LSHSS

Clinical Forum

Development of an Interdisciplinary Dysphagia Team in the Public Schools

Emily M. Homer Cheryl Bickerton Sherry Hill Lisa Parham Darlene Taylor
St. Tammany Parish Schools, Covington, LA

he role of the speech-language pathologist in the public school is constantly changing. As the scope of practice in the field of speechlanguage pathology has expanded to include dysphagia, the school-based clinicians recognition of students with potential swallowing problems has increased (American Speech-Language-Hearing Association [ASHA], 1992). Dysphagia, or dysfunctional swallowing, is common in children with severe cerebral palsy and multiple disabilities. It can also occur in at-risk neonates and children with a variety of neurological deficits and structural abnormalities.

ABSTRACT: This article describes the development of a school-based dysphagia team (swallowing action team [SWAT]) within the St. Tammany Parish School System located in Covington, Louisiana. The teams vision was to ensure safe nutrition and hydration for students at risk for swallowing dysfunction during school hours. This article addresses how the team was initially formed, the process of identifying students who were exhibiting a swallowing disorder, steps taken for staff development, and problems encountered in seeking administrative approval. The current status of the dysphagia program, as well as future plans for further implementation, are also presented. KEY WORDS: pediatric dysphagia, interdisciplinary teaming, IDEA, IEP, professional liability, nutrition, assessment

Dysphagia may be characterized by dysfunction in oral, pharyngeal, and esophageal phases of the swallow. During oral feedings, children with dysphagia are at risk for aspiration, defined as the entry of material into the airway below the level of the true vocal folds (Arvedson, Rogers, Buck, Smart, & Msall, 1994). Medically fragile children are attending public schools, resulting in the need to identify and treat associated swallowing disorders. Because of expanding knowledge, speech-language pathologists and occupational therapists in educational settings are now in the position to identify students who exhibit swallowing disorders, make appropriate medical referrals, and follow through with subsequent interventions. Such interventions may include consultation, therapeutic techniques, and training of staff and caregivers. As speech-language pathologists and occupational therapists in St. Tammany Parish Schools became more informed about the diagnosis and management of swallowing disorders, the pattern emerged of a number of students in the system displaying signs and symptoms of dysphagia. Because state guidelines for identifying students eligible for special education and related services do not specifically address dysphagia, these students had not been previously evaluated for this problem. Written procedures needed to explain the identification, screening, and evaluation of students had not yet been developed by the school system. Concomitant findings validated the urgency of the need to

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develop these procedures. For example, 50% of students under 17 years of age who aspirate do so silently (Logemann, personal communication, March 27, 1998). This could indicate that some of our students were possibly, and even probably, aspirating at school. No clear guidelines currently existed as to the amount of aspiration that could be tolerated by an adult or child before complications, such as aspiration pneumonia, arose (Logemann, 1998). Logemann further reported that the symptoms of dysphagia included, but were not limited to: the inability to recognize food; difficulty placing food in the mouth; inability to control food or saliva in the mouth; coughing before, during, and/or after a swallow; frequent coughing toward the end or immediately after a meal; recurring pneumonia; weight loss when no other reason can be defined; and gurgly voice quality (pp. 34). In addition, optimal nutritional status is a vital health requirement for all children, but is of special concern for those who exhibit neurologically based or physiologically induced oral-motor deficits. Consistent provision of adequate calories, protein, and fluid helps to optimize growth and development of the child, which is essential for the learning process to occur. Problems with feeding or swallowing, if not recognized early, may rapidly result in malnutrition and growth failure (Arvedson & Brodsky, 1993). Therefore, the primary concerns within the school system include the maintenance of adequate nutrition and hydration, as well as safety of the student during oral feeding. Because all students eat at least one meal a day in school, and sometimes two, the concern for safe oral intake is a significant component of these students school day. Prior to development of the swallowing team, there was no set procedure for addressing these issues. As a result of these concerns, the development of a school-based swallowing team was felt to be crucial for the identification and management of students at risk for oralmotor dysfunction and swallowing issues. The purpose of this article is to describe the evolution of the St. Tammany Parish Dysphagia Program to serve as a potential model for adoption by other school systems.

