Anxiety and Dysphagia in Public Schools: Tips for OTs

Dysphagia in children is a medical condition that includes difficulties chewing and swallowing food and liquid safely.

Beyond being "picky eaters," this group of children is at high risk for malnourishment, illness and choking. By the time many children with dysphagia enter the classroom, new challenges arise, including balancing physical health with academic progress and social-emotional well-being.  

Recommended course: Pediatric Feeding: Red Flags, Common Recommendations, and the GI Relationship   

Students with dysphagia may develop anxiety toward food and eating demands, which can increase resistant behavior. An effective, holistic approach to treating children with dysphagia must provide the student with anxiety-reducing, self-monitoring, and self-regulation skills and strategies.  

Behavior, anxiety, and dysphagia 

Anxiety can smolder in the background, only surfacing when the student explodes out of fear or frustration. This can make it challenging to assess anxiety’s role in the child’s behavior. Schools' traditional approaches to behavior often don't recognize that anxiety is the underlying cause, and thus may be ineffective.   

For children with dysphagia, the issue is compounded by an existing medical condition. Traditional plans often use rewards and consequences, an approach that is counterproductive in students with anxiety. They shift the focus from eating to external rewards. This is particularly concerning given that children with dysphagia are at risk for developing long-term food aversions and maladaptive behaviors.  

Reframing the behavior  

A more effective way to address anxiety-related challenging behavior is to regard the behavior as a symptom of a skill deficit, much in the same way that an inability to read well is a symptom of dyslexia. For children with dysphagia, school personnel need to consider a therapeutic approach to the physical skill deficits related to swallowing, alongside specific cognitive interventions that teach coping skills, including self-regulation and self-calming.   

When these skills are consciously and effectively taught to students, behavior will improve and anxiety will reduce, allowing better access to treatment and making eating a more enjoyable experience.  

Recommended course: General Pediatric Occupational Therapy: Assessment and Intervention  

Traditional vs. alternative approaches  

Traditional behavior plans, like sticker charts and point or level systems, are based on rewards and consequences designed to motivate the student to behave. Think, "Five bites of chicken will earn you five points toward your computer time.” Typically, criteria for behavior are set and inflexible. They do not take into account the student's fluctuating level of anxiety and their subsequent variable ability to behave and perform.  

Usually, teachers set behavior goals based on the student's abilities when calm. In math class, the student could achieve the expectation of being quiet and attentive. When asked to try a new food, however, it could cause her to become anxious and start acting out. She is not able to meet the behavioral criteria due to the decrease in self-regulation, impulse control, and flexible thinking she experiences when anxious.   

This is not a simple motivation issue that can be addressed with potent rewards and consequences. The plan fails to address the origin of the student's anxiety, which is necessary to see long-term behavior change.  

Anxiety-informed interventions  

Students with anxiety need to learn self-regulation and self-calming skills. Self-regulation is the ability to identify their emotions, understand that emotions and start small and grow larger, and "catch themselves" in the early states of frustration. They can then use a self-calming strategy before they explode or shut down.   

Students often require explicit instruction in each of these steps. A variety of tools and techniques can help teach and reinforce the skills they need. Assigning positive reinforcement, such as points or tokens, for practicing self-regulation or self-calming skills reinforces the use of these strategies in difficult moments.  

Tools for identifying emotions  

An "emotional thermometer" is a great tool to illustrate and label the fluctuating emotions children experience throughout the day. For example, a teacher may say, "I notice you are calm and happy right now." Adding the student's self-regulation strategies to the emotional thermometer is helpful for cueing them: "New foods are hard. I think you're getting frustrated. What can you do about it?"  

"Body checks" are another way to educate students on their emotions and arousal state. Narrating the behavior clues for the student while indicating their feelings can help them understand what an emotion feels and looks like for them.   

The teacher may say: "Your voice is very high-pitched and loud. You're talking fast and you're moving a lot in your chair. You're anxious." Over time, the student will learn to identify the emotion, which is the first step in learning to regulate it.   

For students with dysphagia, regular body checks before, during, and after mealtimes provide the student and school staff with important information on whether to scale back demands or safely increase expectations.  

Self-calming strategies  

Many students do not know how to self-calm, which is why explicit instruction and practice is important. Practicing self-calming techniques (e.g., deep breathing or progressive muscle relaxation) as often as twice a day, especially in the place where the student would be taken if he became upset (e.g., the guidance office or a quiet corner), can foster automaticity of the skills when they are in that space during an actual behavior incident.  

Calming boxes are a collection of small calming items that the student keeps in a box to use in times of stress. It might include putty, a good luck charm, or noise reducing headphones. As with anything else, the student needs to learn when and where to use the items to self-regulate. A calming box can be kept in the student's cubby with their lunchbox. This makes it easily accessible when it's time to walk to the cafeteria or snack table. A lucky penny or similar item can be taken from the box and held during transitions in the building (e.g., to the cafeteria) or stressful eating times.  

Accommodations and transition supports  

For many students with anxiety, transitions from any activity to an eating demand, such as reminding a student "after chorus it will be time for lunch" or "5 more minutes of reading before it's time for snack" can be triggers for behavioral issues.   

Accommodations may include letting the child start in the cafeteria a few minutes before the other children arrive. They may include introducing new foods during non-scheduled eating times through food play. Video-modeling can be a helpful and explicit way of previewing behavioral expectations and cueing past success before, during, and after mealtimes. This can help mitigate anxiety.  

For children with anxiety and dysphagia, surprise changes to schedules that affect eating times can also trigger anxiety and challenging behavior. Previewing any unexpected change and prompting the student to use a coping strategy can help a student handle these moments. For events like field trips, this may mean having a backup of foods or high-calorie drinks that are historically successful.  

A holistic approach for students with anxiety and dysphagia must acknowledge and reduce the role of anxiety and underdeveloped skills in a student's resistance toward eating and food.  Teaching self-regulation and self-calming skills allows students to better manage anxiety. This will position them to have a more successful, healthy, and positive school experience.  

References  

• Prasse JE, Kikano GE. An overview of pediatric dysphagia. Clinical Pediatrics, 48(3), 247-251.  
• American Speech Hearing and Language Association. Pediatric dysphagia. Available at: www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965&section=Causes.  

This article was em>written by:

Jessica Minahan is a behavior analyst, special educator, and director of Behavioral Services at NESCA in Newton, Mass. She is the author of The Behavior Code Companion (Harvard Education Press, 2014). With Nancy Rappaport, she is coauthor of The Behavior Code (Harvard Education Press, 2012).  

Dr. Kerry Davis is a public school speech-language pathologist in the Boston, Mass. area. Dr. Davis specializes in children with complex feeding and communication profiles.