Development and Validation of a Scale for Assessment of the Risk of Aspiration in Children with CP

This doctoral study is composed of three studies focusing on the validation of an already existing feeding classification system (Study 1), a parental clinical assessment tool (Study 2) and development of a new scale for Speech-Language Pathologists (SLPs) (Study 3) each of which can be used to evaluate aspiration risk in children with cerebral palsy (CP) and support clinical decision making regarding referral for VFSS. Study 1 aims to establish the concurrent validity of the Eating and Drinking Classification System (EDACS) to identify aspiration risk using the Pediatric version of the EAT-10 tool (PEDI‐EAT‐10) as the reference test in children with CP. The second aim is to investigate the relationship between the EDACS and the PEDI‐EAT‐10 spiration vs. non-aspiration groups. In a convenience sample of 131 children with cerebral palsy and feeding problems (77 males, 54 females; median age 4.4y [IQR 2.5y]) data gathered from the EDACS and PEDI-EAT-10 were analyzed. Using PEDI-EAT-10 scores of ≥ 5 points, the EDACS was shown to be a valid tool to identify aspiration risk in children with CP (118 out of 131) classified in Levels III – V, with a 78% (95% CI=71%-86%) and specificity of 92% (95% CI=88%-97%) respectively. Positive predictive value = 0.989, negative predictive value = 0.316, LR+ = 9.75, and LR- = 0.24. The EDACS and PEDI-EAT-10 showed a significant correlation (rs=0.597, p<0.001). In conclusion, when possible, we recommend the use of both tools, the EDACS and the PEDI-EAT-10, when making decisions regarding referral for an instrumented swallowing study. Study 2 aims to use Rasch analysis to validate the PEDI‐EAT‐10 in a sample of children with CP. The PEDI-EAT-10 was developed based on the adult EAT-10 scale. Children with CP (n = 137, 24 – 83 months old) were assessed on the EDACS and the PEDI-EAT-10. The validity of the PEDI-EAT-10 was supported based on Rasch analysis. Rasch analysis also identified the PEDI-EAT-10 is a unidimensional measurement tool with a good item separation index, reliability, and absence of ceiling and floor effect. However, the PEDI-EAT-10 exhibited disordered Andrich’s thresholds of scoring categories and a lack of ‘easy’ items reflected by an unacceptable person reliability value equal to 0.79 (<0.80). Based on Rasch Analysis, the PEDI-EAT-10 would benefit from more ‘easy’ items on which a maximum score could be easily endorsed. Moreover, definitions for each scoring category might improve the overall Rasch analysis outcome. This pilot study 3 evaluated the intra-rater and inter-rater reliability, validity based on the Rasch analysis for the SARA scale developed to assess aspiration during the pharyngeal phase of swallowing in children with cerebral palsy. In addition, we were able to show the SARA can be used to assess feeding and swallowing SARA during video recorded mealtime sessions. Sixty-six children with CP (24 – 83 months of age) were videorecorded while being fed four food textures (up to five trials per texture) by their parents. The mealtime videos were evaluated by four SLPs trained to assess swallowing mealtime behaviors included on SARA. Intra-rater reliability was calculated using assessments from 13 videos (n = 214 trials) and inter-rater reliability was determined based on 12 videos (n = 195 trials) (six of which were used in intra-rater reliability study). Rasch analysis was used to evaluate item and person reliability, appropriateness of scoring system and the multidimensionality of the scale. The intra-rater reliability was excellent for item score (ICC = 0.94) and total score (ICC = 0.996), and substantial for identification of swallowing behaviors (Cohen’s Kappa = 0.74). The inter-rater reliability was acceptable for item score (ICC = 0.704) and excellent for SARA total score (ICC = 0.917). Identification of swallowing behaviors fair (Fleiss’ Kappa = 0.371). Rasch analysis showed SARA to be reliable, multidimensional tool and indicated the two subscales and the scoring system should be revised. The standardized definitions of the SARA indicated this may be a reliable clinical tool to identify children with aspiration risk, even in a telehealth setting. However, the inter-rater reliability study of swallowing behaviors' identification demonstrated unacceptable values and pointed to the need to standardize the definitions of swallowing behaviors, which might be accomplished by creating a panel of dysphagia experts. Rasch analysis showed that SARA is a valid tool to identify children with AR. Further research is needed to finalize revisions including the creation of two subscales and the revision of the scoring and the final item set.