PROGRAM DEVELOPMENT Phase I: Team Formation

In spring 1997, the St. Tammany Parish SpeechLanguage-Hearing Program initiated discussions with the occupational therapy department regarding formation of a committee to address dysphagia in the schools. At this point, the occupational therapists were working with students who had feeding disorders and oral-motor problems associated with feeding; however, they were not addressing swallowing disorders. Both disciplines agreed that our school system needed a structured program to address swallowing issues. The assistant coordinator of the Speech-Language-Hearing Program discussed the need for program development with special education administrators. The administration was receptive and requested that a team of speech-language pathologists, occupational therapists, and nurses collaborate to design a program and then submit a written plan for approval to adopt system-wide. Personnel who had experience in dysphagia were asked to volunteer for this project. The committee, consisting of eight speechlanguage pathologists, three occupational therapists, and two nurses, adopted the name Swallowing Action Team (SWAT). The first meeting was held in June 1997 to share ideas, concerns, and possible solutions among possible team members. Concerns were discussed at length and documented. Table 1 outlines questions and issues pertaining to the procedures, training, personnel, and liability issues that were identified during this meeting and later served as stepping stones for program development. The collaborative goal for the summer months was to explore the Internet and professional journals in an effort to locate other school systems that already had an established dysphagia program in operation that could be used as a model. When the team reconvened in the fall of 1997, members were disheartened to learn that summer research had been in vain. The team was unable to locate any school systems with a dysphagia program in place. In fact, most of the schools contacted indicated that they were reluctant to venture into this area of service. It was decided to design a program, but to continue to investigate other sources for guidance and professional input. The assistant coordinator of the Speech-Language-Hearing Program was designated as the SWAT chairperson due to easy accessibility to higher administration personnel. During the 19971998 school year, the chairpersons responsibilities included the following: (a) scheduling team meetings, (b) notifying principals in writing that the SWAT members would be attending these meetings, (c) sending written reminders to the team members, (d) setting the agenda, (e) summarizing minutes from prior meetings, and (f) making revisions and copies of forms and guidelines between meetings. SWAT met monthly for 2 hours at the same location. Team members formed subgroups and each subgroup was assigned an area of concern from Table 1 to explore and compile possible ideas or solutions. Each subsequent meeting consisted of all team members analyzing the judgements and findings of each subgroup and discussing

VISION OF THE DYSPHAGIA TEAM

A team of professionals trained in dysphagia was formed to design procedures that would ensure safe nutrition and hydration for the students during school hours, while simultaneously protecting the professionals who work with these students. The seven goals were to accomplish the following: (a) identify students at risk, (b) refer parents to physicians with specific recommendations, (c) immediately implement an emergency plan for children who are at risk for dysphagia, (d) evaluate the student, (e) participate in a modified barium swallow study (MBS), when recommended, (f) design and implement a treatment plan, and (g) develop compensatory strategies for safe swallowing when appropriate.

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

Procedural 1. How can we identify potential students at risk? 2. Swallowing diagnostic issues are not currently part of the Pupil Appraisal Services according to Louisiana guidelines. 3. Can students receive dysphagia services if they are ineligible for speech and/or occupational therapy? 4. IEP objectives to address specific treatment for dysphagia are needed. 5. How can we obtain a needed medical history regarding feeding and swallowing?

Personnel Role delineation of the speechlanguage pathologist and occupational therapist. Nursing involvement is needed, although personnel are more limited in number. Swallowing issues are not included on the medical intake history. Personnel are hesitant to address dysphagia. Who will follow up on the referrals that are received?

Training There is a lack of dysphagia training in the school system. How can we educate the school system on dysphagia and its terminology? Essential personnel are not trained in CPR.

Liability There is no professional liability insurance. There is a limited knowledge of school board and union support/coverage. Physician orders are needed for evaluation and treatment.

Individualized emergency plans do not address choking. How can we train case managers on dysphagia procedures?

What personnel have adequate training? Failure to recognize a potential swallowing problem and initiate appropriate intervention may result in liability issues. Input from the school board attorney is needed. Does the school system continue to feed a student when aspiration is suspected and the family refuses to release medical information? What are the criteria for determining sufficient training in dysphagia for school-based clinicians? Is the school system responsible for a students safety if the parents refuse recommendations?

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?

Who will attend the video studies? What is the referral criterion for a video study?

Who will organize and fund the training? All school caregivers, such as classroom teachers, paraprofessionals, and cafeteria monitors, need to be educated. The responsibility for implementation of the recommendations is unclear to parents and teachers. Who will educate family and school-based personnel on strategies and safety issues?

