School of Speech Ep 12
[00:00:00] Carolyn Dolby: Hello everyone. My name is Carolyn Dolby and I am your SpeechTherapyPD. com podcast host for School of Speech. School of Speech is designed specifically for us school based SLPs so we can come together, we can discuss some of those current topics, tackle difficult situations, and I want us to share all of our insights.
[00:00:22] Our goal is really, we want to bolster our confidence, celebrate our triumphs. and really foster that community, the community that's really dedicated to the excellence in the school setting. I'm excited today. Our episode is Developing Dynamic Dysphagia Plans. And this episode is for the clinician that is ready to advance their feeding and swallowing interventions by taking a transdisciplinary approach through developing dynamic plans of care implemented by well trained staff.
[00:00:56] Providing daily opportunities to work on sensory shaping and skill acquisition, promoting positive outcomes with our students with pediatric feeding disorders and dysphagia. I just want to go through my disclosures Right quick down here in Texas. I receive a salary as the district level dysphagia support speech pathologist for Cypher ISD.
[00:01:20] I'm also compensated for my graduate course that I teach through the at University of Houston. I also consult with school districts across the nation, supporting program development and staff training. I also received compensation from SpeechTherapyPD. com to host this podcast. I am a member of the Texas Speech and Hearing Association.
[00:01:43] I'm part of their feeding and swallowing task force, which I completed a three year commitment just recently. I'm also a volunteer for Feeding Matters. And I'm also a member of ASHA's special interest groups 13 Swallowing and Swallowing Disorders, as well as SIG 16 School Based Issues. A little history on me.
[00:02:05] I do specialize in pediatric feeding and swallowing evaluations and interventions at the district level for my school district here in Northwest Houston. I teach a graduate course I mentioned before for University of Houston, and it is focused on school age feeding and swallowing assessments and treatments.
[00:02:23] I present nationally and internationally on the topic of pediatric feeding and swallowing disorders for the school age in the school age population. I'm a published author and I consult to school districts around the country, assisting in program development and staff training. Basically, I do all things feeding and swallowing, which gets us into today's topic, which I am super excited about.
[00:02:48] So, I want to start with A question. Easy question, right? When does a student require dysphagia intervention? Well, this is an easy answer that ASHA has provided us in their document, in their documents from 2007. ASHA states that it is the responsibility for the school system to ensure that students are safe.
[00:03:11] When eating and drinking that schools must have appropriate personnel food that's going to come into play later and procedures that we the schools must provide these in order to minimize risks of choking and aspiration during oral intake. Students also must have sufficient physical well being and energy in order to function in their setting.
[00:03:36] Students that are undernourished or dehydrated due to swallowing and feeding problems just can't attend adequately to the learning environment and their academic performance Really might suffer. Students must also have adequate health. That would mean that they are without aspiration complications.
[00:03:57] Literature shows that students with swallowing and swallowing feeding disorders really are more susceptible to illnesses related to malnutrition and dehydration. And children or students really might start missing more school more frequently than their peers due to health related issues impacted by aspiration incidents.
[00:04:20] So in order for students to participate fully in the education in programs, they need to be efficient eaters during their regular meal times, during their snack times with their peers. So we're thinking about meal times about 30 minutes, but us in the schools, we laugh when we say they have 30 minutes in those cafeterias, maybe 20 and then their snacks about 15 children that have really.
[00:04:48] Pro long meal times. We do know that that's a real red flag. That something else is going on. Maybe the diet is too advanced for them. And it really can be indicative that there's an excessive efforts That and energy, actually, that's going to interfere with other activities that are really important for the school, the student to be in their, during their school day. Also prolonged mealtimes is a stressor. It's stressed on the caregiver, the paraprofessional, the feeding facilitator. I'll start using that term. The feeding facilitator is trying to get the child fed and back to class because they're on a schedule. Everyone's on a schedule. But if you think about the stress the student is under, that stress can really carry over to the remainder of that school day for them.
[00:05:40] And so, you know, Asha supports that sometimes our students might need frequent snacks and meals. I'm going to talk about that too. Well, Federal state federal and state litigation has led to federal regulations establishing a child's right to FAPE, free and appropriate public education. I know I'm speaking to the choir here.
[00:06:01] Basically, it really should not come to any surprise that districts have the responsibility to provide a safe environment for all students while at school, and that does mean their mealtimes and snacks. Therefore, the question was, who requires feeding and swallowing intervention? Who requires a dysphagia plan?
[00:06:26] Well, the answer is simple. Any student whose feeding and or swallowing system is unsafe, inadequate, or inappropriate. An unsafe feeding system or swallowing system would be a diet that is too advanced for their current functioning, putting them at risk for choking or aspiration. And it at an inadequate system would be a diet that's too advanced or too limited that their caloric needs are at risk.
[00:07:00] And an inappropriate System would be a student that is stuck on a diet that is below their developmental and skill level. Now, going forward in on today's episode, I am making some assumptions. I'm going to assume that your district has a procedure in place for identifying at risk students and a plan that is supportive and provides intervention for your students.
