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Selective Mutism: A Pragmatic Approach

28 Selective Mutism: A Pragmatic Approach

Suzanne Hungerford

28.1 Introduction

Typically, children with selective mutism (SM) speak normally at home, but do not speak in certain social situations outside the home, particularly school. It is generally considered to be an anxiety disorder; however, other risk factors have been identified, including bilingualism, developmental delay, an inhibited temperament, environmental stressors, and the presence of a speech or language disorder.

28.2 Clinical History and Description

At age 7, KL was referred to a university speech clinic by her school principal and mother. They reported that KL had never spoken in school, but did speak normally at home. She did not communicate by any means at school except for an occasional head nod, and her teacher became particularly concerned when KL started urinating herself in the classroom. She rarely used the bathroom at school and did not eat or drink when other children were around.

KL spoke to no one at school, but did her schoolwork if it did not involve speaking and got average grades. Her mother reported that when around unfamiliar people, she would slump over, avoid eye contact, put her head down, and become unresponsive. However, she did interact and play with familiar classmates in school, albeit nonverbally.

28.3 Clinical Testing

Case history information was gathered through a written case history form and an interview with KL’s mother. She reported

KL had a normal birth history, met developmental milestones, and had no significant illnesses or injuries. She said KL appeared to hear well and spoke normally at home to her sisters and parents. English was the only language spoken in the home. Through the clinical interview, a matrix was created to clarify the people and environments in which she spoke (▶ Table 28.1). During the assessment, KL’s mother provided the clinicians with home audio recordings of KL reading aloud, which her teacher used to assess reading fluency. These recordings revealed mild articulation errors (f/ɵ and w/r).

Approaching the assessment room, KL walked slowly and then sat slowly in a chair. She did not make eye contact with the clinician; she lowered her head, looked down, and held her hands st iﬄy at her side. She made very little spontaneous movement and did not respond verbally o r nonverbally to attempts to engage verbally or nonverbally in any social interaction or activity. He aring screening and speech/language testing requiring interaction could not be accomplished.

The Social Skills Improvement System (SSIS) was used to obtain information about KL’s social skills and behaviors. The SSIS is a checklist based on obser vational data. The teacher and the parent forms were administered and both suggested KL h ad seve re deficits in social interaction and significant internalization (e.g., anxiety; ▶ Table 28.2). Additionally, a pragmatic language checklist was used to describe KL’sdeficits in verbal and nonverbal interact ion in the clinic and to track changes in behavior over time (▶ Table 28.3). Severe deficits were obser ved not only in all verbal aspects of pragmatics, but also in nonverbal aspects, including physical proximity, body posture, body movement, gestures, facial expression, and eye g aze.

Table 28.1 Discriminative stimuli for speaking: baseline

Home (only family present)

Mom X X (when she

Dad X

Sister 1 X X (when no

Sister 2 X X (when no

Grandma X (only on the

telephone)

Teacher

Peers

X,contexts in which KL spoke.

Home (nonfamily present)

Classroom Hallway Playground Mall Grandma’s

thinks no one else can hear)

one else is around)

X (when she thinks no one else can hear)

X (whispers answers to questions)

Selective Mutism: A Pragmatic Approach

Table 28.2 Results of the Social Skills Improvement System (SSIS): parent and teaching ratings

Teacher rating Parent rating

Social skills

Communication Below average Below average

Cooperation Average Average

Assertion Below average Below average

Responsibility Average Below average

Empathy Below average Below average

Engagement Below average Below average

Self-control Below average Below average

Total Standard score = 62;

Problem behaviors

Externalizing Average Average

Bullying Average Average

Hyperactivity/inattention

Internalizing Above average Above average

Total Standard

Low scores in social skills indicate the child has fewer social skills; high scores in problem behaviors indicates the presence of more problem behaviors.

percentile rank = 1

Average Average

score = 104; percentile rank = 67

Standard score = 63; percentile rank = 1

Standard score = 111; percentile rank = 80

28.4 Questions and Answers for the Reader

1. Which of the following statements about KL’s case are most likely true? a) KL’s SM was most likely caused by childhood abuse or

trauma.

b) Since KL made average or good grades in school, the dis-

order was not educationally relevant.

c) KL was initially not a good candidate for cognitive behav-

ior therapy.

d) KL was most likely simply refusing to speak.

