Pediatric Dysphagia And Limited Self-Efficacy Among Speech-Language Pathologists

Pediatric feeding involves any aspect of eating and drinking which includes the gathering and preparing of food and liquid, sucking or chewing and swallowing (Arvedson & Brodsky, 2002). Pediatric swallowing is the complex process involving saliva, liquids, and foods which are transported from the mouth to the stomach while keeping the airway protected (ASHA, n.d.). Pediatric dysphagia is characterized by impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill and/or psychosocial dysfunction (Zimmerman, 2016). Speech-language pathologists are the preferred providers of pediatric dysphagia therapy (ASHA, n.d.).

The diagnosis and treatment of pediatric dysphagia not only requires significant depth and variety of knowledge, but it also requires swift problem-solving skills, quick decision-making, as well as flexibility and adaptability within the moment. One may also surmise that a high level of self-efficacy would be necessary for clinicians managing pediatric dysphagia. Albert Bandura defined self-efficacy as “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations” (1986). Bandura hypothesized that one’s self-efficacy affects how that individual will approach an activity or task (1977, 1982). For example, a person with limited self-efficacy for accomplishing a task may avoid it while another who believes himself to be capable of the task should participate eagerly (Schunk, 1989). Without self-efficacy, one might not feel comfortable managing pediatric patients with dysphagia needs or they may avoid it all together.

Outcome expectations are significant when considering self-efficacy of clinicians in the assessment and management of pediatric dysphagia. Outcome expectations are the beliefs regarding the possible outcomes of an individual’s actions (Schunk, 1989). There is no motivation to perform tasks that result in negative outcomes (1989), therefore, a novice clinician may feel uncomfortable with the management, that is the treatment and evaluation, of pediatric dysphagia. Schunk further goes on to state that “assuming adequate skills, positive outcome expectations, and valued outcomes, self-efficacy is hypothesized to influence the choice and direction of much human behavior (1989).” Is limited self-efficacy in pediatric dysphagia influencing novice speech-language pathologists’ (SLP) decision to manage feeding and swallowing disorders among the pediatric population?

The overall knowledge and skills obtained by SLPs in their professional training provides an exemplary and essential foundation for successful evaluation and treatment of dysphagia (Professional Advocacy Committee, 2006). The education of the SLP includes knowledge of “anatomy and physiology of oral, pharyngeal and laryngeal function and the aerodigestive tract, development of respiratory control, oral, pharyngeal and laryngeal skills in infants and children, aging and its effects on swallowing and swallowing disorders and swallowing disorders across the life span (Professional Advocacy Committee, 2006). However, despite the increase in the prevalence of feeding and swallowing cases, speech-language pathologists report low self-confidence and significant concerns regarding their breadth and depth of knowledge and training to provide pediatric dysphagia therapy (Angell et al., 2008; Bailey et al., 2008, Kurjan, 2000). Furthermore, there are numerous speech-language pathologists who report a lack of preparation and unease in providing pediatric dysphagia therapy (Knollhoff, 2023). ASHA encouraged graduate programs to increase education and training demands and provide students with the knowledge and skills to evaluate and treat dysphagia across a variety of populations and settings (AS-L-H, 2007). ASHA Code of Ethics indicated that speech-language pathologists working with pediatric dysphagia settings should be specifically educated and that experience in adult dysphagia does not qualify an individual to provide dysphagia assessment or treatment services to children (AS-L-H, 2010).

Zimmerman (2016) completed a study of 100 SLP master’s programs to determine if these programs offered a pediatric dysphagia class. It was found that 79% of the examined master’s programs did not offer a pediatric dysphagia course, but instead a course geared towards dysphagia over the span of life. Zimmerman also reviewed 2010 American Speech-Language-Hearing Association (ASHA) Code of Ethics which stated that SLPs working in pediatric dysphagia settings should be specifically educated and that experience in adult dysphagia does not qualify an individual to provide dysphagia assessment or management services to children. This study also looked at perceived preparedness of SLPs who had not had a course in pediatric dysphagia. Of 175 participants whose data were analyzed, 124 participants (70.86%) did not complete a pediatric dysphagia course. A total of 64.5% of these participants reported not feeling prepared to work with this population (2016).  