[00:07:31] Now, if you're listening in and your district's not quite there yet, please don't go. We've got a great, great information. However, if you are just beginning, I do urge you to listen to the podcast my podcast with Emily Homer for the basics of setting up your district procedures. And also I would suggest popping over to her website Students Eat Safely.
[00:07:54] And if you are in Texas, you can also send me an email. At C1Dolby at gmail. com. And I can provide some additional resources. And I also I referenced Emily in the handouts. There is a handout for this talk. So if you don't have that, grab that because I will be referring to it quite a bit.
[00:08:17] So while you're getting that out, I'm going to talk semantics for just a minute. I am going to refer to dysphagia plans as safe eating plans. I might be, I might call them a safe feeding and swallowing plan. I also refer to them as mealtime plans. And hey, you might even have another name that for yours, but as long as we're on the, all on the same page that we're all talking about feeding and swallowing plans of care we're really, we're golden here.
[00:08:46] And that actually brings us to our next question. What interventions are appropriate for addressing pediatric feeding disorders and dysphagia in the school setting? Well, we have two intervention approaches that would be indirect and direct. Okay, indirect interventions include modified meals, meal time and swallow strategies, utilizing adaptive equipment, and of course, training, staff training.
[00:09:17] With indirect interventions, the goal is for maintaining safe and efficient oral intake. And the second approach, which would be our direct interventions. Now, students may be a candidate for direct interventions once. They are safe and efficient. Such interventions include our oral, sensory, and behavior supports.
[00:09:46] The goal here for our direct interventions is for promoting independent functioning and optimizing feeding and swallowing skills. But let's start with maintaining safe and efficient oral intake. All right, I'm going to ask you to take a look at your handouts because I have shared my eight building blocks.
[00:10:08] You'll find that in your handout. So when we are looking at building blocks, Establishing and maintaining a feeding plan of care for safe and efficient oral intake. Here are the, the eight levels that I am looking at. Not all children are going to need something in the, in all eight, but I do need to look at every every level here.
[00:10:29] The first one is the level of support. The second, their environmental needs, dietary modifications and accommodations. cultural preferences, posture and positioning, equipment and feeding techniques. And of course, precautions. Now I utilize these eight when I am crafting my dysphasia feeding and swallowing plans, which are considered indirect interventions.
[00:10:58] So this is your intervention for pediatric feeding disorders and dysphasia. And what do I mean when I titled this episode dynamic? What do I mean when I say that dysphagia plans are dynamic? Well, as we know that the Individuals with Disability Education Improvement Act, or IDEA, is our primary special education law which established the right of faith free and appropriate public education for children with disabilities.
[00:11:28] Now, IDEA may not specifically name dysphagia. However, it does mandate services. Displasia is one of the most common causes for health related disorders directly impacting a student's education. Therefore, the resulting health issues that might occur if dysplasia is not addressed may negatively impact a student's ability to attend school, which may deny access to their curriculum, impeding their ability to socialize with their peers.
[00:12:05] In addition, when providing FAPE, We also need to keep in mind least restrictive environments, LRE. Therefore, schools must provide an environment that maintains safe feeding practices, facilitates efficient eating, promoting adequate nutrition and hydration, all while fostering socialization. All right, so dysphagia or safe feeding and swallowing plans are the first step in dysphagia management.
[00:12:38] Don't get me wrong, dysphagia plans are themselves a treatment plan, and I do construct them to be a live document or a dynamic document that is to be executed by trained staff supported by standard procedures. So think about your district's feeding and swallowing plans. Are they static, addressing only safety and restrictions?
[00:13:04] Well, in time, a static plan can negatively impact the student's right to the least restrictive environment. So in order to protect, in order to protect least restrictive environment, and in turn, Preserve FAPE dysphagia plans need to be constructed to promote the shaping of behaviors while fading the prompts and restrictions to promote the improvement of skills.
[00:13:36] So let's discover some ways to develop these dynamic dysphagia plans designed to maintain safe and efficient oral intake, as well as improving feeding competence using resources. Currently available or soon to be in available if you choose to take them on. All right, here we go. Let's start through those eight building blocks starting with the level of support.
[00:14:06] How much supervision or level of support does a student need who's making the decisions on how much student supervision is required. All right. Are all emerging feeders, are all emerging self feeders the same? Do they all need the same level of supervision? I don't think so. Sometimes too much of a good thing turns into a more restrictive environment.
[00:14:32] So I've created a Supervision rubric, and I've included that in your handout as well. The triangle. Now, please make sure you note that this is my hierarchy for students with dysphagia, a feeding or swallowing disorder. So this would be specifically for those students identified with a feeding and swallowing disorder.
[00:14:55] Now, when I train the staff on this hierarchy, I am always speaking to the shaping of self feeding skills and fading of prompts and physical support so we can move them through that continuum when, when appropriate. Okay, so let's go through this hierarchy. We're going to start at the bottom with one on one supervision.
[00:15:19] Now, this is the most restrictive environment. Dependent feeders with dysphagia make up the bulk of the caseload that require this level of support. Dependent feeders present with a much higher risk for swallowing complications since their pacing is so slow. Their choice making and the rate of presentation of foods or size of foods, excuse me, and liquids are influenced by the feeding facilitator.