Answer: c is correct. Cognitive behavior therapy is an intervention based on active collaboration with the therapist and patient, and requires active patient participation in the therapeutic process. The therapist and the patient work together to activel y solve problems and evaluate distortions in thinking that lead to maladaptive emotions and behaviors. Since KL initially had no means of communication with the therapist, this active therapeutic process was not possible; thus, a behavioral approach was used.

a is incorrect. Research indicates that childhood abuse is not a common cause of SM. The disorder is most often attributed to social anxiety. Social phobia is frequently reported in family members of people with SM.

b is incorrect. Many Common Core Learning Standards include oral communication skills, such as “ask and answer questions about what a speaker says in order to clarify comprehension,” and “speak audibly and express thoughts, feelings, and ideas clearly.” Children learn language and academic content by using language to engage with others in the academic environment.

d is incorrect. Children with SM are not simply refusing to speak. It is generally believed that children with SM find it impossible to speak in certain social situations because of overwhelming anxiety.

2. Which of the following best describes the role of the speech-

language pathologist in the assessment and treatment of individuals with SM?

a) Because this is a psychiatric problem, SM is outside the

scope of practice of speech-language pathologists.

b) The speech-language pathologist’s role is to monitor the

child’s progress with communication and make a referral for treatment if no progress is made in a year.

c) Speech-language pathologists, using evidence-based

treatments, can eﬀectively treat SM.

d) Speech-language pathologists can only work in the con-

text of interprofessional teams in the assessment and treatment of SM.

Answer: c is correct. Speech-language pathologists, with appropriate training in relevant evidence-based practices, can be eﬀective in the treatment of children with SM.

a is incorrect. The American Speech Language Hearing Association scope of practice documents indicate that speechlanguage pathologists may work with individuals whose communication disorder is of psychiatric etiology.

b is incorrect. Early intervention of SM is more eﬀective; the longer the duration of SM, the poorer the prognosis.

d is incorrect. Because of the complex nature of SM, it is preferable to assess and treat children with SM using interprofessional teams. Ideally, teams should include a physician (who may prescribe medications), the classroom teacher, a clinical or educational psychologist, and a speech-language pathologist. In KL’s case, the parent did not follow through on a referral to a psychiatrist, and in KL’s small, rural private school, there were no school professionals willing or able to treat her at school. When an interprofessional team cannot be established, a trained speech-language pathologist can and should provide evidence-based therapy for this pragmatic communication disorder.

3. Which of the following is true?

a) A “silent period” is a normal stage of second language

learning; therefore, SM cannot be diagnosed in children who are nonnative speakers of the ambient language.

b) Children who have articulation or language delays or dis-

orders cannot be diagnosed with SM.

c) Children with developmental disabilities such as autism,

fragile X, or intellectual disability cannot be diagnosed with SM.

d) None of the above.

Answer: d is correct. Research indicates that articulation or language disorders and second language learning are risk factors for the development of SM. Additionally, SM has been documented

in a wide variety of populations, including those with other developmental disorders such as autism spectrum disorder. The emergence of SM appears to depend on a variety of temperamental, developmental, and environmental factors. While social anxiety appears to be at the core of SM, the population is heterogeneous in other ways.

