Team Lunch Check out a successful statewide model to help students with disabilities receive customized supports at mealtimes. Features
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Features  |   May 01, 2018
Team Lunch
Author Notes
  • Perry Flynn, MEd, CCC-SLP, is the speech-language pathology consultant to the North Carolina Department of Public Instruction and a professor in the Department of Communication Sciences and Disorders at the University of North Carolina at Greensboro. He is ASHA’s vice president for planning and is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 16, School-Based Issues. pfflynn@uncg.edu
    Perry Flynn, MEd, CCC-SLP, is the speech-language pathology consultant to the North Carolina Department of Public Instruction and a professor in the Department of Communication Sciences and Disorders at the University of North Carolina at Greensboro. He is ASHA’s vice president for planning and is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; and 16, School-Based Issues. pfflynn@uncg.edu×
  • Lauren Holahan, MS, OTR/L, is the occupational therapy and Medicaid consultant at the North Carolina Department of Public Instruction, and an associate professor in the Division of Occupational Science/Occupational Therapy at University of North Carolina Chapel Hill. lauren_holahan@med.unc.edu
    Lauren Holahan, MS, OTR/L, is the occupational therapy and Medicaid consultant at the North Carolina Department of Public Instruction, and an associate professor in the Division of Occupational Science/Occupational Therapy at University of North Carolina Chapel Hill. lauren_holahan@med.unc.edu×
  • Access North Carolina’s materials related to this article at on.asha.org/meal-support.
    Access North Carolina’s materials related to this article at on.asha.org/meal-support.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / School-Based Settings / Features
Features   |   May 01, 2018
Team Lunch
The ASHA Leader, May 2018, Vol. 23, 58-65. doi:10.1044/leader.FTR2.23052018.58
The ASHA Leader, May 2018, Vol. 23, 58-65. doi:10.1044/leader.FTR2.23052018.58
It’s been a while since Holly finished her snack, but she’s coughing and tearing up. This catches a speech-language pathologist’s attention as she walks through a self-contained classroom for students with severe disabilities. In talking to the teacher assistant who fed Holly, the SLP learns that Holly consistently experiences this sort of tearing and slight coughing about a half-hour after meals.
Immediately the SLP and teacher check Holly’s IEP to see what’s noted about her eating or drinking. Nothing is noted. The SLP initiates the school’s Multi-Tiered System of Support (MTSS) team process and notifies the school nurse of her observation. Because this is an issue with potentially significant health implications such as choking or pneumonia, Holly’s parents are notified of the concern and the IEP team is convened. The SLP and nurse talk with the parents regarding any information about difficulties in eating. The parents report a behavior pattern mirroring what the SLP and teacher assistant see but did not connect this with eating.
The SLP coordinates an IEP team meeting to determine a course of action. The team calls for a re-evaluation of Holly, recommending a modified barium swallow study. The parents arrange for this through their physician. The results show Holly is aspirating small amounts of thin liquid. The IEP team reconvenes, bringing in Holly’s physician via phone to clarify the medical statement and explain her aspiration. The team calls in the school district’s nutrition director to help them write a feeding plan and modify Holly’s IEP, which will now include goals for feeding positioning and caloric intake, as she has been losing weight.
The team determines that the nurse will monitor caloric intake, the occupational therapist (OT) will guide the teacher and assistant in positioning, and the SLP will instruct the teacher and assistant in feeding the student smaller portions and in thickening liquids with a product provided by the school. The school nutritionist will modify the consistency of foods according to the medical statement. Each team member will collect and share data on Holly’s feeding progress at meetings every six weeks.

Our model ensures that students receive the hydration and nutrition required to thrive academically, functionally, socially and emotionally at school.

This example shows the benefits of an interprofessional team approach, in which “mealtime problem-solving teams” (as we call them) develop feeding plans for students with disabilities. These teams include representatives from speech-language pathology, school nutrition, nursing, occupational therapy, education, and state and local agencies such as ours—the North Carolina Department of Public Instruction (NCDPI).
Here in North Carolina we use a framework—the “Whole School, Whole Community, Whole Child Model”—per the Centers for Disease Control and Prevention—to guide the work of these teams. Although SLPs are critical to comprehensive mealtime support—and may often be the school-based hub of service coordination—they are one of many collaborators in this model.
Many of our students have complex health conditions, such as cerebral palsy, food allergies, autism spectrum disorder or cranio-facial anomalies. Our model ensures that they receive the hydration and nutrition required to thrive academically, functionally, socially and emotionally at school. We apply this model in all our state schools to coordinate the efforts of professionals in the school and outside community.
Our approach to school mealtimes for children with disabilities is informed by several core values. All members of the mealtime team acknowledge the seriousness and complexity of these students’ needs and work to create safe, typical mealtime situations. We collaborate with parents and respect their concerns so that students can thrive, and we work to comply with local, state and federal mandates.

