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[Dysphagia] Ethics and speech pathology.



There's no question that the child was refluxing.  There had already
been identification of GER but the group responsible is strictly
Skinnerian - everything can and must be explained by behavior- there
are no " inner states" - so that these children are identified as
voluntarily vomiting. I gave a talk to such a group once in which I
tried to explain (simply) dysarthria and that if there were no
innervation, there could be no muscle activity. One of the group said,
"But certainly behavior analysis could cure that."  I wish I were
making this up then I wouldn't feel so outraged and helpless.

On Mon, Mar 16, 2009 at 9:14 AM, Stephens, Shaun R.
<Shaun.Stephens at cvmc.org> wrote:
> 1. Sounds like a situation you would place a normal person in if you wanted them to become "autistic." Agree with Ms. Nelson on the approach to take.
>
> 2. I don't work with infants, but, the rumination issue sounds like it could be related to esophageal dysmotility/achalasia, GER, or other gastro-esophageal mechanical problem. Recommend pediatric GI and/or lactation consultant consult. Disagree with the lemon juice, because it is unlikely to be a behavior over which the baby has conscious control. This article had good suggestions:
>
> Olden KW. Rumination. Curr Treat Options Gastroenterol. 2001 Aug;4(4):351-358.
>
> Rumination is an unusual gastrointestinal symptom that is characterized by the repetitive regurgitation of gastric contents into the oropharynx. The
> regurgitation occurs very soon after a meal and tends to persist for 1 to 2
> hours. Rumination is defined by the setting in which it occurs. It is seen in three distinct populations: infants; individuals with psychiatric and neurologic disorders, particularly developmental disabilities; and adults who do not have overt psychiatric or neurologic disorders. The hallmark of rumination, which separates it from other disorders of the upper gastrointestinal tract (such as gastroesophageal reflux disease or cyclic vomiting syndrome), is the fact that in patients with rumination, the gastric contents appear in the oropharynx without retching or nausea. Rather, the patient makes a conscious decision on how to handle the regurgitated material after it presents into the oropharynx. The
> regurgitated meal usually consists of undigested or partially digested food. The regurgitation is effortless or at most is preceded by a sensation of belching immediately prior to the regurgitation itself. The management of patients with rumination needs to be accomplished in a highly individualized manner. Children with infant rumination syndrome often have symptoms related to significant defects in bonding with their mother. Thus, problems of mother-child bonding in pediatric patients with rumination syndrome should be identified and appropriately addressed. The management of adult patients with developmental disabilities or neurologic impairments who ruminate focuses mainly on behavioral modalities, including adversive conditioning and contingency management. The healthy adult who ruminates and has no evidence of neurologic or developmental disability is best seen as someone with a habit. Management in these patients is directed towards adjunctive therapies (ie, the use o!
> ?f proton pump inhibitors or H(2 )receptor antagonists to decrease acid injury to the esophagus) as well as
> identifying situations and emotions that trigger the patient's symptoms.
> Randomized controlled trials of various treatment modalities need to be
> undertaken; likewise, the evaluation strategy needed to best diagnose rumination is yet to be well defined. At this time, the challenge for gastroenterologists is to understand the nature of rumination, to identify individuals at high risk, and to use the management strategies most associated with good outcomes in patients with rumination in various clinical settings.
>
> Shaun Stephens, MS, CCC-SLP
> Central Vermont Medical Center
>
> -----Original Message-----
> From: dysphagia-bounces at dysphagia.com [mailto:dysphagia-bounces at dysphagia.com] On Behalf Of rene taylor
> Sent: Sunday, March 15, 2009 10:14 AM
> To: dysphagia at b9.com
> Subject: [Dysphagia] Ethics and speech pathology.
>
> What would you do under these circumstances? And no, I am not making these up.
> 1) A young man diagnosed (probably inaccurately) as autistic. Lives in
> a custom-built house that consists of a reception area with TV
> monitors, a living room containing a couch, a chair bolted to the wall
> and a stool bolted to the floor, a bedroom containing a single bed
> from which all sheets, blankets are removed during the day and a
> bathroom with a steel commode, a steel sink (the tap can be turned on
> only remotely by staff so that he cannot wash or drink), and a steel
> shower stall. He is constantly under TV scrutiny 24/7.There are no
> curtains, only blinds kept closed all day. He has lived here for some
> years, being provided "therapy" (unspecified) by a team of Applied
> Behavior Analysts who approach him only in pairs (he has no other
> human contact) because he becomes upset and "aggressive". It was
> decided that he had a swallowing problem (he actually does not) and a
> speech pathologist asked to assess/treat but without being allowed to
> touch him or approach him but "assess" only through inch thick glass.
> Would you agree to such a request?
> 2) Parents come to you distressed by the therapy they have been
> directed to perform in their six-month-old infant who was identified
> as having "rumination", by squirting a small amount of lemon juice
> into her mouth whenever rumination or its precursors were detected.
> What would you do?
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