8. What local facilities are equipped to perform studies and what is the cost? 9. What protocols are needed for referrals, screening, evaluations, and tracking.

Who might serve as the data coordinator?

Who will initially contact the parents regarding swallowing concerns addressed at school?

practical implementation for SWAT program development. Several specific issues were discussed during consecutive meeting dates. These included legal responsibilities of school-based clinicians, criteria for requesting an MBS study, and the development of a protocol. Approval of our request for an MBS study to be completed was critical. Results of the MBS study would serve to rule out aspiration and identify specific swallowing abnormalities in the students felt to be at risk. It would also provide information to determine whether modifications of texture, consistency, position, or oral stimulation could be used to protect the airway, maintain oral feeding status, or facilitate dysphagia therapy. Although more frequent planning sessions would have been a better scenario to expedite program development, it was difficult to accommodate the schedules of all of the personnel involved. An agenda was prepared in advance so that the team meetings were focused on the specified areas

to be addressed. Meeting dates were alternated between Wednesday and Friday afternoons to conform with already established planning times for speech-language pathologists and occupational therapists, respectively. However, if planning conflicted with scheduled intervention assignments, team members were required to reschedule any student sessions canceled. Because it was already difficult to coordinate meetings with the three participating disciplines, a decision was made that other related personnel, such as dietitians and social workers, would be consulted as needed throughout program development.

Phase II: Identification and Initial Management of Students at Risk

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

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reviewed the Louisiana Department of Education, Pupil Appraisal Handbook, Bulletin 1508 (Louisiana Department of Education, 1993). This publication describes the process used by pupil appraisal services in the State of Louisiana to identify children eligible for special education and related services. Developed in compliance with the Louisiana legislation regarding the implementation of programs for exceptional children, the handbook includes procedures, standards, criteria, and rights of students and parents. Reviewing Bulletin 1508, the team found that neither swallowing disorders nor dysphagia were specifically mentioned in the state guidelines. Because dysphagia is not considered as either an exceptionality or a criteria for eligibility of exceptionality, no state guideline or procedure existed to identify students at risk. However, the team realized that students at risk for swallowing disorders might exhibit characteristics of other impairments recognized in Bulletin 1508, such as speech, language, and motor impairments. The decision was made, therefore, to survey speechlanguage pathologists and occupational therapists in the school 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 developed consisting of a checklist for clinical symptoms of dysphagia. Each student on the caseload of a speech-language pathologist or occupational therapist was observed for: poor oral-motor functioning, pocketing of food after meals, coughing/choking during meals, history of swallowing problems, weight loss or malnourishment, repeated respiratory infections, and so forth (Appendix A). All 92 speechlanguage pathologists and 11 occupational therapists within the school system were surveyed. A SWAT meeting was then held to review the returned surveys. Results indicated that, of the 2,800 students receiving speech-language therapy or occupational therapy, 75 (3%) were identified to be at risk for potential dysphagia or aspiration. A speech-language pathologist or occupational therapist team member was then designated as a case manager for each identified student. Case managers were assigned four to eight students to assess and determine informally if these students were at risk for swallowing dysfunction. A tracking form was designed to facilitate follow-up of students for all case managers. This form included the name of the student, school, and school-based clinician, as well as the date and results of initial consultation. Based on the information gathered from the surveys and observations of the student by the case manager, the team decided that crisis management was needed for several students immediately because they exhibited symptoms such as weight loss, choking during meals, recurrent fever, and respiratory infections, as well as significant oral-motor deficits. For these emergency students, the SWAT members felt that immediate action should be taken to ensure their safety even though our procedures were not yet fully developed or approved by the administration. Team members, including speech-language pathologists, occupational therapists, and nurses, maintained constant contact with each other and the administration while slowly working through the process of: (a) establishing an emer-

gency plan, (b) informing parents of the concern and the need to obtain a release of medical information, (c) conferencing with the students parents and physician, (d) attending the recommended MBS, and (e) designing a treatment plan specific to the individual needs. There were at least four problems encountered by the SWAT members during crisis management. need to arrive at a determination of role delineation for each discipline, need to inform partents of the expertise of schoolbased professionals to identify or address swallowing dysfunction, need to address parental denial that a swallowing problem existed and the impact that dysfunctional swallowing might have on the child, and need to reassure parents when an unfamiliar professional is making decisions concerning their child.