[00:15:54] One on one indicates a dedicated feeding facilitator providing their full attention to all feeding tasks that are required. I think I may be unanimous in this next statement, but the best part of school is lunch and recess, right? Our students really don't have any other time for a brain break and to socialize.
[00:16:21] And this is a right our special populations shouldn't have to forfeit. So I charge you. All of you to do a quick inventory to see how many of your students are on safe mealtime plans are also receiving one on one supervision. Now, this construct should just be reserved for those most medically complex.
[00:16:48] Or this should be indicated during therapeutic mealtimes where skills are being targeted one on one supervision is not the gold star for a feeding and swallowing. Plan it is. It is the most restrictive environment and it really should be considered heavily before that one is provided. So I want you to think of the next one, the next step up, which I titled supervision with constant model, constant monitoring.
[00:17:22] This one could be called small group. This is where a trained feeding facilitator is charged with supporting maybe two, maybe three students. A dependent feeder may be a candidate to be in a small group with just maybe one other that's a little higher functioning eater. Emerging eaters with a more developed skill set really benefit from a small group supervision.
[00:17:49] With close monitoring to assess to assess, to assist with feeding needs such as preloading utensils or guiding the utensil. And this way they can really be promoting self-feeding skills while being provided a little higher level of safety monitoring. Our immersion emergent feeders really need to be given some flexibility such as maybe a little extended time.
[00:18:18] Or given some space so they can start attempting to do as much self feeding as possible while still maintaining proper nutrition and hydration. All right, going up one more, we're going to take a look at supervision with close monitoring. Now assisted feeders, those that might just require initial plate setup, which would be maybe opening packets and, and opening containers possibly they might need some verbal or visual prompts perhaps some physical cues for safety, such as reminders to bite, chew, swallow, and still might require some feeding assistance.
[00:18:57] But they are safe to be monitored in a small group. Again, small group consists of two to three students, and these students are requiring just some close monitoring. Now, a dependent feeder would not be appropriate for this monitoring category. And then as you go up to the top, standard supervision.
[00:19:18] Now, this is, Feeders that are in this category. Remember, this is still students with feeding swallowing plan. This feeder might have the skills to self feed. However, due to their physical or cognitive and safety requirements, these students. must still have staff monitoring that are trained on their dysphagia plans.
[00:19:42] And this feeder may be appropriate for standard supervision with the addition of possibly plate setup because they might have some restrictions on their meals, but they are fully functioning and able to eat when the meal is properly modified and presented and plate plated for them. So this The standard supervision with this extra with the monitoring would make, be making sure that the food is correct, that drinks are accessible, and also making sure if there are any adaptive equipment needs that those are readily available.
[00:20:20] Now at this level, the supervising staff member must also be aware and follow their dysphagia plan and emergency procedures. Independent feeders may be independent, but due to their dysphagia diagnosis, may still need some supervision. Alright, let's move on to the environment. Environmental considerations support our sensory students that need that change of venue to assist with regulating their internal environment, or it can be used for the skill building student with the purpose of fostering success and independence and safety.
[00:20:55] Thank you Our goal is always to have students eating with their peers to the greatest extent possible. So this may, this may mean that their mail main meal is provided in a less distracting environment, but their snacks or highly preferred foods are offered with their peers in the cafeteria. Sometimes I put students During their scheduled lunch period, I have them eating their snack with their peers, and then their actual lunch is going to be at their snack time.
[00:21:27] Sometimes that really does work out well with their with everybody's schedule. Now, for the skill building student, a more modified meal might be provided with their peers in the cafeteria to work on socialization and safety. And then the more advanced textures provided with increased monitoring and support in a less distracting environment, such as the classroom during snack time.
[00:21:52] All right, let's go to diet modifications. Modifications can be used to increase independence and efficiency by lowering the task demand. And it also can be used on, to work on feeding competence. Hold on because I've got more to say on that. So stay tuned in. Diet accommodations such as cut solids.
[00:22:14] This really keeps least restrictive environment in mind when we're providing students access to the regular menu when appropriate. Cultural preferences. Within the provision of faith, cultural foods and faith based, faith based feeding preferences really must be honored. For example, a student might be metorically able to manage pork, but due to their family keeping kosher, Pork should be eliminated from their menu.
[00:22:47] Similarly, a student may be cleared for thin liquids, but secondary to their family's vegetarian or more specifically vegan diet, milk and other forms of dairy and animal products should be avoided. Now, some of you may have received some pushback from nursing, stating that they need physicians orders for diet restrictions.
[00:23:09] You are not alone. And kind of not wrong. But here we go. I'm not asking for a medical alert to be placed on their profile. However, after speaking directly to our district dietitian that heads up our department of special diets, we worked out a compromise. Which was to add the request for specific cultural and faith based foods to be omitted or avoided.
[00:23:37] We wanted that to be flagged on the student's point of sale in the cafeteria. I emphasize that a large percentage of our caseload that require safe eating plans are not able to advocate for themselves. And they really require us. and their plans to be their voice. Additionally, when I'm training staff on a student's plan, I really stress the ethics behind honoring cultural diversity and how the school family relationship is bolstered by valuing individual cultural beliefs and practices.