Although SLPs are critical to comprehensive mealtime support—and may often be the school-based hub of service coordination—they are one of many collaborators.

Tiers of mealtime support
To realize these values, NCDPI supports mealtime teams’ use of MTSS when students show a previously undocumented feeding concern and do not have an IEP. Guided by this system, teams evaluate the mealtime needs of students with disabilities and intervene using either core (Tier 1), supplemental (Tier 2) or intensive (Tier 3) mealtime supports.
In the opening example with Holly, the SLP notified the MTSS team, but because Holly had an existing IEP, the team recommended a re-evaluation to collect additional data. If, however, a student does not have a previously identified disability and accompanying IEP, that student would require a more extensive MTSS progression through the tiers.
Of course, each state implements MTSS in unique ways, so you will want to apply the particular MTSS framework used in your state or district. According to the North Carolina approach, mealtime problem-solving begins with ensuring core (Tier 1) supports are available to all students. This guarantees a safe, appealing mealtime experience in natural environments, such as the cafeteria or locations where all students might eat.
Core mealtime supports include:
  • Safe food-handling procedures by anyone who touches food or drink consumed by students.

  • Nutritious and appealing meals, snacks and beverages.

  • Clean, welcoming, unhurried, meal/snack environment.

  • Supportive cafeteria logistics.

  • Opportunities to socialize.

  • Opportunities to learn mealtime routines/manners.

  • Behavioral expectations that are taught and reinforced.

Some students’ mealtime needs cannot be met with core supports alone. These students may require supplemental (Tier 2) supports, which may include:
  • United States Department of Agriculture (USDA) meal pattern adjustments (for example, to accommodate for diabetes, lactose intolerance, nut allergies, or other medical conditions).

  • Quieter areas to accommodate sensory differences/overstimulation.

  • Adult-led tables to model/teach/monitor social-emotional-behavioral skills and routines.

  • Adjusted table/seat heights.

A small number of students with significant and unique mealtime needs may require individual problem-solving and intensive (Tier 3) supports, such as:
  • Embedded, explicit social-emotional-behavioral instruction.

  • Separate, low-stimulation mealtime setting.

  • Extended time/adjusted routine for eating.

  • Adapted/modified physical set-up (for example, positioning equipment or utensils).

  • Adapted/modified food (ingredients, texture, viscosity).

  • Adult or peer helper.

Depending on the nature and severity of a student’s feeding needs, the MTSS team may refer the student for special education evaluation. All the information gathered on the student through MTSS will inform the IEP team.
Legal requirements
SLPs who practice in school settings are likely well-versed in MTSS, the Individuals With Disabilities Education Act, and Section 504 policies and procedures. But they may be unaware of USDA regulations affecting school mealtimes.
Of particular relevance to SLPs are USDA requirements that schools make reasonable modifications to accommodate children with disabilities at every meal; make substitutions on a case-by-case basis when supported by a medical statement; and work collaboratively with parents.
On receiving a signed medical statement—required by the USDA and North Carolina model before any student receives accommodations or modifications—the district/school determines what reasonable accommodations, services and supports the student needs to ensure mealtime access. If the school receives a medical statement for a student with an existing IEP or 504 plan, the required mealtime supports are added to the plan. If the student does not have an IEP or 504, the receiving school needs to determine if the new medical statement raises suspicion of a disability.
A suspicion of disability triggers the school/district’s Child Find obligation to evaluate the student. The SLP may be the person who reaches out to school nutrition services to include them in IEP discussions of accommodations/modifications described in the medical statement.
In compliance with USDA, North Carolina’s Medical Statement specifies foods/beverages/textures to avoid, necessary substitutions or modifications, and the nature of the student’s physical or mental impairment. The statement must be completed by a “medical authority,” which can include a physician’s assistant or nurse practitioner. (USDA requires a medical statement for school nutrition to modify typical meals served in schools.)
Team member roles
To determine what meal supports a student requires, the district/school initiates a team evaluation. The collective expertise of all disciplines bolsters knowledge and understanding of the unique needs of the student and provides more seamless coordination of services. Evaluation team members may contribute to the process as follows.
Student—describes own strengths, needs and experiences during mealtime; identifies goals for mealtime participation and health.
Parent—identifies concerns for student’s mealtime participation at school; provides school staff with medical documentation, instructions, medications and medical orders as directed by a physician; facilitates communication between authorized school staff, such as the school nurse and the student’s community-based providers.
Pediatrician or other community providers (dietician, nutritionist, feeding specialist)—completes medical statement; provides complete information regarding the student’s physical or mental impairment and its impact on the student; provides any previous and/or existing feeding/nutrition evaluations, care plans or other pertinent documentation from the student’s medical records; consults with the student’s school mealtime planning team as it analyzes student mealtime performance data.
School nutrition leader—often the director of school nutrition for the district, reviews the medical statement to assess the capacity of the school nutrition program to meet identified needs; consults with the assessment team on USDA regulations for meeting unique mealtime needs (such as ensuring the safe preparation and handling of food by trained staff).
School OT—conducts mealtime evaluation (or refers to the district’s mealtime supports and services team) by assessing environmental factors, mealtime routines, sensory issues affecting mealtime participation, biomechanics/motor skills, seating and positioning for mealtime participation. The OT also assesses the student’s need for adaptive equipment, diet/texture modifications and feeding techniques, refers the family to community providers, and consults with community providers about the student’s mealtime needs.
School nurse—assists the evaluation team in interpreting the medical statement, communicates with community providers to clarify/refine the medical statement, conducts nutrient analyses of the student’s diet, and assesses the student’s food/fluid intake and other health-related data (such as weight, vitality and growth). The nurse also describes required medical procedures during mealtime, such as tube feeding, allergy precautions and sterile procedures.
Instructional staff—provide data on student’s mealtime performance, describe classroom routines, and report on capacity of staff to meet student’s needs during meals.
School speech-language pathologist—conducts mealtime evaluations (or refers to the school district’s mealtime supports and services team) by assessing the student’s social skills and feeding and general mealtime performance, including the potential need for adaptive equipment. The SLP also identifies diet/texture modifications and appropriate feeding techniques and optimal positioning. In addition, the SLP helps families secure community-based evaluations and consults with community-based providers on students’ mealtime needs.
In many cases, the SLP acts as the school-based coordinator of all meal-related services for these students. However, depending upon the individual team, others—including the OT or school nurse—may serve in this service-coordinator role. Depending on the individual team and expertise of members, the SLP may also be a “mealtime needs specialist” devoted solely to these students across the district. Or they may be the school-based SLP who serves all students at the school. Because North Carolina is a site-based management state, we are flexible about which disciplines meet students’ various mealtime needs and take the lead in service coordination within the framework.