100

Selective Mutism: A Pragmatic Approach

Table 28.3 Assessment of the pragmatic aspects of language

Rating (0 = inappropriate; 1= emerging; 2 = appropriate)

Verbal aspects Time 1 Time 2 Time 3

a) Speech acts

1. Speech act pair analysis (takes both speaker and listener role)

2. Variety of speech acts (comments, asserts, requests, etc.) 0

a) Topic

3. Selection (appropriate selection of discourse topic)

4. Introduction (introduction of new topics) 0

5. Maintenance (maintenance of topic across discourse) 0

6. Change (change of topic in discourse) 0

a) Turn-taking

7. Initiation (initiation of speech acts)

8. Response (responds to speaker’s speech acts) 0

9. Repair/revision (to conversation breakdowns) 0

10. Pause time (between words, sentences, turns) 0

11. Interruption/overlap (in discourse) 0

12. Feedback to speakers (verbal and nonverbal indicators) 0

13. Adjacency (utterances occur immediately after partner’s utterance) 0

14. Contingency (utterances semantically related) 0

15. Quantity/conciseness (of verbal output) 0

a) Lexical selection/use across speech acts

16. Specificity/accuracy (of content)

17. Cohesion (unity/connectedness of discourse) 0

a) Stylistic variation

18. Varying of communicative style

Paralinguistic aspects

a) Intelligibility and prosodics

19. Intelligibility

20. Vocal intensity 0

21. Vocal quality 0

22. Prosody 0

23. Fluency 0

Nonverbal aspects

a) Kinesics and proxemics

24. Physical proximity

25. Physical contacts 0

26. Body posture 0

27. Foot/leg and hand/arm movements 0

28. Gestures 0

29. Facial expression 0

30. Eye gaze 0

Source: Prutting and Kirchner 1987.

a is incorrect. Some children newly immersed in an unfamiliar language environment will go through a silent period. Most children will emerge from this silence and begin to speak the new language as it becomes more familiar to them; however, very anxious or inhibited children may “get stuck” in this period, and the silence and reticence to speak become habitual, eventually becoming SM.

b is incorrect. Articulation and language disorders appear to be risk factors for the development of SM. Communication disorders may make an anxious or inhibited child self-conscious about speaking, which may contribute to the development of SM.

c is incorrect. SM can be found in children with and without other developmental disorders.

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Selective Mutism: A Pragmatic Approach

28.5 Description of Disorder and Recommended Treatment

Children with SM typically find it challenging to speak in the face of severe anxiety in certain social situations. SM is a relatively rare disorder and presents certain challenges to parents, teachers, and therapists. Although often thought of as “treatment resistant,” emerging data suggest that behavioral interventions (e.g., using reinforcement, shaping, stimulus fading, systematic desensitization) and cognitive behavior therapy (a type of psychotherapy that aims to change a person’s maladaptive thinking, emotions, and behaviors) can be eﬀective in treating the disorder. Other general therapy recommendations include use of “defocused” communication, reduced speaking pressure, and errorless learning.

Like some other children with SM, KL presented with a global disorder of verbal and nonverbal social interaction (pragmatics) manifested in specific contexts. Therapy began targeting early developing social interaction behaviors that precede verbal interaction, and worked up to oral communication in a hierarchical manner. The early developing skills targeted included joint attention behaviors (body and gaze orientation to others), shared aﬀect, gestural communication, and reciprocal play. Reciprocal social interaction was initiated through hand-overhand manipulation so that KL could engage in craft activities (e.g., gluing objects) and games that required nonverbal turntaking. Hand-over-hand assistance was slowly extinguished and independent participation in these nonverbal activities was eventually obtained. Desensitization was used to increase KL’s tolerance for noise making. Toy musical instruments were used, for example, to participate in a “band” with the clinician. Speech was shaped through reinforcement of noncommunicative vocalization of voiceless phonemes and then consonant– vowel combinations in gamelike activities. Real words were eventually shaped and were slowly transferred from noncommunicative contexts to communicative contexts. Clinicians sought to maintain a relaxed and supportive atmosphere and moved slowly and in small increments through behaviors that varied in novelty, communicative load, loudness, and modality (e.g., written and spoken communication).