[00:24:19] Posture and positioning is paramount and it's the gatekeeper for secretion and bolus containment. It supports mastication and aids in swallowing safety. Postural stability through positioning allows the body to focus on eating, rather than the constant strain of trying to stay upright. Think about those cafeterias, cafeteria stools, right?
[00:24:48] How they're attached to the table, right? And how far away the table it is attached to, and how high off the ground the stools are. Now, walking through the cafeteria, it always gives me pause when I see these itty bitty three year olds. Basically suspended in air with their feet dangling. I know if there are any OTs listening right now, they are cringing along with us.
[00:25:17] Now, in cases where students might need a little extra seating, seating support, I find placing just a regular classroom chair with a back right over the stool can just be enough. This also keeps least restrictive environment in mind as well as expenses when we can purpose a typical chair versus a feeding chair in the cafeteria.
[00:25:41] Okay, this leads us into in equipment. Hmm. That's a nice segue. Here we go. Now, when I'm looking at equipment, I always defer to our multidisciplinary transdisciplinary team, which includes our occupational and physical therapists. This equipment, this is their wheelhouse, right? So I'm always bringing them in or they're bringing me in we're collaborating with this.
[00:26:05] But, but, On my side, I'm also always going to be looking for ways to utilize non therapy items. There's a brand called Take and Toss in my area that I can find at my local grocery store and they're just these plastic, durable spoons that I can use. They're a small bowl and I can use these for students that require extra pacing for bowl of size.
[00:26:29] I like to use these also for any of our students that might have a tonic bite so they're not breaking a plastic or hurting their teeth on something metal. Alternatively, though, I really do love adaptive equipment. Don't get me wrong. I love adaptive equipment because they, these items really can facilitate some independence, and it will compensate for some skill deficits.
[00:26:52] For example, increasing pacing through the encouragement of utensil use, for example getting a student to be able to use utensils creates a naturally slower rate of bolus presentation. Also, utilizing a smaller bowl spoon, like I just mentioned, naturally paces bolus size. Now, what about those cutout cups, those nosy cups?
[00:27:18] Those are great because those can be utilized to increase lip closure and tongue retraction. This is where I really love pairing with occupational therapy. All right, the next one, feeding techniques or safe swallow strategies. I like to put on my feeding plans. Now, these are the interventions and maneuvers Intended to offer support, improve efficiency with the intent of fading, the support for increased independence.
[00:27:46] We're going to revisit these in just a minute, right after I speak to precautions for just a second. Okay. Just right quick precautions. They're an integral component to our dysphasia plans. This includes. Training on and the provision of our aspiration precautions when needed. An emergency plan and procedures when responding to choking.
[00:28:11] And of course, food allergies that can be life threatening if not closely monitored. Okay, done with that. Let's get back to feeding techniques. You might be asking yourself, how can mealtime plans improve feeding competence? I'm so glad you asked. Let's take a look at some of these safe feeding and swallowing strategies that can provide opportunities for improving feeding competence.
[00:28:38] Well, let's start Literature tells us that skill shaping and skill acquisition may be supported through applying or performing strategies customized to illustrate, build, or reinforce production of the actions needed to carry out that maneuver. Okay, so I love how safe swallow strategies, which might have initially been used as a compensatory strategy for safety, can be strategically designed and effectively utilized by the treating SLP as a therapeutic feeding or swallowing intervention, and then included in the student's plan that is dedicated to and provided by well trained.
[00:29:27] Beating facilitators. All right, I think this might be a good time to talk a little bit about the importance of training. It is all fine and good that you have constructed these stellar safe feeding plans, but it renders itself completely useless if this, if the staff is not trained. In order to obtain buy in and fidelity of the application of these strategies, the staff need to be trained not only on the feeding plan But the reason behind each safe swallow strategy, the why behind the strategy or the maneuver, which is the therapy target is powerful, but equally as important is the training on the negative impact the failure to provide the support has on the student's quality of life.
[00:30:19] I like to emphasize that all students have the right to dine with dignity. All right, back on track. We have strategies. I'm going to target I've listed a few in your handout that we're going to target today. But for quick reference, if you don't have your handout, we're going to discuss smaller, more frequent meals, boldest chasers.
[00:30:40] placements and supports. Here we go. The use of providing smaller, more frequent meals not only aids in student comfort and managing GI issues such as reflux or GERD, but it also provides multiple shorter opportunities to work on skills. I know main meals should not be used for therapy, but rather enjoying and carrying over The skill development.
[00:31:07] So therapeutic snack times are best for introducing and practicing skills. Smaller, more frequent meals can also be a strategy utilized for our students where fatigue or physical stamina is lacking. Initially, you may have determined that modifying solids to maybe minced and moist or puree really increase the student's ability to consume an adequate amount of calories during their main meal.
[00:31:37] However, if we are wanting to work on improving feeding competence, You may consider keeping a regular or a soft and bite sized diet, but include smaller, more frequent meals. This would only work if the student has been cleared for regular or soft solids in small doses. Now, the intervention here is working on advanced textures in small, more frequent sessions provided by well trained staff throughout the day.
