Swallowing disorders—formally referred to as dysphagia—affect people of all ages, from infants with developmental delays to seniors with progressive neurological diseases. Swallowing disorders not only adversely affect an individual’s quality of life but can also threaten their health, safety, and well-being.
The goal of speech-language pathologists specializing in swallowing disorders is to maintain or maximize the health, functional abilities, and quality of life of patients with atypical eating and drinking behaviors.
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Understanding Swallowing Disorders in Different Patient Populations
Swallowing disorders involve difficulties with any step of the feeding process. Those with swallowing disorders demonstrate developmentally atypical behavior in the eating and drinking processes. This may include not being able to use age-appropriate feeding devices and utensils, not accepting age-appropriate foods or liquids, or not being able to eat independently.
Swallowing disorders can occur at one or more stages of the swallowing process:
- Oral Phase: Difficulty sucking, chewing, or moving food or liquid from the mouth to the throat
- Pharyngeal Phase: Difficulty initiating the swallowing reflex, moving food down the throat, and/or closing off the airway to prevent aspiration and choking
- Esophageal Phase: Difficulty relaxing and tightening the esophagus to move food from the esophagus and into the stomach
Pediatric Swallowing Disorders
Estimates reveal that between 25 and 45 percent of typically developing children demonstrate some types of feeding and swallowing problems. Infants and children with swallowing disorders (called pediatric dysphagia) may refuse food, only accept a very narrow variety of foods and liquids and in small amounts, or display age-inappropriate eating and drinking behaviors.
Among children with developmental disabilities, the prevalence of swallowing disorders is quite a bit higher, with estimates of between 30 and 80 percent suffering from some type of dysphagia. Further, 3 to 10 percent of typically developing children diagnosed with swallowing disorders were found to have what would be considered significant swallowing disorders that result in severe problems like failure to grow or chronic illness. Somewhere between 26 and 90 percent of atypically developing children with swallowing disorders have issues this severe.
Signs and Symptoms
Although signs and symptoms of swallowing disorders vary according to the age of the infant or child, typical symptoms include:
- Coughing or choking during or after swallowing
- Crying during mealtimes
- Difficulty chewing age-appropriate foods
- Breathing difficulty (changes in skin color, heart rate, respiratory rate)
- Uncoordinated suck-swallow-breathe pattern
- Frequent congestion and coughing, usually after meals
- Noisy or wet breathing during and after feeding
- Loss of food or liquid from mouth while eating
- Prolonged feeding times
- Refusal of food or liquids
- Taking only very small amounts of food at a time and/or holding food in the mouth for long periods of time
- Weight loss or inappropriate weight gain
Causes of pediatric swallowing problems include:
- Developmental disabilities
- Structural abnormalities (e.g., cleft lip, cleft palate, head and neck abnormalities)
- Neurological disorders (e.g., traumatic brain injuries, meningitis, cerebral palsy, encephalopathy)
- Factors affecting neuromuscular control and coordination (e.g., low birth weight, prematurity)
- Complex health conditions (e.g., pulmonary disease, gastroesophageal reflux disease, heart disease)
- Genetic syndromes
- Behavioral/social/emotional factors
- Medication side effects
Note: The area of pediatric swallowing and feeding disorders is one of the most rapidly growing focus areas for speech-language pathologists. School-based speech-language pathologists must have the knowledge and skills needed to manage swallowing and feeding disorders. In some instances, speech-language pathologists specializing in swallowing disorders may confer with school-based SLPs and recommend related services necessary for classroom management. Recommended swallowing and feeding plans are often referenced in students’ Individualized Education Programs (IEPs).
Adult Swallowing Disorders
Adult swallowing disorders are usually the result of neurological conditions, head and neck cancer treatments, and medical and surgical conditions.
Neurological Disorders – Swallowing disorders can result from any number of central nervous system disorders, as well as disorders associated with cranial nerves and muscles, such as head injury, stroke, and progressive neurological diseases, such as amyotrophic lateral sclerosis (ALS), Parkinson’s disease, progressive supranuclear palsy (PSP), postpolio syndrome (PPS), multiple sclerosis, and Alzheimer’s disease.
Head and Neck Cancer – Head and neck cancers, including oral and pharyngeal cancers, can result in swallowing disorders, depending on the size and location of the tumor, as well as the type of surgical intervention and reconstruction that results. Often times, swallowing disorders are a result of organ preservation (chemotherapy and radiotherapy) or tumor removal.
