A combined treatment approach that incorporates speech and language therapy with feeding and swallowing exercises can benefit children in a classroom setting. This approach can alleviate some of the stress of feeding, Justine Joan Sheppard, PhD, CCC-SLP, BRS-S, has found.
"The amount of time you can work on feeding issues is limited because of the amount of stress it puts on the child," explained Dr. Sheppard, an adjunct associate professor of speech-language pathology in the Department of Biobehavioral Sciences at Teachers College, Columbia University, in New York, NY. However, "if you mix swallowing and feeding therapy in with the language therapy, you can limit the amount of time according to what the child can tolerate and not waste the rest of the time. You've got something else to do-you've got language work."
Some children may benefit from a therapy structure that alternates feeding therapy with language therapy, she told ADVANCE. "It gives the clinician enormous flexibility driven by the child's needs at the time and their particular tolerance."
Dr. Sheppard recently established a feeding and swallowing program at the Lake Drive School, a public school in Mountain Lakes, NJ, that serves students who are deaf or hard of hearing. The students were scheduled for four speech-language therapy sessions a week. To tailor treatment to the individual needs of students, the school clinicians decided to take a flexible approach to the dual language and feeding sessions. Some sessions focused far more time on feeding or swallowing issues than language, while others tended to favor speech and language issues over feeding, depending on the child's needs.
"There were some sessions when the dysphagia issues were being generalized in the classroom," said Dr. Sheppard. "As therapy progressed and relatively little time was needed for the dysphagia exercises, more time could be devoted to language.
She attributes much of the success she has seen with the program to the built-in flexibility in the therapy sessions and the benefits to both the students and clinicians. "Rather than the more typical pattern of segmenting a program into feeding and speech-language therapy, integrating these two elements is a very useful strategy," she said.
Before clinicians implement a school feeding or swallowing program, it is vital that they ensure school administrators are aware and supportive of the plan, said Dr. Sheppard, a member of Nutritional Management Associates LLC, in Lake Hopatcong, NJ, which offers pediatric and adult feeding and swallowing consultation services. Feeding and swallowing consultants can assist in working with school administrators to structure the program.
"A successful program involves both therapy and generalization into the classroom, as well as active work with families," she said. "The place to start is developing a cogent program with the administration. Once this collaboration is established on paper, you can treat these children in a manner that will advance them effectively."
Typically, the feeding team includes the school speech-language pathologist, occupational therapist, physical therapist, classroom aides, psychologist or social worker, and school nurse, as well as classroom teachers and parents or caregivers. Team members need to be aware of their individual roles and responsibilities within the treatment plan and the time commitment required.
Children who present with additional medically complex issues may require an additional outreach collaboration with the medical community, including their pediatrician and the local speech-language pathologist who treats them outside of the school setting.
"If the children are involved with the medical community, you need to establish lines of communication and use that community to support and inform your program as the child changes," Dr. Sheppard said.
Once administrators approved the structure of the feeding and swallowing program at the Lake Drive School, treatment commenced with the students and the school-based team. A consultant provided monthly evaluations of the child's progress, attended individual education plan (IEP) meetings, was available for daily support via e-mail and phone sessions, and conducted inservices for the feeding team.
Inservice training using a case example is provided at an intermediate to advanced level, Dr. Sheppard explained. "A child is there, along with the teacher, clinicians and other team members. We also invite the parents in. As a group, we learn from the case study and provide the next steps in transitioning the child's program ahead."
The basic goal of the Lake Drive School program was to develop compliance in speech, language and feeding activities.
"The clinician becomes a conditioned stimulus for compliance," she said. "That compliance is used to advance speech and language activities and to advance eating activities, so you're working on behaviors as they may occur in both activities."
Many of the children in the program were noncompliant. Noncompliance can become a major interference in feeding and swallowing therapies if left untreated and can impede progress in speech-language therapy as well.
Initially, therapy was guided by a visual information system using pegs and a pegboard that allowed children to observe their progress in therapy. The number of pegs indicated the number of trials that the child had to complete during that exercise. Following each successful trial during a therapy session, the clinician or child removed one of the pegs to demonstrate completion of the trial.
Non-feeding and swallowing-based exercises were introduced into therapy using the same visual pegboard system to allow children to see their progress. Clinicians marked successful attempts with verbal encouragement and positive facial expressions.
"By tackling the behaviors at that level, we could get them under control and advance the child in both areas," Dr. Sheppard said. "We may work daily on whatever elements of the eating program are needed by the child at that particular stage of the therapy program and then transfer or generalize the skills to practice in the classroom."
Transitions included adding a classroom aide as a feeding partner and allowing the child to eat meals in the school cafeteria to incorporate the social aspects of mealtime.
When children achieve consistency in both areas and their therapy progresses, the feeding or swallowing and speech-language tasks are alternated in therapy sessions. "Both areas move ahead with a common base of compliance work and ability to engage in challenging tasks," she explained. "That forms a common foundation for both the feeding work and the speech and language work."
Language therapy serves to enhance typical feeding therapy overall and to introduce additional therapeutic opportunities and social elements to the child, Dr. Sheppard believes. "There's a lot of language you can use in feeding sessions and eating, as a social activity is only enhanced by that practice. It's a good model."
McKirdy, L.S., Sheppard, J.J., Osborne, M.L., et al. (In press). Transition from tube to oral feeding in the school setting. Language, Speech, and Hearing Services in Schools.
For More Information
Justine Joan Sheppard, PhD, e-mail: firstname.lastname@example.org, online: www.nutritionalmanagement.org.
Alyssa Banotai is an Associate Editor at ADVANCE. She can be reached at email@example.com.