[00:32:09] Now, if the intervention is to work on stamina, you may wish to get downgrade the task demand utilizing the minced meal or the pureed meal But you won't shorten the time. In this instant, you are simultaneously promoting efficiency as well as adequate caloric intake. Now, I would also consider adding a therapeutic snack time, if appropriate, where the student has an opportunity to work on chewing skills.
[00:32:41] With trained staff, possibly using transitional solids at this point or some advanced textures with trained staff. Let's talk about bolus chasers. This is a great strategy that may have been initially indicated to decrease oral holding or increase oral clearance. For example, if a student presents with decreased attention to task, perhaps one who is an, or one who's an under responder, right?
[00:33:10] By providing a bolus chaser, such as a sip of liquid a thin liquid if they're cleared for that, or maybe a bite of thin puree. This is going to provide sensory input that triggers the brain to organize for the next swallow. However, bolus bolus chasing or cyclical ingestion is also a great intervention to increase internal pacing skills for those students that's over stuff.
[00:33:39] Let's talk about placement, bolus placement. When a student presents with impaired oral containment due to possibly tongue thrust, by training staff on proper bolus placement that would be like, for example, spoon placement. This could be accomplished by placing the spoon mid tongue blade with a slight downward pressure.
[00:34:01] By passing that tongue tip, which is going to promote tongue retraction, lip closure, and for solids by placing or holding the solid laterally on their molar surface again. Bypassing their tongue tip and the need for immediate lateralization because since you're holding the solid where it needs to be to elicit that chew.
[00:34:23] Now, this is a great strategy that you would first be facilitated by the feeding facilitator, but we don't want it to always be provided by the feeding facilitator, do we? No, we want them to start fading it out so that the self feeder can start employing this independently. Right. Those visual supports, I love the use of communication placemats.
[00:34:47] You can have a universal placemat that all students in the class use, or they can be individually constructed to target specific skills, such as pacing, positioning, and procedures, along with augmenting communication, all at the same time. All right. Well, wait a second. Let's recap for a second before we start moving on.
[00:35:11] Maintaining safe and efficient feeding is accomplished through developing dynamic, student centered dysphagia plans. They must be implemented by well trained staff with fidelity of the safe feeding strategies recommended. Now, once a student is a safe eater, everyone is trained on the student's unique feeding and swallowing needs.
[00:35:38] The student might be a candidate for further dysphagia interventions and treatment programs, such as promoting independent functioning and optimizing feeding and swallowing skills. Well, you might be asking, how does self feeding translate into a focus for speech therapy? Granted, promoting independent feeding skills is specifically targeted by the classroom teacher with an IEP goal that is co implemented by occupational therapy, right?
[00:36:10] Because feeding does not fall into the scope the SLP scope and sequence of practice. However, we can assist with carry over when addressing our goals of feeding and swallowing skills, as well as navigating the benefits and the risks involved with self feeding within our dysphasic population what I'm trying to say is our, our population with dysphagia, the process of self feeding or even assisted self feeding can really benefit by the sensory and the motoric stimuli, stimuli that is jump starting the brain that the body, the body better get ready, could get on board and ready to receive some nutrition.
[00:36:58] In an article, it's titled Critical Components of Effective School Based Feeding Improvement Programs by Bailey and Ingell. They provided the following insights. That when applying instructional strategies that develop self feeding skills may also improve feeding and swallowing. Now the next part I'm really going to paraphrase here.
[00:37:20] Simply by allowing a person to self feed or assist in lifting the food to his or her mouth may add to that individual's awareness that a swallow is needed. They go on to say that caution is warranted when teaching self feeding skills because it's important to remain aware. Aware that the effects of state safe feeding have on a student's feeding and swallowing behaviors Meaning, the energy extended in self feeding may, well, one, increase the length of that mealtime and become physically taxing, which could lead to fatigue, which will now decrease feeding and swallowing abilities.
[00:38:04] So we don't want one, building one skill to actually cause some unsafe. environments. So fortunately, it is often possible to facilitate the development of self feeding skills by pacing self feeding or by alternating some self feeding with being fed in order to minimize those fatiguing effects. All right, now I want to showcase how we can improve dysphagia outcomes when enhancing feeding competence resulting in diet upgrades.
[00:38:43] Thus, widening, widening, oh my goodness, widening the variety of consistencies and textures available when it's appropriate for the student. Okay, right now some of you are probably wanting to yell, lady, we are not feeding clinics. And again, you are not wrong. Now, I'm assuming just like me, you are often asked, what about feeding therapy?
[00:39:11] This is a loaded question, and it really can get very complicated depending on what is really that question's intent. What is the ask, asker asking? And since I, Carolyn Dolby, always come from a place of yes, I really needed to get a good yes for this request. So here is my broad answer to that broad question.
[00:39:36] I'm using air quotes right here. If you, if you are just listening, picture me with air quotes. Okay, this is dysphagia services according to Carolyn Dolby. Yes, we provide dysphagia services to all students that require dysphagia intervention to maintain safety, facilitate efficiency through shaping positive behaviors, and improving swallow function while fostering feeding independence.