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

Through the interdisciplinary team approachthe combined expertise of occupational therapists, speechlanguage pathologists, and nursesthe process of crisis management laid the groundwork for efficient program development regarding students in the school system who were yet unidentified. Many modifications were necessary due to working through the experience of crisis management, reviewing the issues and concerns identified on Table 1, and considering the problems mentioned in Phase II. However, an outcome was a flowchart that considered all concerns (see Figure 1). The agreed-on process, outlined on the flowchart, requires that the referral form (Appendix A) be completed by the school-based clinician or occupational therapist on any student who exhibits swallowing difficulties. Then, as the flowchart in Figure 1 displays, this referral is forwarded to the SWAT coordinator for assignment of a case manager from the SWAT members. The school-based clinician or occupational therapist then notifies the parents of their concern and the request for a consultation with a SWAT member and inquires into feeding and swallowing concerns at home. The school-based clinician usually has already established rapport with the parents. This relationship seems to be preferable in contrast to someone who may be unfamiliar to the parents. The case manager then schedules and completes an interdisciplinary consultation with the school-based clinician and occupational therapist. This is a hands-off observation of the students behaviors during eating, drinking, and routine swallowing at school (see Appendix B). Based on the findings of the consultation, the school administration (principal) is contacted and made aware of the concerns. The SWAT member then informs the teacher to schedule an individualized education plan (IEP) conference. This conference includes the teacher, speech-language pathologist, occupational therapist, nurse, parent, and school administrator. At this meeting, the emergency plan is

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Figure 1. Swallowing disorders procedure.

Referral form is completed by the school-based speech-language pathologist/occupational therapist and is sent to the dysphagia coordinator for assignment of a case manager. M The school-based speech-language pathologist informs the parent of the concern and that a dysphagia team member will be consulted. M Interdisciplinary consultation, which is a hands-off observation of students feeding and swallowing behaviors, is conducted. M An IEP meeting is scheduled and conducted; includes teacher, speech-language pathologist, occupational therapist, nurse, parents, and school administrator. M An emergency plan is discussed and signed. M A release to send and receive medical information is signed by the parent at the meeting. M MBS, special diet, and positional recommendations are discussed. M A feeding/swallowing plan is written for immediate implementation; once the MBS is completed, the plan may need to be adjusted. M Following the IEP, school personnel are trained on the emergency and treatment plans. M Medical information is requested and an input letter and form are sent to the physician. M Bedside evaluation is completed at the school (if ordered by physician). M MBS is set up (if requested by physician); case manager attends the study. M The school dietician is notified and diet orders are implemented. M Therapy feeding guidelines and a swallowing treatment plan are developed. M The IEP is developed based on the revised feeding/treatment plan. M School personnel and parents are trained in the feeding/treatment plan. M The feeding/treatment plan is initiated. M The dysphagia team monitors the case on a monthly basis.

reviewed and signed by the parent (see Appendix C). Medical information is requested from the parents in order for the team members to have access to or analyze any previous swallowing diagnostic information (Appendix D). Permission to send and receive medical information is obtained, and an MBS study, special diet, and positional recommendations are then discussed. A feeding and swallowing plan is written on the IEP for immediate implementation for those students considered to be at risk. This is a temporary plan pending the results of a bedside evaluation or MBS. School personnel are then trained in implementing emergency and treatment procedures. Following the IEP meeting, the students physician is faxed or mailed a copy of the release of information along

with a physicians letter and input form to be completed (Appendices E and F). These forms are used to inform the physician of the purpose of SWAT and the specific signs and symptoms that were observed during the consultation with recommendations for further medical input. These recommendations may include a swallow study or specific changes in diet consistency. The administration asked SWAT members to revise the physician input form. In the revision, the team was requested to simply state that a problem was observed and to ask the physician what, if any, recommendations were indicated. The dysphagia team met again and the proposed revisions were discussed. The team members felt strongly about the necessity of making specific recommendations to