According to Knollhoff (2023), “research suggests limited opportunities within the academic setting to learn and develop pediatric swallowing and feeding skills, and perceived levels of discomfort are reported by SLPs.” The purpose of this study was to expand on previous research in academic preparation in pediatric dysphagia. Data was stated to be limited on how these skills are “currently” being addressed within graduate SLP programs. Stated research questions involved how graduate SLP programs are addressing pediatric dysphagia within academic coursework, how many hours of clinical experience in the area of pediatric dysphagia are being obtained by graduate SLP students, and what are the SLPs’ perceptions on how they were prepared to support the pediatric dysphagia population (Knollhoff, 2023).

First, 272 of American Speech-Language-Hearing Association (ASHA)-accredited academic programs were investigated to identify course offerings. A total of 3,960 course descriptions were analyzed, with only 316 (7.9%) categorized under dysphagia. Only 16 (0.4%) were further categorized as pediatric dysphagia. It was found that most programs offer one graduate-level dysphagia course that covers the subject matter across the life span (Knollhoff, 2023).

Next, this study investigated clinical clock hours and experiences received while participating in a graduate SLP program. This consisted of a survey created and disseminated using Qualtrics software and consisted of 18 questions regarding basic demographic information, clinical clock hours obtained, and perceived levels of preparation. A total of 93 surveys were analyzed, and the analysis indicated that dysphagia accounted for 19.7% of total hours reported with 7.4% falling within the pediatric dysphagia category. Further analysis indicated that pediatric dysphagia accounted for 1.8% of the total assessment hours and 1.3% of the total treatment hours reported. Perceived levels of preparedness were also captured by this survey using a 5-point Likert scale. It was reported that 60.3% of participants indicated their graduate program prepared them for assessment and treatment of pediatric dysphagia “not well at all” (Knollhoff, 2023).

This study reports staggering data that does not demonstrate support for SLP graduate students, nor does it support the area of pediatric dysphagia. However, the survey sample size is limited. Furthermore, clinical clock hours were obtained based on the participants’ memory, which may result in bias. Future studies should continue to explore the relationship between increased coursework and clinical clock hours in pediatric dysphagia and the skill set and confidence of SLP graduates and professionals. Furthermore, Knollhoff (2023) reports that “a common misconception is that pediatric swallowing and feeding is simply a miniature version of adult swallowing and feeding. The reality is that significant differences exist between the two age groups and individuals progress through many stages across the lifespan.” For example, some differences include anatomical (size, location) and physiological (chewing patterns, suck-swallow-breath pattern), which supports the idea that assessment, intervention, and training for pediatric and adult swallowing should be uniquely addressed (Knollhoff, 2023).

In conclusion, with obvious deficits in the education that is provided to the majority of SLPs at the Master's graduate level combined with the rigorous skillset necessary to evaluate and treat pediatric dysphagia, it is likely that novice SLPs do not have the self-efficacy needed in order to treat pediatric dysphagia. With the number of children requiring these services, this causes a major problem in the healthcare, to include nutrition, of our children. Further studies are necessary to determine if limited self-efficacy in novice SLPs is a determining factor in the lack of treatment of children with dysphagia. Furthermore, if limited self-efficacy is a determining factor, we must develop a methodology to improve self-efficacy among novice SLPs.

References

American Speech-Language-Hearing Association (n.d). Pediatric Feeding and Swallowing. (Practice Portal)

Arvedson, J.C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management. Singular

Association AS-L-H. (2010). ASHA Code of Ethics. Http://www.asha.org.policy2010r.

Association AS-L-H. (2007). Graduate curriculum on swallowing and swallowing disorders.

Bailey, R., Stoner, J., Angell, M., & Fetzer, A. (2008). School-based speech-language pathologists’ perspectives on dysphagia management in schools. Language, Speech, and Hearing Services in Schools. 39(4), pp. 441-450

Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychology, 37, pp. 122-147.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychology Review, 84, pp. 191-215.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory, Prentice Hall, Englewood Cliffs, New Jersey.

Knollhoff, S. M. (2023). Pediatric dysphagia: A look into the training received during graduate speech-language pathology programs to support this population. Language, Speech & Hearing Services in Schools, 54(2), pp. 425-435. https://doi.org/10.1044/2022_LSHSS-22-00114

Kurjan, R. (2000). The role of the school-based speech-language pathologist serving preschool children with dysphagia: a personal perspective. Language, Speech, and Hearing Services in Schools. 31(1), pp. 42-9.

Schunk, D. H. (1989), Self-efficacy and achievement behaviors. Educational Psychology Review, 1, pp. 173-208.