[00:40:05] Oh, unquote. I want to highlight the word require because just like in in just speech therapy itself. All students would benefit right from speech therapy, but in the school setting, we are a different system. Then private or clinics, we are a school system, and we are providing services to students who require a service in order to preserve their right to think.
[00:40:31] This being said, I am also saying that students who are not safe, not efficient, or not independently able to maintain their nutritional needs will need to be provided some level of support because if these supports are not provided, the they may result in a negative impact to their educational growth, not just academic process progress.
[00:41:01] Okay optimizing feeding and swallowing skills using texture fading. Texture fading is using small incremental steps that intensify texture slowly and can target both sensory needs and skill deficits. But before I jump into texture fading, we have got to talk about ITC. All right. We're going to talk about ITSE, and we're also going to talk about your cafeteria's role and responsibility of food modifications.
[00:41:36] All right, ITSE. I'm probably going, I hope you know what I'm talking about, but if not, it stands for the International Dysphagia Diet Standardization Initiative. Now, ITSE is a universal and culturally sensitive framework for modifying both liquids and solids. Asha endorsed ITSE, and it really supports the district wide adoption of this framework.
[00:42:01] The use of standardized terminology, which is teamed with really easy to understand descriptors. enhanced by clear color coding, it, it will blow your mind. It really takes the guesswork out of diet modification. The ease of ITSE's implement, the ease of ITSE's implementation boosts the confidence of caregivers with the fidelity of its application by reducing risks of misinterpretation and ensuring the continued safety of our students.
[00:42:35] Staff, students, and families all find Soft and bite sized much more palatable than mechanically softened or mechanically altered for full details of the framework and additional resources. I gave the resource in the handout, but it's easy. Just go to www. isddi. org. All right. Hold on to your hats. I'm about to share with you.
[00:43:05] Your school cafeterias responsibilities. All right. School cafeterias are responsible to comply with positions prescribed dietary orders, according to the USDA and federal law that governs the national school meal programs require cafeterias to make accommodations such as. Texture modifications for children who are unable to eat the school meal as prepared due to a disability medical di directives such as physician prescribed dietary orders, just like I mentioned may be needed, but having the meal modification indicated in the student's IEP paperwork.
[00:43:58] Holds just as much water as the physician, the physician's directive. You heard that right. So your school district might initially insist that you get a physician's direct order. That's okay. However, you need to be armed with the knowledge that what is written in the student's IEP is also legally binding.
[00:44:24] Yay. Yay. All right. I have a little side note right here. I want to talk about another effective way to keep dysphagia plans dynamic when a student's feeding. Okay. Whoops, started going too fast. When a student's feeding plan is reflected as an accommodation and attached to IEP. This allows for updates to the plan be made as needed.
[00:44:52] Without the need of an IEP meeting. I'm going to restate that. So if you indicate in the IEP paperwork As on their accommodation plan, I just put dysphagia plan, or if you use it, say feeding plan or whatever you use, you put that on the accommodation plan. That is what you're needed. Okay. I also indicate in the student, student level, present levels that the student requires his individual Safe and swap safe feeding and swallowing plan to promote safe and efficient mealtimes while at school.
[00:45:31] I reflect this plan on the accommodations page. And then, of course, since the feeding plan was presented in full during the meeting. It will also be reflected in the minutes or the deliberations, whatever you call that at the end. All right, let's get back to what our cafeterias are mandated to do. They must provide meals as prescribed by the physician, or as indicated on their Mealtime Accommodations Plan, such as puree, minced and moist, or soft and bite size.
[00:46:06] Okay, now, to ensure diet modification compliance, Districts such as mine chose to centralize production utilizing specialized staff trained on the ITSE framework to standardize required modifications. What I did is I collaborated with our food services and we had dietician and nutrition, nutritionist support and we curated a specialty menu that we designed from the offerings from the district's established menu.
[00:46:41] Dysphasia menus Offering entrees, puree, minced, and moist and soft and bite size really allow for unified meals with efficient, effective quality control checks, all the while maintaining nutritional integrity. Let me paint you a word picture of how things were being addressed before I took on my role as the dysphagia support SLP. I'm gonna start with some liability. Depending on the campus I was at, the food was either being modified by the cafeteria staff, maybe, or it was being modified by the classroom staff. Now, this put the students at risk of not receiving the proper modification and or even a complete meal due to inconsistency and some integrity issues.
[00:47:30] Inconsistencies with texture, inconsistencies with taste, inconsistency with temperature. And these And there was also inconsistencies of texture. So if you think about mechanically soft and mechanically soft chopped those two words, they look different to different people. And for that matter, there's many levels of puree, if you think about it.
[00:47:56] Well, this left. The staff wide open for inconsistencies of taste as well due to staff decisions on what they added to the food and furthermore inconsistencies of temperature were due to the fact that foods were being modified. After they had been cooked or heated, and removed from the kitchen and taken to the classroom.