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the physician. The administrators did not understand the disorder and the role that the speech-language pathologist or occupational therapist played in diagnosing dysphagia in medical and clinical settings. The main concern was that, without these written recommendations on the form, the physician may not have understood the risk involved with the students, resulting in inadequate orders for follow-up evaluation and treatment. The form was revised; however, not all requested changes were made. A compromise was reached that was agreeable to both administrators and SWAT members (Appendix F). The team understood that initially, physicians in the area might need to become educated in the new process of dysphagia identification within the school system; however, the team believed that, once this process had been in effect, physicians would come to understand the service being provided by the interdisciplinary dysphagia team in the schools and would feel comfortable making referrals based on the observations of the school-based speech-language pathologist, occupational therapist, and nurses. Once the physician orders the MBS study, a SWAT member accompanies the student to the procedure. When all needed information is obtained, such as from a bedside evaluation or an MBS study, a comprehensive treatment program is designed using input from the school-based clinician, occupational therapist, SWAT member, hospitalbased speech-language pathologist, parent, and physician. This program may include changes such as positioning, postural, diet consistency, or compensatory strategies to ensure safe nutrition and hydration intake. A qualified SWAT member trains all staff and family in appropriate techniques (ASHA, 1990). In cases where the prognosis for safe oral feeding is poor and the physician advises that a percutaneous endoscopic gastrostromy (PEG) tube be placed, the school nurse will train the speech-language pathologist, other team members, or family as necessary in accord with the physicians orders. Finally, the IEP is revisited, updating the general student information section and adding goals and objectives for therapeutic intervention regarding swallowing dysfunction.

language pathologists and occupational therapists within the state, as well as local pediatricians. This effort drew 100 professionals from other work settings in the area and netted funds for the purchase of needed equipment and supplies for all students in the school system with special needs. SWAT members were designated to attend two intensive courses in New Orleans, Louisiana on the management of dysphagia and the interpretation of radiographic swallow studies given by a nationally recognized expert. Following the courses, SWAT members attending the courses shared research findings and treatment techniques about dysphagia in the pediatric population. To educate the other staff, nurses participating on SWAT initiated sessions with other school nurses on the implementation of the new emergency plan for choking.

Phase V: Seeking Administrative Approval

The chairperson of the SWAT committee met with the special education administrators to present the proposed process, protocol, and methods of documentation. Documentation was presented for the definition of dysphagia, initial concerns, proposed solutions, and the teams vision. The roles of the speech-language pathologists, occupational therapists, and physician in the diagnosis and treatment of dysphagia were included. The administrators expressed enthusiasm about the development of this new program, but they also had some questions and concerns for the school systems attorney to answer. Primary concerns were whether the school system was required by the Individuals with Disabilities Education Act (IDEA) to address swallowing disorders (or was swallowing strictly a medical issue) and whether the school system would incur the medical cost of the MBS study. One administrator conveyed her shock that the team had the audacity to tell a physician what tests were indicated. Based on the dialogue with the administrators, six questions were prepared for the school systems attorney to address. 1. Is the school system required by IDEA to address swallowing problems? 2. If dysphagia has not been diagnosed, does a school system with knowledgeable professionals have a responsibility to make the necessary referral for diagnosis to ensure safe eating? 3. Is the school system financially responsible for an MBS study if it is determined that this medical test is necessary? 4. If parents refuse to send a child for the MBS study or, if the physician will not give the orders, then is the system correct in not addressing the swallowing at school, even though it has been determined that the child may be at risk for aspiration? If not addressed, the student would then maintain the existing diet and the dysphagia problem would not be included in therapeutic goals. If choking occurs at school or if complications develop from recurring aspiration, are school personnel liable?

Phase IV: Inservice Education

To implement a child-specific treatment plan, the responsibility would need to shift from the district-wide SWAT to school-based staff. Because many of the speechlanguage pathologists, occupational therapists, and nurses in the school system had little or no knowledge about or experience with swallowing disorders, it was evident that the system would need to provide education in this area. To initiate the educational process, the Speech-Language-Hearing Program hosted an inservice workshop presented by a nationally recognized authority on pediatric dysphagia. This workshop was mandatory for all speechlanguage pathologists in the school system. In addition, all occupational therapists, physical therapists, and nurses within the system were invited to attend. To increase regional awareness of swallowing disorders in children and our school systems commitment to serve these children more effectively, registration was open to all speech-

