The American Speech-Language Hearing Association (ASHA) has a platform and guidelines addressing swallowing disorders in

1. Request to Form a Swallowing Disorders Committee within the Georgia Organization of School-Based Speech-Language Pathologists (GOSSLP)‏By: Michelle D. Harvey M.S., CCC-SLP

2. Background:Speech-Language Pathologist for Forsyth County School System and Northside Hospital19 years experience as a Speech-Language Pathologist in the medical, clinical and school settings

3. History of DysphagiaSpeech-language pathologists have been involved with the management of oral feeding and swallowing disorders in children since the 1930’s. Initially, clinicians evaluated and rehabilitated children with cerebral palsy. Soon, other medical conditions arose indicating a need for the assessment and management of dysphagia. The focus on swallowing disorders increased greatly in the 1970’s with published articles on clinical or bedside assessment and management and, subsequently, on the use of instrumental evaluation procedures as cinefluoroscopy/videofluoroscopy, followed by sonography, endoscopy, manometry, and scintigraphy. Changes in health care have dramatically influenced the types of children who are requiring, requesting, and receiving services for communication and swallowing problems in the public schools. Medically-based communication and swallowing problems have dramatically increased in the public schools in the last decade and are likely to continue to increase. As more students with chronic conditions receive their care in a traditional school setting, the speech-language pathologist is required to have a medical knowledge base for pediatric communication and swallowing disorders. The trend in the past was to have center-based facilities to educate these students. At the present time, local school districts have become increasingly responsible for serving students with complex needs in the least restrictive environment, which often includes their home-district school. Thus, all school personnel must become knowledgeable and skilled in working with medically fragile students as well as those with multiple disabilities.

4. The American Speech-Language Hearing Association (ASHA) has a platform and guidelines addressing swallowing disorders in the school system setting.

5. Relevant Laws and Regulations-1975: Education for All Handicapped Children Act (P.L. 94-142)-Mandated local schools to provide services to students with severe disabilities, including medically fragile students. -1990: The ASHA Task Force on Dysphagia (1990) developed guidelines addressing the knowledge and skills needed by speech-language pathologists providing services to persons with dysphagia. -1997: Individuals with Disabilities Education Act (IDEA, 1997) dictated that intervention for children with complex medical problems be provided in educational settings. -1997: Omnibus Survey of the American Speech-Language-Hearing Association (ASHA, 1997) revealed that 19% of school-based speech-language pathologists work with clients with dysphagia. -2002: ASHA’s Code of Ethics mandates that speech-language pathologists must be competent in any area in which they provide services. -2004: Individuals with Disabilities Education Improvement Act (IDEA, 2004) stated that health services are part of related services providing education to children, along with the requirement that schools provide a free and appropriate public education. This act also stated that school personnel mush ensure that children are safe at school, including mealtimes, and that students have stable health and sufficient energy to participate in school activities.

6. State of Georgia Eligibility:(j) - SPEECH-LANGUAGE (SI) IMPAIRMENT.Definitions.Speech or language impairment means a communication disorder, such as stuttering, impaired articulation, language impairment or a voice impairment that adversely affects a child’s educational performance (academic and nonacademic). A speech or language impairment may be congenital or acquired. It refers to impairments in the areas of articulation, fluency, voice or language. Individuals may demonstrate one or any combination of speech or language impairments. A speech or language impairment may be a primary disability or it may be secondary to other disabilities.(5)Feeding and Swallowing Impairments: School Districts must develop procedures for addressing the special education needs of children whose swallowing impairment adversely affects their progress in their curriculum (capacity and performance in daily educational contexts). Qualified Speech-Language Pathologists, trained in the management of swallowing disorders of children shall coordinate the evaluation and: Follow District's policy in dealing with the child’s with medical concerns.Identify with documentation that the swallowing disorder has a negative impact on the child's education. Coordinate with medical staff, follow and train school staff in the medical recommendations for feeding/positioning/diet and diet consistency. Speech-Language Pathologists trained in the treatment of dysphagia may be asked to serve as members of the team that assists the child’s who have swallowing problems.Effective: July 1, 2007

7. Development of an Interdisciplinary Dysphagia TeamIn the Public School SystemSwallowing disorders in the public school system is not the sole responsibility of the speech-language pathologist. An interdisciplinary team is inevitable for the identification and management of students at risk for oral-motor dysfunction and swallowing issues. A team of professionals trained in dysphagia should be 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. Purpose of the interdisciplinary dysphagia team: -Identify students at risk -Refer parents to physicians with specific recommendations-Immediately implement an emergency plan for children who are “at risk” for dysphagia -Evaluate the student -Participate in a modified barium swallow study when recommended -Design and implement a treatment plan -Develop compensatory strategies for safe swallowing when appropriateMembers of the interdisciplinary dysphagia team: -Speech-language pathologist -Occupational therapist -Physical therapist -School Nurse -School Administration -Director of Special Education

8. Forsyth County School DistrictThe Swallowing TeamPolicy and Procedures

9. When to make a swallowing referral • When a student presents with: • Difficulty swallowing any texture food/liquid • Difficulty handling secretions (drooling)‏ • Coughing, choking, or gagging incidents when eating/drinking • Watery eyes after swallowing • Wet or “gurgly” voice. • Increased congestion or noisy breathing. • Runny nose or watery eyes during feedings (when your child does not have a cold). • Dusky, bluish, or red color changes in the face, on or under the eyes, or around the mouth – these color changes may occur quickly or slowly. • Big changes in mood and energy level—for example, an alert child quickly turns sluggish and fussy.

10. Feeding and Swallowing Procedures 1. Referral Form -Send to Michelle Harvey, Coordinator of Swallowing Disorders team, at Settles Bridge Elementary School: 770/887-1883 mharvey@forsyth.k12.ga.us 2. Parent Letter-Referring SLP/Teacher will send letter home to parent 3. Parent Questionnaire-Send this form to parent along with the parent letter 4. Feeding-Swallowing Consult-Team completes during swallowing evaluation 5. Feeding Swallowing Plan-Team completes during swallowing evaluation 6. Physician Recommendations-Team sends to physician following evaluation

11. ReferencesAmerican Speech-language-Hearing Association, (1990, April). Knowledge and skills needed by the speech-language pathologist providing services to dysphagic patients/clients. Asha, 32, 5, 7-12.American Speech-Language-Hearing Association, (1996, Spring). Scope of practice in speech-language pathology. Asha, 38, 16-20. Arvedson, J., & Brodsky, L. (1993). Nutrition. Pediatric swallowing and feeding: Assessment and management, San Diego, CA: Singular, pp. 157-208.Homer, E.M. et al (2000). Development of an interdisciplinary dysphagia team in the public schools. Language, Speech, and Hearing Services in Schools, 31, 1, 62-75.Kurjan, R.M. (2000). The Role of the School-Based Speech-language pathologist serving preschool children with dysphagia: A personal perspective. Language, Speech, and Hearing Services in Schools, 31, 1, 42-29.Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. Austin, TX: PRO-ED.Logemann, J.A. (2000). Therapy for children with swallowing disorders in the educational setting. Language, Speech and Hearing Services in Schools, 31, 1, 50-55.O’Toole, T.J. (2000). Legal, ethical, and financial aspects of providing services to children with swallowing disorders in the public schools. Language, Speech, and Hearing Services in Schools, 31, 1, 56-61.