[00:48:20] So these inconsistencies negatively impacted the students accepting of their meals. Nutritional integrity was challenged. When staff members were literally just piecemealing a student's plate together from items from the regular menu and therefore denying our students access to a complete balanced meal that would include a protein, a grain, a vegetable, and a fruit.
[00:48:49] These foods were being taken off the line and then modified before portioning. I'm purposeful in pointing this out because there's a difference in portion when one, the original portion was from the regular menu modified. Which meant the foods were maybe watered down, if you will. Some of the portion was left in the processing.
[00:49:09] Some was left in the plating process. Not to mention sometimes some of the portions were lost due to staff mistakes. Whereas now our portions are maintained because we are portioning Already modified entrees, therefore maintaining nutritional integrity. We found that moving away from campus based modifications and by curating a specialized dysphagia menu that was produced at our central food services and they were delivered directly to our campuses regularly.
[00:49:44] So when we asked the question. Ready to be heated and served. This was our answer. The nutritional integrity was preserved. Because now balanced meals consisting of a protein, a grain, fruit and vegetable. Was being served. And the portions were maintained by plating post process on on trace. And they were also being modified by trained staff.
[00:50:08] Utilizing nutritionally strong liquid additions. Okay, that was a lot, but let's get back to texture fading. Opportunities for dysphagia treatment and improved feeding competence is optimized when safe food consistencies can be accessed daily. Moving students through the continuum of eating is really augmented when the availability of pureed, minced and moist and small and bite sized edibles are available.
[00:50:39] Both sensory feeding goals and skill based swallowing goals can be effectively targeted by campus clinicians when utilizing the or combining their district dysphagia meals. Then the carryover and skill maintenance can be monitored Daily by staff following an individual safe swallow strategy and interventions that have been indicated on their students feeding and swallowing plan.
[00:51:08] All right. I break texture fading into. two categories. The first one I titled texture tolerance and the second I call texture progression. Now don't get me wrong, both of these treatment practices use small incremental steps to either increase acceptance, that's why I call it texture tolerance, or to increase skill and competence.
[00:51:33] That's why I call it texture progression. Now to repeat, they are actually the exactly the same structure, but I'm indicating on their plan if we are working on a deficit that is sensory in nature, some of it might, some people might call that a behavior based intervention, or if we're utilizing it to work on a skill based deficit.
[00:51:57] Texture tolerance facilitates. A healthy relationship with food, which can result in improving acceptance of tastes, textures and temperate and temperatures, while texture progression provides daily opportunities to work on feeding competence. Now these two are used as carry over activities to support and follow the student's skill acquisition and or their sensory and behavior shaping progress.
[00:52:26] The purpose of this is for the student to eat two meals. Staff must be trained and demonstrate the the understanding that the purpose here is not for the student to eat two meals. For example, if the student is working on from progressing from puree to minced and moist, and they're getting both the exact meal in those two consistencies, puree and minced and moist.
[00:52:48] And we're making small incremental adjustments to intensify the pureed texture and move them to the minced and moist. The purpose is not that they are going to eat two meals. Because here we overfeeding discomfort. That's not what we're going for. Okay. We are wanting to combine the two textures slowly over time.
[00:53:14] For either tolerance or progression and this really has achieved some positive outcomes resulting in diet upgrades. We don't want our kids stuck on a puree if we can quickly get them to a minced and moist, for example. I wanted to have you meet a case study meeting Casey. Casey moved into our district at the beginning of his And he was eligible to receive special education services under the criteria, the eligibilities of autism spectrum disorder, intellectual disability, and speech impairment.
[00:53:48] His evaluation from his transferring district indicated that his birth history was unremarkable. His oral structures and function were judged to be adequate for both speaking and feeding tasks. Upon enrollment, his parents indicated that Casey had not progressed his diet. And in fact, mom indicated that his diet had even become even more limited.
[00:54:12] The transferring school indicated that he was exhibiting non compliant behaviors that looked like Task refusals, eloping, physical aggression, etc, etc. And the frequency of these behaviors varied from day to day. But what they found is there was a correlation that they noticed that behaviors improved on the days that he would eat.
[00:54:38] Now eating was a struggle for Casey. He, if he did not have his one brand one flavor of baby food. He's fourth grade. Okay. He would refuse to eat. Apparently they had discontinued his original flavor that he ate. And he went through some drastic changes at the transferring school where he ended up refusing to eat at school for three weeks.
[00:55:08] I know completely frightening. Well, luckily, the teachers and the therapists at that campus and with support with the parents were able to get Casey to work. And accept a new flavor. Thank goodness. So when he started to, to eat that new flavor, they were able to get him to work for his preferred activities because he is, he's now getting his nourishment.
[00:55:32] Well, we, baby food is not nourishment, but that's a story for another day, ladies and gentlemen. All right. So unsurprisingly, I was called in to consult. I called mom and she indicated that Casey was still only eating one flavor puree. out of its original container. And actually he was only drinking one flavored drink out of a specific sippy cup as well.
[00:55:56] Mom at this time was sending in four baby food containers. It was a stage three to school each day. It was only one brand and only one flavor of juice along with his one sippy cup he would use. Mom continued to reassure us that he was eating soft table foods at home like scrambled eggs, pastas, titty grams, and ice cream.