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5. If the physician agrees with diet recommendations made by the speech-language pathologist, but the parents do not agree, which options are then appropriate? 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 members regarding liability? On September 22, 1998, the supervisor of special education received a letter from the school board attorney stating that it was his legal opinion that school systems have an obligation to evaluate all children with disabilities who are in need of special education and related services. Medical services and school health services are included as related services according to IDEA. Therefore, if a school system suspects that a child has a swallowing problem, which is a disability requiring special education and related services, it is obligated to conduct an appropriate assessment, or to arrange for an assessment by an individual who is trained and qualified to do the assessment. When it is determined that an MBS study is necessary, then the school system would be responsible for payment or services would have to be secured from another public agency that allocates 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, when parents refuse to follow through on recommendations of the dysphagia case manager, subsequent actions would need to be decided on a case-by-case basis; however, the school system has an obligation to respond in the interest of the child. School personnel must make reasonable and documented attempts to secure parental cooperation. Reports of health- or life-threatening situations should be directed to the proper authorities. These steps ensure that the school system has taken appropriate steps to minimize the risk to the child and, as a result, has reduced the systems exposure to liability. The school system has an obligation to defend school personnel against lawsuits, which are based on actions or omissions occurring during the proper course and scope of their duties. (It should be noted that the responses to these questions were based on the opinion of one attorney and on Louisiana State guidelines, and regulations may differ from state to state.) The response by the school board attorney gave the SWAT members the clearance they needed to proceed with the execution of the established process and procedures. In addition to affirming the teams vision, the attorney stated in the last paragraph of his letter that he commended the team for its innovative and proactive approach taken in dealing with the issue of swallowing disorders in the schools.

Phase VI: Plans for the Future

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

policies and procedures for addressing students potentially at risk for dysphagia. In the 19981999 school year, utilization of the flowchart procedures shown in Figure 1 was initiated. SWAT continues to meet regularly to problem solve, evaluate, and revise procedures and to provide training for school personnel and parents. They offer diagnostic and therapeutic support for the school-based speech-language pathologist and occupational therapist. The members of the team also serve as case managers and have direct contact with both the speech-language pathologists in the school and the students. Next, a system will be established for tracking children who need to be screened as well as those with known swallowing problems. IEPs will be developed for children with dysphagia and will include information relating to the use of compensatory techniques, oral exercises, dietary restrictions, and use of adaptive equipment (Langley & Lombardino, 1991). Materials and supplies needed for oral motor therapy and feeding will be purchased, such as toothettes, tongue depressors, nuk brushes, blow toys, rubber gloves, adaptive feeding equipment, food thickeners, and positioning equipment. School-based speech-language pathologists and occupational therapists will provide dysphagia therapy. Using an apprenticeship model, clinicians with minimal training will be assisted by those who are experienced. Parents and school personnel will require child-specific instruction and training on all precautions, compensatory techniques, and use of adapted equipment to assist the child in safe and efficient eating. Some training procedures recommended by the team include actual demonstrations of the compensatory feeding techniques, written directions for both parents and staff, as well as viewing of videotaped and narrated samples from MBS studies, depicting aspiration and therapeutic interventions, if possible. These procedures will help parents and school-based personnel to understand the disorder more completely and the implications of intervention. The more educated the caregivers are on swallowing disorders and treatment, the more successful the treatment may be. Continued professional growth opportunities for all speech-language pathologists in St. Tammany Parish Schools, featuring information on the diagnosis of swallowing disorders, therapeutic techniques, ethical issues, and counseling of caregivers, will be available throughout the school year. In conjunction with Southeastern Louisiana University, a graduate-level course on dysphagia was offered within our school district in the fall of 1998 for all interested school speech-language pathologists. The system is in the process of working on plans for providing members of the school staff with training on cardiac pulmonary resuscitation. As mentioned previously, Louisiana State Bulletin 1508 currently does not include dysphagia as an exceptionality. This bulletin is being revised to reflect changes resulting from IDEA. The St. Tammany parish coordinator and assistant coordinators of the Speech-Language-Hearing Program will work with state department officials to incorporate dysphagia evaluation and service eligibility criteria into the revisions.

