Hearing Association. (2007). Clinical Topics/Pediatric Dysphagia. Available from http://www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia.
- Arvedson, J. (2001). Pediatric clinical feeding and swallowing evaluation. Swallowing and Swallowing Disorders (Dysphagia), 10(2): 17-23.
- Handleman, J. (1995). Raising a child with developmental disability: understanding the family perspective. In Rosentthal, S., Sheppard, J., and Lotze, M. (Eds.), Dysphagia and the Child with Developmental Disabilities. San Diego: Singular Publishing Group, Inc.
- Homer, E. (2016). Management of Swallowing and Feeding in Schools. San Diego: Plural Publishing.
- Homer, E., Bickerton, C., Hill, S., Parham, L., & Taylor, D. (2000). Development of an interdisciplinary dysphagia team in the public schools. Language, Speech, and Hearing Services in Schools, 31: 62-75.