28.6 Outcome

Once KL was speaking, pragmatic aspects of discourse were targeted in therapy. These included appropriate loudness of speech, quantity of conversational output, conversational adjacency and contingency, lexical specificity, and use of a variety of speech acts (e.g., asking, commenting, asserting). Skills obtained

in the clinical context were then carefully generalized to the school setting through the use of stimulus fading; KL and the clinician met and talked in the school library before school began, and over time, teachers and, students were slowly integrated into the interaction.

Standardized testing was now possible, and revealed KL’s language skills were within normal limits; composite standard scores on the CELF-4 ranged from 90 to 104; the standard score on the PPVT-4 was 100. KL no longer demonstrated articulation errors, and she participated in and passed a hearing screening.

Two and a half years after the initiation of therapy, KL interacted and spoke to her teachers and classmates in and out of the classroom. She no longer engaged in the immobile body posturing when in new social situations. She readily smiled and laughed. When the therapist called the school 6 months after discharge, her teacher reported her social and communicative behaviors were indistinguishable from those of her peers, except that she was “rather bossy.”

28.7 Key Points

●

SM is an anxiety disorder in which children speak normally at home, but do not speak much, or at all, outside the home. It is not due to any (other) communication disorder that prevents speech production (e.g., apraxia of speech, dysarthria).

●

It is psychiatric in its etiology, but SM is a profound pragmatic communication disorder. Communication disorders of psychiatric etiology are within the speech-language pathologist’s scope of practice.

●

Using evidence-based practices, SM can be eﬀectively treated by psychiatrists, psychologists, behavior therapists, speechlanguage pathologists, and interprofessional teams.

●

The problem can be much more pervasive than mutism, and clinicians may need to initially target nonverbal reciprocal interaction behaviors and production of speech sounds in noncommunicative contexts.

Suggested Readings

[1] Bergman RL, Gonzalez A, Piacentini J, Keller ML. Integrated Behavior Therapy

for Selective Mutism: a randomized controlled pilot study. Behav Res Ther. [serial online]. 2013; 51(10):680–689

[2] Lang C, Nir Z, Gothelf A, et al. The outcome of children with selective mutism

following cognitive behavioral intervention: a follow-up study. [serial online]. Eur J Pediatr. 2016; 175(4):481–487

[3] Toppelberg CO, Tabors P, Coggins A, Lum K, Burger C. Diﬀerential diagnosis of

selective mutism in bilingual children. J Am Acad Child Adolesc Psychiatry. [serial online]. 2005; 44(6):592–595

[4] Prutting CA, Kirchner DM. A clinical appraisal of the pragmatic aspects of lan-

guage. J Speech Hear Disord. 1987; 52(2):105–119

102

School-Based Swallowing and Feeding Treatment

29 School-Based Swallowing and Feeding Treatment: Oral Phase Dysphagia Secondary to Cerebral Palsy and Moebius Syndrome

Emily M. Homer and Katie C. Miranda

29.1 Introduction

Moebius syndrome is a nonprogressive craniofacial/neurological disorder that manifests primarily in facial paralysis. Individuals with Moebius syndrome cannot smile or frown, and do not have lateral eye movements. Respiratory problems, speech and swallowing disorders, visual impairments, sensory integration dysfunction, sleep disorders, and weak upper body strength may also be present.

29.2 Clinical History and Description

ML was a 7-year-old boy referred to the school district for multidisciplinary evaluation at 2 years, 6 months due to a diagnosis of Moebius syndrome, cerebral palsy, and global developmental delays. An initial screening revealed the student was “at risk” with regard to vision, hearing, sensory, fine motor, gross motor, speech, health, dysphagia, social/emotional/behavioral, and preacademic/readiness. Parent interview revealed a maternal family history of hearing loss, maternal and paternal history of depression, and a paternal aunt with mental disability. According to the parents, ML’s birth and developmental history included a full-term pregnancy; however, prenatal care was not obtained for the first 6 to 7 months of pregnancy due to lack of health care. ML’s delivery was uneventful. Developmental mile- stones, however, were significantly delayed. Medical history was unremarkable: no reported major accidents or illnesses requiring hospitalization. No daily medications were reported at the time of the evaluation. ML’s parents reported diﬃculty chewing and expressed concern regarding his feeding. However, ML was currently receiving all nutrition and hydration orally.