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CONCLUSIONS
The St. Tammany Parish SWAT members have accomplished much thus far; however, there is more work to be done. Implementation of a successful dysphagia program is ensuring that children will receive safe, adequate nutrition allowing them to make developmental and academic gains, thereby fulfilling their potential. Several of the students targeted for emergency intervention for swallowing problems are now, as a result of intervention, stronger and better able to participate in their academic program due to increased nutrition. Considering whether to adopt a SWAT program within a school system is a challenging endeavor. The following seven suggestions may facilitate the process of adoption.
1. Do not assume that anyone knows what you are

ACKNOWLEDGMENTS
The authors would like to express appreciation to the supervisors, administrators, and principals of St. Tammany Parish Schools for their cooperation during the process of addressing the issues of dysphagia in the schools. Appreciation is expressed to Judeyanne Coudrain, Elizabeth Duncan, Pamela Gaden, Maureen Larsen, Carol Negrotto, Donna Thomas, Roberta Torman, and Sandy Zeringue for their assistance with this project. The authors would like to extend a special thanks to Jeri Logemann for her invaluable support and encouragement during the drafting of this manuscript.

REFERENCES
American Speech-Language-Hearing Association. (1990, April). Knowledge and skills needed by the speech-language pathologist providing services to dysphagic patients/clients. Asha, 32 (5), 712. American Speech-Language-Hearing Association. (1992, March). Instrumental diagnostic procedures for swallowing. Asha, 34(Suppl. 7), 2533. Arvedson, J., & Brodsky, L. (1993). Nutrition. In J. Arvedson & L. Brodsky (Eds.), Pediatric swallowing and feeding: Assessment and management (pp. 157208). 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, 173181. Langley, M. B., & Lombardino, L. J. (Eds.). (1991). Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Austin, TX: PRO-ED. Logemann, J. (1998). Evaluation and treatment of swallowing disorders (rev. ed.). Austin, TX: PRO-ED. Louisiana Department of Education. (1993). Pupil appraisal handbook [Louisiana State Bulletin 1508]. Baton Rouge, LA. Author.

talking about.
2. Maintain your vision, but be prepared to compromise. 3. Use the question Is it best for children? as a guide

to decision-making.
4. Follow your systems chain of command when

presenting the concept of establishing a dysphagia team. Prepare the following, written in lay persons terms: definition of dysphagia summary of the concern/problem outline of the solutions
5. Have an idea of what this model will cost the

systembut be ready to point out that this may prevent future due process hearing.
6. Consider cost issues, such as:

Personnel: Can the model be adopted with the personnel currently in the system? Training: How much will it cost to train personnel currently in the system? Videoflouroscopy/MBS: The school system will be responsible for some of these tests. Medicaid or private insurance should cover the cost for most of these assessments. Materials for evaluation/therapy: Minimal costs will be incurred for materials, such as toothettes, tongue depressors, mirrors, and so forth.
7. Keep everyone involved informed throughout the

Received September 21, 1998 Accepted September 27, 1999

process.

Contact author: Emily M. Homer, Assistant Coordinator SpeechLanguage-Hearing Therapy Programs, St. Tammany Parish Schools, Covington, LA 70433. Email: emh@stpsb.k12.la.us

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APPENDIX A. CASELOAD SURVEY/REFERRAL FORM

Please complete this form. If you have any students with the following characteristics, complete one form per student by checking the characteristics that apply. Note that if you do not have any students with these characteristics, 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 Current nutritional intake adequate Alert and oriented Voluntary swallowing (on command) Cough, choking, gagging during meal Increased time to eat Wet sound, cough/voice/breath Gag reflex Specific food avoidance behaviors Diagnosed Oral Apraxia/vocal cord path. Hx frequent URI, pneumonia, BPD Hx of cleft Hx of dysarthria Chronic low grade fever Medical history of aspiration Yes No Unknown

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Intake questionnaire Hx prolonged intubation/tracheostomy Neurological impairment Previous hx of non-oral feeds Food allergies Tracheostomy PEG tube General Observations

Yes

No

Unknown

Behavior: ____ Cooperative _____ Resistant Alertness: _____ No Deficit _____ Partial Deficit _____Moderate Deficit _____ Severe Deficit Follows directions: _____ Verbal _____ Gestural _____ None ____ 1 Step _____ 2 Step Vision: _____ No Deficit _____ Partial Deficit _____ Moderate Deficit _____ Severe Deficit General Physical Observations Abnormal reflexes: ____________________________________________________________________ Trunk: ____Excessive Extension _____Dystonia _____Scoliosis _____Kyphotic _____ Asymmetric Head control: _____ Adequate _____ Poor _____ Receives external positioning _____Receives manual positioning _____ Reflexive position patterns _____ Excessive head/neck hyper extension Facial: _____Asymmetrical _____Contortions _____Jaw extension _____ Grimaces/tics _____ Open mouth posture _____ Increase tone _____ Decrease tone Breathing Patterns: _____ Mouth Breather _____ Audible inhalation Observation of Feeding Indicate functioning by checking (+) for adequate and () for inadequate for each food texture. Liquid + Accept Lip Closure Tongue Movement Jaw Movement Swallow Cough + Puree + Soft + Solid

