By Lauren Tandy, M.S., CCC-SLP
This post is the second in the dysphagia teletherapy series. As I mentioned in the previous blog, dysphagia intervention by telepractice looks different for different age groups and impairments.
This week we will discuss oral myofunctional feeding intervention with a 10-year-old boy. This case scenario will be presented in a class on Tandy Therapy Box LLC at tandytherapy.com/shop shortly with a video demonstration, case study, and sample SOAP note.
A typically developing 10-year-old is more cognitively aware, self-aware, and able to attend to follow directions. In this case, I use a hybrid of parent coaching and child coaching.
The child presented with a tongue-thrust swallow. This affects his oral myofuntional development, facial development, dentition, and airway control. He had a ”gulpy” sounding swallow due to swallowing air while eating and drinking with tongue thrust. This gulping and air swallowing made him have to burp frequently. He was working on mouth-closed posture with appropriate resting position and tongue retraction for a more mature swallow during therapy.
For this case, I could start with teaching appropriate resting posture using online educational materials, including images that I either create or am able to share with screen share. Other options I might use may be getting the parent’s permission to email or text educational materials that I want to use in the session. Parents have the option to either pull them up on their computer when the session time comes or print them out ahead of time (if they have a printer at home). I recommend having the family print them if they are using a phone with limited screen space.
In order to teach resting posture, I might have the parents find something in the home that is similar to a tongue depressor that I can teach them and the child to locate their appropriate “spot” for tongue resting posture. This allows me to include the child in taking responsibility for the therapy while also making sure the parent is helping the child with reminders and practice times.
No "Homework" Rule
My goal is always to incorporate “practice times” into daily routines (like using the end of a spoon right before meal or snack times or using the end of a toothbrush And mirror to locate the spot for tongue placement every morning and night while brushing teeth. The other option I have (and I have used) is to order products from a Website to have mailed directly to the patient. If the patient wants to purchase the item, I will screenshare the Website and product I’m recommending or take a screenshot and email the picture and/or share the image in our client portal on my EMR platform (I use this in Theraplatform).
Modifications I make for teletherapy:
Get creative with tools
Use household food inventory (found at tandytherapy.com/shop in dysphagia telepractice readiness package)
Use household oral stimulation tools inventory to find out what we can use that they already have (also available in the dysphagia telepractice readiness package)
Use my platform’s PDF and resource share function to send recommended products and educational materials securely (I use Theraplatform.com)
Use videos and pictures to demonstrate what you are trying to teach (you can make these ahead of time or use images/videos you have access to send).
I may also videotape how they complete desired task either using my platform or HIPPA compliant program to playback to the client for biofeedback and increased self-awareness.
What my session will look like:
After I’ve followed the family coaching model to plan for the activity ahead of time (see the free step-by-step article “10 Steps for Family-Centered Coaching via Telepractice” article at tandytherapy.com/resources), then I will have the parent set up the session with the requested food and tools in the planned area (most likely the dining room).
Introduce the activity (and maybe have all of your tools and similar foods on your end, if available)
Teach on what you will be targeting for therapy (to parent and child)
Have the child practice targeted behavior (correct tongue resting posture)
Have him reflect on how he did (this continues to be part of the family coaching model).
Then you may want the parent to also reflect by using facilitating reflective questions (“How did that look?” “What did you see?”, etc.)
Give feedback to parent and child with recommendations to try.
Invite the child to practice again.
Reflect on changes/modifications with feedback.
Talk about what to work on between sessions (during routine-based activities so it is not “homework” and won’t be neglected).
Talk about what we will work on next session
What foods will they need?
What tools or utensils will they need?
Who will be present?
Where will the session be located at?
In this case scenario, I provided you with a glance at how I structure a teletherapy session with a hybrid direct/family coaching style therapy. The child is older and may have better self-awareness of goal targets. However, he is still young enough that he may not be motivated enough intrinsically to work on the practice tasks. He may need parent reminders and positive feedback throughout the week.
I would also work with the parent on creating a reward system. It may look different for each child based on what they are motivated by at the time. Some ideas might be positive verbal feedback, a sticker chart that earns an appropriate activity at a certain level, a tangible token (like a bead) that can be put in a jar to watch it fill up and make a necklace together when it is filled, etc. Rewards must be equal to the effort and not overkill, but enough to motivate the child.
Resources for Dysphagia Intervention:
As a supporting tool to help you service your dysphagia caseload, I have taken some of the elements of this blog and created easily adaptable forms for your therapy use. Visit https://www.tandytherapy.com/shop to purchase the Dysphagia Telepractice Packet with the following forms:
Dysphagia Telepractice Using Family Coaching Form
Signs and Symptoms of Airway Invasion
Household Food Inventory
Oral Stimulation Item Inventory
Keep an eye out for our first dysphagia course coming soon!
DISCLAIMER: It is the individual speech-language pathologist’s responsibility to follow all state, ASHA, licensure, and professional guidelines surrounding their intervention and practice. A clinician should always judge whether a family or client is appropriate for telepractice intervention – especially for dysphagia – to make sure that it is: in the client’s best interest; that no harm is being done; and that services may not be provided by a different format or venue that would better meet the child’s needs. This blog post in no way informs individual therapy and judgment that the clinician is responsible to perform. Lauren Tandy, M.S., CCC-SLP, Tandy Therapy Box LLC, Early Intervention Telepractice, and Tandy Therapy LLC is not liable or responsible for the results of the clinician’s intervention. We also do not promise results from therapy by using this information. Please refer to ASHA guidelines at asha.org for guidance in the practice of dysphagia intervention by a speech-language pathologist.
Lauren Tandy, M.S., CCC-SLP is a certified speech-language pathologist licensed in Idaho and Washington. She has a special interest in early intervention, feeding and swallowing issues, oral myofunctional disorders, telepractice, and speech-language development. Lauren is the administrator of Early Intervention Telepractice Facebook group for early intervention professionals. She is the Tandy Therapy LLC founder/CEO, and creator of Tandy Therapy Box LLC products, professional coaching, and classes. You may find more information at tandytherapy.com. Feel free to contact Lauren with any questions at firstname.lastname@example.org.