29.3 Clinical Testing

Multidisciplinary Special Education Evaluation: The evaluation process to qualify for special education services included academic testing as well as language, motor, and self-help assessments. Components of the eligibility evaluation for special education services met the requirements described in the Individual with Disabilities Education Act (IDEA). Academic testing indicated a severe developmental delay.

Speech and Language Testing: ML was assessed by a speechlanguage pathologist (SLP) to determine communicative functioning, including assistive technology needs as well as swallowing and feeding. Formal and informal assessment, parent interviews, and student observations were conducted. Although ML was nonverbal, he used a combination of eye gaze and vocalizations during the evaluation to indicate pleasure

and/or dislike. Mean length of utterances was not obtained due to his lack of verbal communication. Articulation, fluency, and voice were also not assessed due to lack of verbal responses. The Communication subtest of the Developmental Assessment of Young Children (DAYC) was completed and confirmed that ML displayed global language deficits of greater than two standard deviations from the mean. He exhibited deficits in his ability to understand and use vocabulary, comprehend oral information, follow oral directions, use short-term memory, and use appropriate social language skills. Assistive technology

communication strategies to increase functional communication and interaction with others.

Swallowing and Feeding: An examination of the oral peripheral mechanism was attempted, but due to ML’s age and disability, he was unable to fully cooperate. Therefore, structures were observed during play, and the ML’s parents were queried for additional information. ML was not observed to drool during the evaluation; however, his parents reported that ML frequently drooled and grinded his teeth. His parents also reported that ML used a sippy cup or straw to draw liquids. ML routinely overstuﬀed his mouth when eating with no choking or coughing observed. His parents also reported that ML pocketed food and swallowed solid foods without chewing. A videofluoroscopic swallow study (VFSS) was conducted, which indicated no aspiration or penetration. It was recommended that an oral peripheral mechanism be attempted again once rapport and cooperation were established.

Occupational Therapy/Physical Therapy: Occupational therapy evaluation revealed delays in self-help and fine motor skills. Upper extremity functioning, postural control, and mobility skills were decreased. Physical therapy evaluation revealed delayed gross motor skill development at the 6- to 8-month level. ML was dependent on others for transfers and general mobility; he demonstrated severe gross motor deficits. Results of the Developmental Profile 3 indicated moderate-to-severe deficits in all areas of development, including physical, adaptive behavior, social-emotional, cognitive, and communication skills.

Based on the multidisciplinary evaluation, ML met criteria for the classification of Other Health Impairment. Along with special education instruction, he was eligible to receive speech and language pathology, assistive technology, occupational therapy, physical therapy, adaptive physical education, and health services. He was referred to the swallowing and feeding team for comprehensive evaluation of his oral phase dysphagia.

Once in school, the school-based swallowing and feeding team conducted a clinical evaluation to determine how to safely feed ML at school. An oral mechanism examination was reattempted. ML presented with low tone in the cheeks and lips. Tongue cupping was observed, indicating possible ankyloglossia (tongue-tie); however, the SLP was unable to assess for

103

School-Based Swallowing and Feeding Treatment

tongue-tie secondary to ML’s lack of cooperation. High palatal arch and impaired dentition were noted. During oral intake, mild tongue and jaw protrusion were observed. ML exhibited a decreased rotary chew with munching pattern. He utilized his preferred sippy cup from home or a straw to draw liquids. Impaired lip rounding was observed with open cup drinking and, as a result, he was unable to drink from an open cup unassisted. Anterior loss of solids and liquids was also noted.