During this assessment, patient was fed _________________ by whom ___________ Positioning _____________________Equipment _______________________ Observation: _____ Drooling _____ Excessive oral secretions _____ _____ Poor oral hygiene _____ Residual food in oral cavity _____ _____ Food remnants on lips _____ Bites tongue/lips _____ _____ Tongue thrust _____ Oral apraxia _____ _____ Gagging _____ Coughing (>2x) _____ _____ Increase clearing throat _____ Absence tongue lateralization

Cued Swallow Hoarse/wet voice Poor jaw control Fatigues easily Delayed swallow

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 _________________________________________ Occupational Therapist (SWAT) __________________________________________ Speech-Language Pathologist CCC-SLP __________________________________________ Occupational Therapist (SWAT)

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APPENDIX C. INDIVIDUALIZED HEALTH SERVICES PLAN FOR STUDENTS 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 Heimlich maneuver if unable to cough. If still in distress, repeat. Observe results. If foreign object (food) seen in mouth, 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 to call 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, or bus driver may have my child transported to the emergency room at __________________________hospital or the nearest hospital and that I will be responsible for payment of emergency transport and care given.

Signature of Parent/Guardian Date:_________________

Signature of Witness Date:_________________

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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 Ventilator Tube or Button Feeding IV Therapy Tracheostomy Tube Seizure Monitoring

Developing/Motor Concerns: Speech Concerns:

Brief medical history:

Date of Next Visit: ________________________ Physicians Name (Please Print!):

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APPENDIX E. SAMPLE PHYSICIANS LETTER

Date: ________________

Dear Dr. _________________, Your patient _________________ was seen on consult for a possible swallowing disorder by the St. Tammany Parish 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 for parish 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 in your patient. As a precautionary procedure we have, when appropriate, placed the student on an emergency restricted 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 our evaluation should an evaluation be indicated. It should be mailed along with a copy of the signed Physician Input Form to the case manager. Thank you for your assistance. If you have any questions or would like to discuss this case further, please feel free to contact the case manager at the number listed below. ______________________________ Case Manager ______________________________ Phone Number ______________________________ ______________________________ ______________________________ Address

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APPENDIX F. PHYSICIAN INPUT FORM

Date:____________________________ School: _________________________________________________ Date of Birth:________________________

Students Name:______________________________________

Dear Dr. ___________________, Your patient was observed during speech and/or occupational therapy on __________ due to feeding and swallowing concerns. The clinical indication(s) of possible aspiration included: _____ _____ _____ _____ _____ _____ _____ _____ Changes in respiration rate Coughing Oral residue Facial grimacing Gagging Refusal to eat Delay in swallowing Other: ___________________________ _____ _____ _____ _____ _____ _____ _____ Reddening of the face Audible breathing Gurgled vocal quality Chronic low grade fever Pneumonia or history of it Chronic, copious, clear secretions Questionable nutritional intake

To ensure safe and adequate nutrition and hydration during school, we suggest a medical evaluation to investigate the need for a special diet, a bedside swallowing evaluation, a Modified Barium Swallowing Study (Videoflouroscopy), etc. For further information, please contact the therapist(s) below. Sincerely:

______________________________________ Speech-Language Pathologist CCC-SLP _______________________ Phone #

________________________________________ Occupational Therapist _______________________ Phone #

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I recommend the following: _____ _____ _____ _____ _____ _____ Modified Barium Swallow/Videofluoroscopy Interdisciplinary Swallowing Evaluation Special Diet: ____________________________________________________________ Other: _________________________________________________________________ Impressions: ____________________________________________________________ No recommendations at this time.

Physicians Signature:__________________________________ Date: ___________________

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Development of an Interdisciplinary Dysphagia Team in the Public Schools Emily M. Homer, Cheryl Bickerton, Sherry Hill, Lisa Parham, and Darlene Taylor Lang Speech Hear Serv Sch 2000;31;62-75

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