CAOT Position Statement
Feeding, eating and swallowing and occupational therapy (2010)

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The Canadian Association of Occupational Therapists (CAOT) acknowledges the knowledge, skills and expertise that occupational therapists have to fulfill their roles in providing client services regarding feeding, eating and swallowing. CAOT also recognizes occupational therapists’ skills and abilities to fulfill leadership roles in the planning, organization and functioning of eating, feeding and swallowing services.

Occupational therapy services enable people to engage in everyday living through occupation (Townsend & Polatajko, 2007). Ingestion is an essential occupation of daily life which includes the actions of feeding, eating and swallowing. Having an understanding of the relationship among the person, occupation, and environment uniquely positions occupational therapists to provide evidence-based services that enhance a person’s ability to engage in the occupation of ingestion.    

Recommendations for occupational therapists

1. Occupational therapists advocate for their role in feeding, eating and swallowing management. 
2. Occupational therapists collaborate with stakeholders at national and regional levels to promote and engage in research to further our understanding of the impact the occupation of ingestion has on our health and well being.
3. Occupational therapists collaborate with stakeholders at national and regional levels to promote and engage in research to further best practices in all areas of feeding, eating and swallowing including dysphagia assessment and management.
4. Occupational therapists continue to develop consensus regarding interprofessional standards, assessment and management protocols for feeding, eating and swallowing.
5. Occupational therapists engage in continuing professional development to enhance their skills, knowledge and expertise in the areas of feeding, eating and swallowing.
6. Occupational therapists, working in the true spirit of interprofessional collaboration, recognize, respect and understand the scope, roles and contributions of all professional groups.
7. Occupational therapists recognize individual expertise, skills and knowledge of team members.
8. Occupational therapists utilize mentorship opportunities to share expertise, build workforce capacity and develop best practices.
9. Occupational therapists provide direct care, or care through the supervision of support personnel (e.g. occupational therapy assistants or personal care assistants), to enable the occupation of ingestion.
10. Occupational therapists seek out opportunities for leadership within the practice context (e.g. case management). 

CAOT Initiatives

To enable occupational therapists to develop and deliver quality services regarding feeding, eating and swallowing, CAOT will:

1. Work in collaboration with the profession and stakeholders that have a direct interest in the advancement of quality services.
2. Provide occupational therapists with access to research-based evidence and resources (e.g. McGill Ingestive Skills Assessment (Lambert et al., 2006a, b) to support implementation of best practice.
3. Foster opportunities for mentorship such as the mentoring gateway.
4. Offer continuing education opportunities on the assessment and management of eating, feeding and swallowing disorders.
5. Promote leadership within the field of feeding, eating and swallowing.  

Background

The Canadian Association of Occupational Therapists is the national not-for-profit voluntary organization that provides resources and services to develop excellence in occupational therapy services. Occupational therapists are graduates of university programs with baccalaureate or Master level degree and are regulated health professionals in all 10 provinces. Occupational therapists work with individuals, families, groups, communities, organizations and populations; with people of all ages, and levels of ability to promote health, well-being and justice through occupation. Occupations are groups of activities and tasks of everyday life that people are engaged in such as work, volunteerism, school, leisure and personal care.

Occupational therapists provide quality services in health care organizations, community services, schools and industry in both the public and private sectors. An evidence-based, client- centred approach is central to occupational therapy service delivery (Canadian Association of Occupational Therapists, the Association of Canadian Occupational Therapy University Programs, the Association of Canadian Occupational Therapy Regulatory Organizations , and the Presidents’ Advisory Committee, 1999). Occupational therapists utilize key enablement skills: adapt, advocate, coach, collaborate, consult, coordinate, design/build, educate, engage and specialize (Townsend & Polatajko, 2007).

The acquisition of sufficient nutrition and hydration is essential to life. Difficulties with nutrition and hydration have a pervasive impact on health and wellbeing. Occupational therapists have been enabling clients to meet their nutritional needs, in a reasonable amount of time, safely and with pleasure (Owens & Robertson, 1990) since the middle of the 20th century (Holser-Bueler, 1966). Occupational therapists regard feeding, eating and swallowing as a dynamic interaction between the person, environment and occupation.
 
Occupational therapy intervention may include, but is not limited to:

• Adapting , environments, equipment, feeding schedules/ routines or modifying food/liquid textures and consistencies
• Advocating for client rights to self-feeding.
• Coaching clients to progress in oral feeding and/or transition from tube feeding.
• Collaborating with other professions in the development of client-centred care plans for feeding and/or alternate forms of nutrition.
• Consulting to establish institutional practices for individuals with feeding, eating and swallowing problems.
• Coordinating service delivery and prioritization of care.
• Designing/building specialized equipment in the physical environment to support feeding or design
  behavioural modifications to manage sensory/ behavioral feeding difficulties.
• Educating client, families, caregivers, support personnel, teachers and other health professionals in food selection (including appropriate liquid/food consistencies) and preparation, appropriate feeding techniques, positioning for feeding, feeding schedules
• Engaging clients in psychosocial aspects of feeding.
• Specializing in the administration of instrumental assessment (e.g. videofluoroscopic swallow studies ,Fiberoptic Endoscopic Evaluation of Swallow (FEES), auscultation,) or treatment strategies to strengthen musculature and to reduce effects of abnormal muscle tone and sensory responsiveness.

Occupational therapists in Canada use a client-centred, process-based approach in the evaluation and management of feeding, eating and swallowing. They receive entry-level education which provides the knowledge and skills to be evidence-based practitioners. This education includes anatomy, physiology, neurology, pathology, human behavior and development across the lifespan, as well as profession-specific content related to professional reasoning, activity analysis, evaluation, intervention strategies, therapeutic activities, equipment adaptations and outcome measures.