29.4 Questions and Answers for the Reader

1. Michael, a 6-year-old male student with Down syndrome, has oral phase dysphagia. He needs the following to be safe during meals at school: to have his food soft and bite-sized, to be supervised one-on-one during all meals and snacks, alternate one drink per three bites of food with cueing, and thin liquids in a low-flow cup. A swallowing and feeding plan is established for him and the classroom staﬀ are trained. What should the school-based swallowing and feeding team SLP do to assist with the implementation of a student’s swallowing and feeding plan? a) Train the classroom staﬀ/feeders on implementing the

swallowing and feeding plan. Staﬀ need to be trained on all areas of the plan, including texture modification of the student’s cafeteria meal.

b) Share the swallowing and feeding plan with the teacher

and tell her to put it in an easily accessed location.

c) Have the parents demonstrate how to feed the student at

school.

d) Train the teacher so that she can train her paraprofession-

als.

e) Write the swallowing and feeding plan on the student’s

individual education plan (IEP).

Answer: a is correct. It is important that the classroom staﬀ completely understand how to follow the student’s plan and that they have demonstrated correct implementation when observed by the team SLP.

b is incorrect. Although is it important to share the swallowing and feeding plan with the classroom teacher, it is not suﬃcient to give her/him a copy to file. Classroom staﬀ will need to be trained on how to implement the plan.

c is incorrect. It is of ten helpful for parents to demonstrate how the student eats at home; however, the school must feed the student according to what the district swallowing and feeding team has determined to be safe. As a member of the team, the parents should be aware of the student’s plan, which they may want to implement at home. The parents may choose not to be trained on the plan but the training should be oﬀered to them.

d is incorrect. Teachers must know how to safety feed all of the students in their classroom; however, they should not be responsible for training the paraprofessionals who may be the primary feeders. The team SLP and/or occupational therapist (OT) should do the training of at least three classroom staﬀ members.

e is incorrect. The IEP describes the student’s disorder and indicates what services the student will receive, including goals and objectives. The swallowing and feeding plan is a separate and more detailed description of how the student should be fed safely at school. The entire contents of the swallowing and feeding plan will not be on the IEP.

2. Mary is a 12-year-old student in the severe/profound special

needs class. Her swallowing and feeding evaluation indicated low tone in her cheeks and lips and overstuﬃng if left alone. Her swallowing and feeding plan included minced and moist food modification, swallowing before taking another bite, and one-on-one supervision during all meals and snacks. Monitoring and consulting is part of a comprehensive swallowing and feeding procedure. What service should the school-based SLP swallowing and feeding team member provide now that a safe feeding plan has been established?

a) Check on the student once a month to make sure the plan

is still eﬀective.

b) Consult with the classroom staﬀ on a regular basis by

observing the student eating and providing suggestions when indicated.

c) Send written reminders to the teachers and paraprofes-

sionals on how to feed the student correctly.

d) Once the classroom staﬀ is trained, tell the teachers to

contact the swallowing and feeding team if there are any concerns.

e) Remind teachers that the plan should be follow when

possible.

Answer: b is correct. The team should work closely with the

ensure that the plan continues to be correct

classroom sta and that it is being implemented with fidelity. The team should be available to classroom staﬀ to answer questions, demonstrate techniques, and guide them with implementation. The frequency of the monitoring will depend on the student and the therapist.

a is incorrect. For some students, once a month monitoring may be recommended; however, every child is diﬀerent and some will need more frequent monitoring and more active participation by the SLP and other team members.

c is incorrect. Although sending a written reminder might be one way the team communicates with teachers, it should not be the only method. Swallowing and feeding training takes a hands-on approach, with the SLP meeting with classroom staﬀ on a regular basis.

d is incorrect. The team cannot wait for a teacher to contact them with a concern. Professionals with training in swallowing and feeding must provide ongoing monitoring and consultation services to the classroom staﬀ.

e is incorrect. The plan must always be followed. The words “when possible” make this answer unacceptable.