Signs and Symptoms
Signs and symptoms of swallowing disorders in adults include:
- Coughing during or after eating or drinking
- Recurring congestions after eating
- Food or liquids leaking from the mouth
- Chewing for an extended time
- Gurgling sounds during or after eating or drinking
Swallowing disorders in adults often leads to:
- Weight loss or dehydration due to difficult eating or drinking
- Recurring pneumonia and chronic lung disease due to aspiration
- Avoidance of social situations involving eating due to embarrassment
Job Scope, Duties, Roles, and Responsibilities of SLPs Who Specialize in Swallowing Disorders
Speech-language pathologists focus on the assessment, diagnosis, and treatment of adults and children with swallowing disorders. Their primary goals include ensuring adequate hydration and nutrition; minimizing the risk for pulmonary complications; and maximizing quality of life.
Their professional roles include:
- Clinical services: Diagnosis, assessment, planning, and treatment
- Prevention and advocacy
- Administration research
The job description of speech-language pathologists focused on swallowing disorders includes the following responsibilities and duties:
- Educating at-risk individuals and their families about swallowing and feeding disorders
- Conducting evaluations and comprehensive assessments using clinical and instrumental evaluation tools
- Identifying normal and abnormal swallowing anatomy and physiology and identifying signs of potential disorders
- Diagnosing dysphagia and making decisions about its management
- Interpreting data resulting from comprehensive assessments and creating dysphagia treatment plans
- Referring patients to other medical professionals for the appropriate tests, and using information obtained from tests that other medical specialists perform
- Serving as an integral member of an interdisciplinary feeding and swallowing team and consulting with other professionals and caregivers regarding the treatment plan
- Developing treatment plans, providing treatment, and documenting patient progress
- Recommending a swallowing and feeding plan for the daily management of swallowing and feeding activities
- Remaining informed of recent advances in dysphagia and helping to advance knowledge as it relates to the nature and treatment of dysphagia
- Advocating for individuals, groups, and their families at the local, state, and national levels
It is the responsibility of speech-language pathologists specializing in swallowing disorders to recommend alternative medical interventions (usually involving gastronomy or nasogastric tubes) if they cannot safely or efficiently support their patients’ nutrition and hydration intake. In these types of situations, SLPs provide education and counseling to patients and their families.
Earning the Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) Certification
During your master’s degree program in communicative sciences and disorders/speech-language pathology, you can get more exposure to information on dysphagia (both adult and pediatric) through elective courses, effectively customizing the curriculum to fit your career goals.
Your post-graduate fellowship is the ideal time to gain valuable, real-world experience working with adults and/or children with swallowing disorders. Consider working under a mentor with specialized knowledge in this area.
After passing the Praxis II: Subject Assessment in Speech-Language Pathology and becoming state licensed, you can then go on to earn ASHA’s Speech-Language Pathology Certificate of Clinical Competence (CCC-SLP) and begin preparing for specialty certification: The American Board of Swallowing and Swallowing Disorders’ Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S) Designation.
To earn the BCS-S designation, you must follow a three to five-year plan that includes a combination of clinical practice, continuing education, education/mentorship, leadership, and scholarship/research. You can read more about the specific requirements here.
Clinical practice requirements, by year, include:
- Year 1: Find a good supervisor with dysphagia experience (preferably someone who is a BCS-S) and find as many opportunities as possible to evaluate and treat patients with swallowing disorders
- Year 2: Begin developing an advanced skill area, such as pediatrics with feeding disorders or adult dysphagia related to a specific disease or etiology
- Year 3: Continue seeing patients with dysphagia, log your hours, find a mentor and begin preparing your application for BCS-S
- Year 4: Continue seeing patients with dysphagia; log your hours
- Year 5: Continue seeing patients with dysphagia; apply for BCS-S
Once you have applied for certification and have been accepted, you must take and pass a written examination through the American Board on Swallowing and Swallowing Disorders designed to assess your ability to achieve clinical competence in this area. You must complete the examination within 3 months of being notified of your acceptance. Your acceptance letter will detail the process of applying for and taking the exam.
You can prepare for the exam by reviewing test prep material and other publications found on the suggested reference list.
The BCS-S designation must be renewed every 3 years upon the successful completion of at least 7.5 CEUs related to dysphagia. Continuing education activities may include:
- Workshops, meetings, or course in swallowing and swallowing disorders
- Independent study (research projects, publications, internships, etc.)
- Self-study (videotapes, audiotapes, journals)