Occupational therapists have a responsibility to maintain an awareness of current developments in the field and may further their expertise by seeking out mentorship, continuing education and research opportunities.

The occupational therapy practice is a context sensitive, dynamic collaborative process. Occupational therapists incorporate client’s hopes, dreams, values into this process; client - therapist collaboration is essential to both process and outcome. Eating and feeding are occupations that are client driven. The approach to a difficulty with eating, feeding and swallowing will depend on the beliefs and values of the client, and the inclusion of culturally appropriate or meaningful habits, traditions and foods. The occupational therapist will enable a client’s participation in this primordial occupation through negotiation of risk, power sharing and vision of possibilities for the client.

Glossary

Client-centred practice: is based on enablement foundations and employs enablement skills in a collaborative relationship with clients to advance a vision of health, well-being, and justice through occupation. (Townsend & Polatajko, 2007) Clientcentered occupational therapists demonstrate respect for clients, involve clients in decision making, advocate with and for clients’ needs, and otherwise recognize clients’ experience and knowledge (CAOT, 1997; 2002a)

Deglutition: act of swallowing (Jacobs & Jacobs, 2009)

Dysphagia: difficulty in swallowing, (CAOT, 2009,Jacobs & Jacobs, 2009)

Eating: “the ability to keep and manipulate food or fluid in the mouth and swallow it; eating and swallowing are often used interchangeably” (AOTA, 2007)

Evidence-based occupational therapy: includes experiential, qualitative, and quantitative evidence. “The occupational therapist provides knowledge of client, environment and occupational factors relevant to enabling occupation. Ideally, this evidence is derived from a critical review of the research literature, expert consensus and professional experience” (CAOT, ACOTUP, ACOTRO, & PAC, 1999, p. 267).

Enabling occupation: The process of facilitating, guiding, coaching, educating, prompting, listening, reflecting, encouraging, or otherwise collaborating with people so that they may choose, organize and perform those tasks and activities of everyday life which they find useful and meaningful in their environment (CAOT, 1997; 2002a).

Feeding: “the process of setting up, arranging, and bringing food [or fluid] from the plate or cup to
the mouth; sometimes called self- feeding”
(AOTA, 2007)

Ingestion: A construct of skills surrounding the taking of food into the body, described by a five-stage process: pre-oral (anticipatory), preparatory, lingual, pharyngeal, and esophageal. The first stage considers the interaction of pre-oral motor, cognitive, psychosocial, and somataesthetic elements engendered by the meal. (Leopold and Kagel, 1997) 

Occupational therapy: is the art and science of enabling engagement in everyday living, through occupation; of enabling people to perform the occupations that foster health and well-being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life. (Townsend & Polatajko, 2007)

Swallowing: involves a complicated act in which food, fluid, medication, or saliva is moved from the mouth through the pharynx and esophagus into the stomach (AOTA, 2007) 

Resources

Alberta College of Occupational Therapists. (2009). Position statement: Occupational therapists role in feeding, eating and swallowing available at http://www.acot.ca/files/Position_Stement_FES.pdf

Ordre des ergothérapeutes du Québec. (2006).Au-delà de la dysphagie, la personne avant tout : Rôle de l’ergothérapeute auprès des personnes présentant des difficultés à s’alimenter ou à être alimentées http://www.oeq.org/userfiles/File/Publications/Doc_professionnels/Dysphagie-doc_ gestionnaires%28sept06%29.pdf

References

American Occupational Therapy Association (2007). Specialize knowledge and skills in feeding, eating, and swallowing:for occupational therapy practice. American Journal of Occupational Therapy. 61, 686-700.

Canadian Association of Occupational Therapists. (1997; 2002). Enabling occupation: An occupational therapy perspective
(1st. Ed.). Ottawa, ON: CAOT Publications ACE.

Canadian Association of Occupational Therapists (CAOT), the Association of Canadian Occupational Therapy University
Programs (ACOTUP), the Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO), and the Presidents’ Advisory Committee (PAC) (1999). Joint position statement on evidence-based practice. Retrieved on October 27, 2003 from http://www.caot.ca/default.asp?pageid=156

Canadian Association of Occupational Therapists (2009). hOT topic: Dyspahgia. Ottawa, ON: CAOT Publications ACE

Holser Beuler, P. (1966). The Blanchard method of feeding the cerebral palsied. American Journal of Occupational Therapy.
20, 31-34.

Jacobs, K. & Jacobs, L. (2009). Quick refence dictionary for occupational therapy (5th ed.). Slack : Thorofare, NJ

Lambert, H.C., Gisel, E.G., Groher, M.E., Abrahamowicz, M. &Wood-Dauphinee, S. (2006) The McGill Ingestive Skills
Assessment. Test Manual and Evaluation Forms. Canadian Association of Occupational Therapists: Ottawa, ON.

Lambert, H.C., Gisel, E.G., Groher, M.E., Abrahamowicz, M. &Wood-Dauphinee, S. (2006) L’évaluation des capacités
d’ingestion McGIll. Instructions et formulaires. Canadian Association of Occupational Therapists: Ottawa, ON.

Owens,S. Robertson,H. (1990). Swallowing Disorders, Home Health Care Publishing Inc.

Townsend, E.A. & Polatajko, H. J. (2007). Enabling Occupation II: Advancing an Occupational Therapy Vision for Health,
Well-being & Justicethrough Occupation. Ottawa, ON: CAOT Publications ACE

Position statements are on political, ethical and social issues that impact on client welfare, the profession of occupational therapy or CAOT. If they are to be distributed past two years of the publication date, please contact the Director of Professional Practice, CAOT National Office, CTTC Building, 3400-1125 Colonel By Drive, Ottawa, ON. K1S 5R1. Tel. (613) 523-2268 or e-mail.