3. Jenna, a 3-year-old student, was identified during her multi-

disciplinary evaluation as having a developmental delay with a swallowing and feeding disorder. The district should:

a) Refer the parents to an outpatient clinic for swallowing

and feeding services.

b) Talk to the parents and request a physician’s script to be

ﬀ to

able to address the swallowing a nd feeding at school.

104

School-Based Swallowing and Feeding Treatment

c) Refer the student to the school-based swallowing and

feeding team for an evaluation of the student’s feeding skills.

d) Inform the teacher that the student may have some trou-

ble eating the cafeteria meal and to watch her.

e) Put the results in the evaluation report and recommend

that the student bring her lunch from school since the cafeteria meal may need to be modified.

Answer: c is correct. The evaluation team identifies the concern of a swallowing and feeding disorder and recommends referral to the school-based team. The core team, made up of an SLP, OT, and nurse, then evaluates the student’s skills and determines how to safely feed the student at school. The evaluation includes a parental interview, clinical evaluation (observation of the student eating at school) and, if there is a concern of aspiration, a referral for VFSS.

a is incorrect. School districts have the responsibility to provide health services (of which swallowing and feeding is included) when they are necessary for the child to stay in school; therefore, they cannot refer the student to a private clinic without providing the services.

b is incorrect. It is important for a district to communicate with both the parents and the physician when a student has a swallowing and feeding disorder; however, it is not a requirement for the district to have a physician’s script to set up a swallowing and feeding plan. If they have a script from the physician, they must consider it but ultimately follow the recommendations of the school swallowing and feeding team.

d is incorrect. The teacher should not be responsible for determining what is safe feeding for a child with a swallowing and feeding disorder.

e is incorrect. School districts have a responsibility to provide a safe environment for their students. Parents cannot be required to provide the student’s lunch for it to meet safe guidelines. The student is eligible for either a free or reduced school meal or the parent has the option to purchase the cafeteria meal. The district should modify the meal if it is required for the child to be healthy and safe at school and to participate in her curriculum.

29.5 Description of Disorder and Recommended Treatment

ML’s IEP targeted increased functional communication, oral motor skills, and diet tolerance/advancement. The following goals were added to ML’s IEP:

●

Improving functional communication skills/initiation of interactions with peers and adults by making requests, labeling, and/or terminating during structured activities/meal using assistive technology strategies (i.e., visuals, voice output devices, switches, etc.) with cueing at 60% proficiency for 8 out of 10 sessions.

●

Performing three to four repetitions of oral motor exercises to improve strength, coordination/mobility, and sensation of articulators for swallowing and vocalizations with maximum assist three times per day.

●

Giving feeding and swallowing compensatory strategies; tolerating least restrictive diet as evidenced by no signs/

symptoms of aspiration, as progress is made, advancing diet to include one new food item per week.

The school district’s assistive technology team recommended ML utilize augmentative communication strategies/equipment to request, comment, and terminate during structured activities, such as meal time. The following augmentative and alternative communication strategies were trialed: a picture exchange system to request highly preferred toy/food items; single message voice output device to request “more” for desired foods, music, activities; multichannel voice output device to participate in educational activities and circle time, such as counting, days of the week, months of the year, and repetitive lines of a story.

The following oral motor exercises were incorporated into

therapy:

●

Facial/labial massage to improve sensation.

●

Lip tapping with gloved hand and lip pulls with trimmed Toothette to improve lip rounding.

●

Tongue pulls with trimmed Toothette to improve lingual retraction.

Because of his history of poor postural control and scoliosis, the SLP consulted with his physical therapist regarding optimal positioning during meals. It was recommended that ML be fitted with an adapted Rifton chair. He was seated at 90 degrees upright at a toddler table. ML’s back brace was also utilized to support his trunk when sitting at a table. Occupational therapy also recommended a low-flow training cup to improve tongue retraction/lip rounding and facilitate open cup drinking, teaspoon/fork with adapted grip, and suction bowl.