The interprofessional team should closely monitor students with swallowing disorders and plan supports that can be adapted over time.

Mealtime supports and intervention
If the team determines that the student has unique mealtime needs, they develop a plan (such as an IEP, 504 or Individual Health Care Plan) to provide mealtime supports in the least restrictive environment. The goal is always to allow students to participate in mealtimes in the school cafeteria and with typical peers as much as possible.
Mealtime accommodations in the school cafeteria may include:
  • Extended time for meal set-up and eating.

  • Specialized food textures and/or ingredients, which could require modified food procurement, menus, preparation and storage.

  • Sensory enhancements and environmental adaptions, such as environments with modified lighting, minimal distractions, or cups and plates that attract the attention of the student.

  • Positioning for safety, energy conservation and hygiene.

  • Specialized equipment such as National Sanitation Foundation-approved food-processing devices, adaptive utensils and dishes, positioning equipment, personal hygiene supplies, oral-stimulation devices and tube-feeding supplies.

Students may also require specially designed mealtime instruction and techniques, such as posture and positioning training, oral-motor interventions, scaffolded self-feeding training, and direct instruction in mealtime routines and social skills. Often, licensed personnel like school nurses, SLPs and OTs conduct assessments and design these special interventions, then train classroom staff (teachers or teacher assistants) to deliver them daily.
The team then needs to monitor students’ feeding progress as staff implement the interventions. This may involve collecting data on:
  • Student caloric intake.

  • Time required to set up and complete the meal.

  • Number of interactions with peers.

  • Number of adult cues needed.

  • Compliance with mealtime rules and routine.

  • Number of choking incidents or emergencies (such as seizures or coughing episodes) related to eating.

The frequency and intensity of a student’s progress monitoring should be driven by the degree of their feeding needs. For instance, the team should closely monitor students with swallowing disorders and plan supports that can be adapted over time. The team also needs to ensure that staff follow physicians’ orders, adhere to safe practices at mealtimes, and address any changes in feeding behavior. SLPs may collect or interpret this kind of data. They may also coordinate feeding data to demonstrate a student’s feeding progress over time.
Our “Whole School” interprofessional approach ensures all aspects of students’ mealtime needs are identified and addressed. As shown in the case study of Holly, the SLP often serves as the “go-to” staff member for feeding. Holly’s SLP brought concerns about Holly’s coughing and tearing to the MTSS team, which pursued a re-evaluation under Holly’s IEP.
In collaboration with Holly’s community providers, the team determined that Holly was aspirating at mealtimes and designed intervention and supports. With the help of the school nutrition director, the team determined food modifications. The OT aided staff with positioning Holly for feeding, and the SLP helped them with feeding her smaller portions and thickening her liquids. Holly’s SLP also helped the team determine goals for Holly’s feeding success to keep her thriving at school in the short and long term.
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FROM THIS ISSUE
May 2018
Volume 23, Issue 5