Thanksgiving is the day set aside in the United States and Canada as a day of pausing to reflect all that we are thankful for by connecting with friends and family over good food. It is also the day of taking special precautions when serving people with developmental disabilities.
Aspiration is a huge risk during the holiday season. Factors that place people at risk for aspiration includes the following:
Being fed by someone else
Poor chewing or swallowing skills
Weak or absent coughing/gagging reflexes which is common in people with cerebral palsy or muscular dystrophy
Eating to quickly
Inappropriate fluid consistency
Inappropriate food texture
For children and adults with autism, Thanksgiving may be a challenge for a variety of reasons:
Sensory and emotional overload with large groups
Picky eaters
Difficulty with various textures of food
To help you mange Thanksgiving with ease, click on the articles below:
Children and adults with developmental disabilities often face challenges with eating, drinking and swallowing disorders than the general population. It is estimated that adults with intellectual disabilities require support from caregivers during mealtime. It is common among people who have a diagnosis of cerebral palsy, intellectual disability, physical disability and muscular dystrophy.
Dysphasia is a medical term used to describe any person having difficulty swallowing foods and liquids taking more energy and time to move food from the mouth to the stomach. Signs of dysphasia may include:
Drooling
Food or liquid remaining in the oral cavity after swallowing
Complaints of pain when swallowing
Coughing during or right after eating or drinking
Extra time needed to chew or swallow
Reflux of food
Dysphasia can lead to aspiration. Aspiration is defined when food, fluid, or other foreign material gets into the trachea or lungs instead of going down the esophagus and into the stomach. when this occurs, the person is able to cough to get the food or fluid out of their lungs, in some cases especially with children and adults with disabilities may not be able to cough. This is known as Silent Aspiration.
A complication of aspiration is Pneumonia which is defined as inhaling food, saliva, and liquids into the lungs
According to the Office of People with Developmental Disabilities Health and safety Alert, factors that place people at risk for aspiration include:
Being fed by others
Weak or absent coughing, and/or gag reflexes, commonly seen in people with cerebral palsy.
food stuffing and rapid eating/drinking
Poor chewing or swallowing pills
GERD- the return of partially digested food or stomach contents to the esophagus
Providing liquids or food consistencies the person is not able to tolerate such as eating whole foods.
Seizures that may occur during eating and/or drinking.
How to recognize signs and symptoms of Aspiration:
Choking or coughing while eating or just after eating
Drooling while eating or just after eating
Eyes start to water
Shortness of breath
Fever 30 minutes after eating
Intervene immediate if there are signs of aspiration:
Stop feeding immediately
Keep the person in an upright position
Call 911 if the person has difficulty or stops breathing and no pulse
Start rescue breathing
Minimize aspiration from occurring by serving the appropriate food texture and liquid consistency. If you are not sure of the right consistency, check with your health care provider. The following are pictures of food consistencies.
Courtesy of OPWDD
Whole. Food is served as it is normally prepared; no changes are needed in
preparation or consistency
Courtesy of OPWDD
1 ” Pieces cut to size. Food is served as prepared and cut into 1-inch pieces
(about the width of a fork).
Courtesy of OPWDD
1/4 Pieces Cut to Size. Food is cut with a knife or a pizza cutter or placed in a food
processor and cut into ¼ -inch pieces (about the width of a #2 pencil)
Courtesy of OPWDD
Ground. Food must be prepared using a food processor or comparable equipment
until MOIST, COHESIVE AND NO LARGER THAN A GRAIN OF RICE, or relish
like pieces, similar to pickle relish. Ground food must always be moist. Ground meat
is moistened with a liquid either before or after being prepared in the food processor
and is ALWAYS served with a moistener such as broth, low fat sauce, gravy or
appropriate condiment. Hard, dry ground particles are easy to inhale and must be
avoided.
Courtesy of OPWDD
Pureed. Food must be prepared using a food processor or comparable equipment.
All foods are moistened and processed until smooth, achieving an applesauce-like or
pudding consistency. A spoon should NOT stand up in the food, but the consistency
should not be runny. Each food item is to be pureed separately, unless foods are
prepared in a mixture such as a soup, stew, casserole, or salad.
Aspiration Precautions
Make sure the person eats slowly and takes small bites of food
Ensure the person takes small sips of liquids
Focus on the person’s swallowing
Make sure the person remains upright for a minimum of thirty minutes after eating
In providing services to those Adults diagnosed with a variety of Developmental Disabilities, the SLP’s role may become much more defined, focusing on what is most functional to an individual in the areas of speech, receptive and expressive language (verbal or non-verbal communication) and feeding/ swallowing. Very often we are attempting to assess and/or maintain an individual’s current level of functioning in the above areas and to train all those involved in the care of that individual in the strategies and implementation of them to achieve that goal. In our Agency, for example, we break the assessment down into the following areas in order to develop functional and measurable outcomes:
Speech
Does the individual use speech functionally to communicate wants/needs in a variety of settings?