The SLP recommended soft, bite-sized solids and thin liquids. A safe swallowing and feeding plan was established based on information gathered from the interdisciplinary swallowing and feeding team. Feeding techniques/precautions included the following:

●

One teaspoon per bite/sip.

●

One bite/sip at a time.

●

Use of utensils as student preferred finger foods.

●

Maintain upright position 30 minutes after meal.

●

Drink after every three to four bites.

●

Direct supervision by classroom staﬀ/feeders was required for all meals and overstuﬃng/rapid intake needed to be monitored. It was recommended that staﬀ provide verbal and tactile prompts as needed to slow rate.

●

Staﬀ/feeders ensured that ML’s mouth was clear of residue after every bite (▶ Fig. 29.1).

All recommendations were included in a written swallowing and feeding plan. Classroom staﬀ/feeders were educated regarding recommendations and demonstrated proficiency in implementation, including texture modification. They were also educated regarding signs/symptoms of aspiration, such as coughing, choking, watery eyes, wet vocal quality, lethargy, and labored breathing.

As part of federal requirements for school cafeteria programs and because ML required a modified cafeteria meal at school, a prescription for meal modification form was completed and signed by a physician. The school’s cafeteria manager and

105

School-Based Swallowing and Feeding Treatment

Fig. 29.1 Students eat safely: swallowing and feeding plan.

staﬀ were notified regarding ML’s modifications to ensure compliance.

29.6 Outcome

ML received speech and language therapy, including assistive technology and swallowing/feeding intervention three times a week for 20 minutes per session. Therapy sessions took place in the ML’s self-contained classroom; classroom staﬀ were also trained regarding strategies to continue therapeutic tasks throughout the school day. ML progressed using a small jelly switch to activate cause/eﬀect toys and adapted computer software. He also used a two-cell, static-display (pictured icons) voice output device to request “more” and terminate (e.g., “all done”) during structured language activities and meals. ML consistently activated switches and voice output devices with

increased accuracy and improved timing; however, he continued to require multisensory prompts and cues.

With implementation of oral motor exercises and use of a low-flow cup, ML exhibited improved tone/sensation, tongue retraction, and lip rounding. Anterior loss of solids and liquids improved, but persisted. He no longer used the preferred sippy cup at school, which required a sucking action, and increasingly attempted an open cup. ML ate lunch in the cafeteria and had a modified school lunch tray prepared for him. Classroom staﬀ prepared the modified meal tray at a blending station in the cafeteria to meet the recommendations of the swallowing and feeding plan and sat with him throughout his meal to ensure compliance with the feeding plan. ML did not exhibit any signs or symptoms of aspiration or penetration and received adequate hydration/nutrition at school. The SLP continued to address functional communication and dysphagia goals per ML’s IEP for the entire school year.

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School-Based Swallowing and Feeding Treatment

29.7 Key Points

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Swallowing and feeding concerns should be considered during a multidisciplinary evaluation to qualify for special education services. Clinical evaluation of swallowing and feeding may be done once the student is enrolled in school. If a student does not qualify for special education services, then the student’s swallowing and feeding concerns may be addressed through a 504 plan.

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School-based SLPs work on many areas, including assistive technology, swallowing, and feeding. The identification and management of swallowing and feeding should be a part of the student’s overall communication and special education program. Therapeutic intervention to improve oral motor and functional feeding skills may often be done while working on communication. Training classroom staﬀ to implement both communication and swallowing strategies simultaneously may be eﬀective in carryover of skills.

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Addressing swallowing and feeding disorders in a school system should be done utilizing a team approach and a districtapproved procedure to provide consistency, accountability,

and clarification of roles and responsibilities, resulting in safe feeding at school.

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When addressing swallowing and feeding in the school setting, it is essential that a safe swallowing and feeding plan be established, that classroom staﬀ/feeders are trained on implementation of the plan, and that there is ongoing monitoring of the plan’s implementation.