[00:56:17] But at home, he only drank his juice out of this one cup. Also. Well, I'm like, where do we even start here? Well, I started by an observation of his current feeding system. And I really observed, I know this is no surprise, a lot of rigid routines, like he had to open the door three times before he would enter.
[00:56:38] And then if the blinds were open, he would insist that they were shut. He was, he was, he unsuccessful full stop in the cafeteria. So the staff had him eating in the classroom. He was completely an independent eater. He can open all of his containers. He could feed himself his baby food by spoon. Remember had to be directly out of the container at room temperature, room temperature.
[00:57:00] Okay. So my initial assumptions were that his deficit stemmed from extreme behavior surrounding his relationship with food and his sensory. Responses to his environment. Now, you and I both know this is way bigger than just SLP, so I brought in the Teddy Graham's at the chocolate chip flavor that was reported.
[00:57:23] He ate at home and it was a no-go at all. So I asked mom, Hey, take a pho a video of him eating those teddy Grahams at home. So another little key component about about our little Casey is that he had sort of this orange tinge to his skin from the carotene of all the veggies that were in the baby food.
[00:57:45] It was just a really carotene heavy diet. All right. So while we were waiting for the video from mom, which unfortunately took several months, it's okay. We definitely got a plan in place. The IEP committee got together and we agreed that occupational therapy needed to evaluate. It was really warranted to address his sensory processing because this was really affecting his activities of daily living with feeding being a major component.
[00:58:14] But we also, the IEP committee also Agreed that psychological services was also needing to be enlisted in a consulted consultative role in order to support his teacher and the educational team to address his ritual, rigid and ritualistic behavior surrounding his relationship with food and his response to his environment.
[00:58:37] As a whole feeding goals were developed to address pre oral phase deficits. These were implemented by the O. T. In the classroom teacher. Now, I, the S. L. P. I was just utilized as a consultant to reassess his oral skills as his acceptance of new foods developed and assisting guiding the treatment plan. The classroom teacher in the O. T. Really shaped his behavior. What they started with is providing really highly motivated vessels in order for him to start consuming his same meal, room temperature, the same way, spoon out of his original container, spoon set in the really fun bowl, and then he would take it.
[00:59:17] Eventually, he was scooping out his puree and putting it into all sorts of different vessels. At the same time it was set up that he was able to rehearse the cafeteria by going through the line with a tray, looking at the items, talking about the food with, with his paraprofessional. He, he, there was no pressure in eating, no pressure in even picking it up.
[00:59:40] But eventually the staff, we were able to entice him through using a blender that let's go through the line. Choose an item, take it back to the classroom, blend it. That was a highly motivating activity for him to do. He loved blending the food and he started slowly accepting tiny increments of blended food to his preferred food.
[01:00:06] Now this is not a sustainable activity. This is not something that we can do every day forever, right? So once we got him used to having that puree. We quickly started him on the district's pureed meals from our dysphagia menu. He was able to interact with the meals. He was able to open up all the containers.
[01:00:25] He was able to scoop an entree of his choice. Now our meals come with the entree, two fruits, two veggies. So he was able to make choice of what he wanted on his tray, along with his preferred food. And we were able to move up the hierarchy. Casey responded positively to the use of what we would call spontaneous presentation.
[01:00:49] That's where he was scooping the novel food and then dipped into his preferred food before eating it. We, meaning really the teacher here, was fading that out fading out that need of his preferred food before eating. And once we had him consuming a pureed meals, We were able to quickly move him to mince and moist piece of cake.
[01:01:10] And then we were able to utilize finally the video of him with the, the Teddy grams from, from home. Utilizing that video, he accepted to be, he accepted eating the Teddy grams at school. So we incorporated that. We quickly, well, I don't know how quickly, but it's quickly, but we were able to make steady progress and move to soft and bite size.
[01:01:35] Yes, this was year long. It did appear to be very, very slow, but we seriously took pride and celebrated even his slow and steady progress. And I am super, super excited to say that he is currently eating a typical diet from the regular menu and is no longer tinged orange. We are really excited.
[01:01:59] That was just one case study that I could share today. Because I think we're running at just about running out of time. I don't want to go over too much. But I am so glad that you joined me for this episode. I know that providing dynamic feeding and swallowing support district wide is really super daunting.
[01:02:18] But the significant health risks that, that are associated with this disorder really do demand specialized clinicians providing student centered feeding and swallowing interventions, supported by well trained staff, all following standardized procedures. You know, our students really truly benefit from the expert guidance in order to balance the interplay of mealtime skills and behaviors paired with those strategic interventions.
[01:02:46] But always thinking of least restrictive environment, but we also need to maintain adequate, safe and efficient nutrition while and hydration in order to optimize their educational participation. So I want to thank everybody for allowing me to share my, my passion for all things feeding with you today.
[01:03:07] And I want to say, oh, I'm going to say thank you. And I think that our time is up. And if you didn't get a hand look at those handouts, please take a look at those handouts and I hope to see you next time. Thanks so much. Bye bye.