Addressing the Unique Mealtime Needs of Students in Public School Setting

Addressing the Unique Mealtime Needs of Students in Public School Setting

Kristi Phillips is a speech language pathologist employed by Wake County Public School System, the 15th largest school district in the nation.  In 2015, she co-founded a centralized Feeding Team with April Suddarth, Lead speech language pathologist. The Feeding Team has grown to 3 full time SLPs, 2 part time PTs, and 4 part time OTs.  They also have a medically fragile nurse specialist and Registered Dietician available for consultation as needed. 

There is a lot of confusion around the topic of how to address the needs of students with dysphagia in the school setting.  Comments I have heard since beginning work on this team include:

We don’t do that in the school setting

School SLPs are not trained in dysphagia

Dysphagia is medical, not educational, it should be addressed by a private therapist

OTs should do it all

SLPs should do it all

Nurses should do it all

I decided to work for the schools so I would not have to do dysphagia

What about the liability

What if a student chokes

Educational Relevance?

Is it educationally relevant to address dysphagia in the school setting?  ASHA says it is.  Our team considers the following guidance from ASHA when considering educational relevance:  

• Students must be safe while eating in school including having access to appropriate personnel, food, and procedures to minimize risks for choking and for aspiration while eating.
• Students must be adequately nourished and hydrated so that they can attend to and fully access the school curriculum.
• Students must be healthy (e.g. free from aspiration, pneumonia, or other illnesses related to malnutrition or dehydration) to maximize their attendance at school.
• Students must develop skills for eating efficiently during meals and snack times so that they can complete these activities with their peers safely and in a timely manner.
  http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965&section=Assessment

Developing your Feeding Team
Because pediatric dysphagia is a specialty that not all SLPs have pursued, school districts should consider forming an Interdisciplinary Feeding Team comprised of competent clinicians.  When forming a Feeding Team, consider the following:

1. Identify your resources:
   1. Identify related service providers in your school system who are clinically competent in pediatric dysphagia.  If there are none, identify people willing to learn/train and simultaneously identify outside consultants who can help in the interim.  Aim for at least 1 SLP, OT, PT, and nurse who will form the core team.
   2. Identify administrative personnel who can assist with policy and procedural decisions.  Providing medical services in an educational setting requires partnership and collaboration among medical and administrative personnel.
   3. Identify medical resources in your community, including medically based Feeding Teams, inpatient feeding programs, dieticians, ENTs, and gastroenterologists.
   4. Research other school systems who have already implemented processes to address unique mealtime needs and dysphagia.
2. Identify Student Needs:
   1. Determine which students have dysphagia/unique mealtime needs and create a database.
   2. Gather information about student needs from a variety of sources including: parents, caregivers, classroom instructional staff, medical providers, and related service personnel.
   3. Obtain a diet order/medical statement for all students who have dysphagia.
   4. Determine what inventory you will need: e.g. liquid thickener, therapy materials, adaptive equipment.  Establish a budget.
3. Meet Student Needs: 
   1. Create a Feeding Plan for each student with dysphagia.  This plan should document dysphagia diet, liquid viscosity, compensatory strategies, behavioral & environmental modifications, adaptive equipment needs, seating and positioning needs, general aspiration precautions, and an emergency action plan in case of choking. 
   2. Update Feeding Plans whenever new information is available or needs change.
   3. Create procedures for delegating Feeding Plan implementation.  Who will be responsible for safety monitoring the student during meals?  Who will train staff to do it?  What kind of mealtime data will be collected and how?  Who will provide fidelity checks and oversight?  Who will provide adaptive equipment?
   4. Develop procedures with School Nutrition Services to provide modified diets appropriately.
   5. Create a referral and evaluation process to address safety concerns and to update Feeding Plan information.  Who will gather additional information/evaluate if there is a concern about a student’s safety or ability to be adequately nourished at school?
   6. Develop transition procedures.  Plan to re-train staff when staff changes occur.  Prepare to support students when they are at summer programs or on field trips or off-campus activities.
   7. Create procedures for developing direct IEP goals.  What are your criteria for determining if direct goals are appropriate and educationally relevant?  Who will create and implement the goals?  How will progress be documented?

Professional Development
Consider how your Feeding Team will obtain and or maintain clinical competence in pediatric dysphagia.   ASHA states on the Practice Portal:  “Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children. An understanding of adult anatomy and physiology of the swallow may provide a good basis for understanding dysphagia in children; however, additional knowledge and skills specific to pediatric populations are needed. As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be educated and appropriately trained to do so.” (https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965&section=Roles_and_Responsibilities)

Resources we have used for developing procedures specific to the school setting:

Webinars:

• Demystifying Swallowing and Feeding in the School Setting (Emily Homer, ASHA)
• Table Manners: Ethics and Building a Feeding Team (Jennifer Meyer, CEU Espresso.com)

Procedural Guidelines from other school districts

• https://douglasesd.k12.or.us/sites/douglasesd.k12.or.us/files/File/rsoi/feeding-students-in-educational-programs-april.pdf
• https://portal.ct.gov/-/media/SDE/Special-Education/feeding_and_swallowing.pdf

Articles:

• Legal and Financial Issues Associated With Providing Services in Schools to Children With Swallowing and Feeding Disorders Lissa Power-deFur Longwood University, Farmville, VA,  Nancy S. N. Alley Richmond, VA
• Ethical Issues in Providing Services in Schools to Children With Swallowing and Feeding Disorders,  Nancy P. Huffman Churchville, NY DeAnne W. Owre Woonsocket School System, Woonsocket, RI
• Establishing a Public School Dysphagia Program: A Model for Administration and Service Provision, Emily M. Homer St. Tammany Parish Schools, Covington, LA
• Family and Cultural Issues in a School Swallowing and Feeding Program, Elise Davis-McFarland Trident Technical College, Charleston, SC

Clinical coursework we have used to develop competency in pediatric dysphagia:

• Pediatric Feeding: CAN-EAT Approach, Krisi Brackett, M.S., CCC-SLP
• Beckman Oral Motor Assessment and Intervention, Debra Beckman, MS, CCC-SLP
• St. Joseph’s Pediatric Feeding & Swallowing Approach
• Improving Oral Motor Functioning in Pediatric Feeding Disorders, J Dahms, M.S., CCC-SLP, BCS-S
• SOS (Sequential-Oral-Sensory) Approach to Feeding, Kay Toomey, Ph.D and Erin Ross, Ph.D., CCC-SLP
• Understanding the Complexities of Pneumonia from Aspiration, John R. Ashford, Ph.D., CCC-SLP
• Managing Pediatric Feeding Difficulties, Pamela Dodrill, PhD, CCC-SLP

What’s next for me?  I have the following 2 trainings on my personal wishlist:  

• Feeding Therapy, It’s Not Just About Swallowing, Melanie Potock, MA, CCC-SLP
• The TR-eat™ Model, Elizabeth Clawson, PhD and Carol Elliott, OTR/L

Kristi Phillips, M.S., CCC-SLP

Feeding Specialist, Wake County Public School System

kphillips2@wcpss.net