If so, is their speech understood by all, some, few communicative partners? Are there any strategies a person might use to increase his/her intelligibility- modifying volume, rate, resonance, increasing fluency, etc.? Does the person use Augmentative Communication to supplement speech when he/she cannot be understood e.g. low/high tech communication device, writing, American Sign Language, Picture Language Board, etc.
Language
Receptive language (Language comprehension) including attention to objects, using objects functionally, identification of objects and/or pictures, comprehending one, two or three-step oral directives, vocabulary, comprehension of attributes and spatial relationships, or auditory comprehension on the word, sentence and paragraph levels. Is comprehension on the literal or inferential levels?
Expressive language- (Language expression)- for those who are verbal, the MLU (mean length of utterance) is assessed. For non-verbal individuals, language expression can be in the form of pointing to one or two picture symbols consecutively on a picture language communication board or AAC device, writing or typing single words, phrases, sentences or paragraphs on paper, computer or AAC device.
-AAC device assessments for nonverbal individuals take into account the individual’s cognitive skills, physical abilities in order to access the device (direct selection with hand or finger, eye gaze, head pointer, switch/scanning, etc.), receptive and expressive language skills, communicative intent and pragmatic language abilities, and literacy. All those involved in the individual’s care play an extremely important role in whether or not someone may receive an AAC device since they will be the ones to set up/take down the device and provide basic maintenance for the device, including programming, charging, etc.
Feeding and Swallowing:
Many people wonder why an SLP would be the one to review an individual’s mealtime plan or protocol. ASHA guidelines state it best: “The speech-language pathologist is a primary professional involved in assessment and management of individuals with swallowing and feeding disorders. These areas include:
Performing clinical swallowing and feeding evaluation;
Performing instrumental assessment of swallowing function with medical professionals as appropriate;
Identifying normal and abnormal swallowing anatomy and physiology;
Identifying signs of possible or potential disorders in upper aerodigestive tract swallowing and making referrals to appropriate medical personnel;
Making decisions about management of swallowing and feeding disorders;
Developing treatment plans;
Providing treatment for swallowing and feeding disorders, documenting progress, and determining appropriate dismissal criteria;
Providing teaching and counseling to individuals and their families;
Educating other professionals on the needs of individuals with swallowing and feeding disorders and the speech-language pathologists’ role in the diagnosis and management of swallowing and feeding disorders;
Serving as an integral part of a team as appropriate;
Advocating for services for individuals with swallowing and feeding disorders;
Advancing the knowledge base through research activities.
In addition, Speech-language pathologists have extensive knowledge of anatomy, physiology, and functional aspects of the upper aerodigestive tract for swallowing and speech across the age spectrum including infants, children, and adults (including geriatrics). The upper aerodigestive tract includes oral, pharyngeal, and cervical esophageal anatomic regions. Speech-language pathologists also have extensive knowledge of the underlying medical and behavioral etiologies of swallowing and feeding disorders. In addition, they have expertise in all aspects of communication disorders that include cognition, language, and behavioral interactions, many of which may affect the diagnosis and management of swallowing and feeding disorders.”
The dysphagia and feeding disorders that are seen in adults with developmental disability include poorly developed and absent feeding and oral preparation skills and competencies, physiological and anatomical impairments that degrade oral-pharyngeal and esophageal bolus motility, and disruptive or maladaptive mealtime behaviors. Nutrition, hydration, saliva management, ingestion of medications, and management of the oral hygiene bolus may be involved. Upper airway obstruction (choking), aspiration, malnutrition, and dehydration may result from the disorder (Rogers et al., 1994, Sheppard et al., 1988). Source: http://www.asha.org/policy/TR2001-00150/#sec1.3
Therefore, in our Agency that serves Adults with Developmental Disabilities, the SLP works as one member of the Team, including the Occupational Therapist, Physical Therapist, Nurse, Residential Team and Family Members to create a mealtime protocol or plan which simply states the best way to maximize nutrition while at the same time attempting to decrease incidents of choking (partial or complete blockage of the airway) or aspiration (food or liquid making its way into the lungs which can lead to aspiration pneumonia). These plans are developed so that all involved in the individual’s care may be informed of the best feeding practices for that individual which include: adaptive mealtime equipment (any cup spoon, plate, straw, etc. used for an individual to improve ability to eat independently and to improve oral-motor control), positioning in chair or wheelchair, degrees of assistance needed for self-feeding, food and liquid consistencies, food allergies and intolerances, the presence of any mealtime behaviors, including rapid pace of eating which may increase risk of choking or aspiration, and any specific instructions the caregiver would find useful in feeding the individual or maximizing the individual’s ability to feed themselves.
I hope you find this information helpful in identifying the SLP’s role in providing services to adults with Developmental Disabilities.
This information is in no way intended to serve as a complete guide in this area, but is meant to simply assist in identifying ways the SLP works as part of the Interdisciplinary Team in serving adults with developmental disabilities in a day habilitation setting
