October 16, 2007 Feature

Gaining Cultural Sensitivity

Student SLPs Work and Learn in Bolivia

by Catherine Crowley

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Speech-language pathologists need to develop greater sensitivity to the diversity within the United States and express that sensitivity in their professional practice. At Teachers College Columbia University (TC), we developed a program to help meet that goal. Speech-language pathology master's students spend a month in Bolivia, living in and providing speech-language services in communities not dominated or defined by mainstream American middle-class school-oriented cultures. We inaugurated our Bolivian program in 2006, and with our 2007 trip, it has become an integral part of our graduate curriculum.

Bolivia is the second poorest country in the Western Hemisphere, with an average yearly income of $1,000. It encompasses great ecological diversity, including the Andes Mountains, the altiplano (plateau region), the pampas (plains), and the Amazon Basin jungle. Bolivia is a multi-ethnic and multi-lingual country: 60% of the people speak Spanish, but for many of them Spanish is a second language, with Quechua, Aymara, Guarani, and Amazonian languages as the first.

The 18 TC students and three ASHA-certified supervisors, including Elizabeth Ijalba, Jenyffer Ruiz, and Miriam Baigorri (coordinator of clinical experience), traveled to La Paz, Bolivia, for four weeks in May and June 2007. They comprised a diverse group: several were native Spanish-speakers from a number of different countries including Puerto Rico, Colombia, the Dominican Republic, Spain, Ecuador, and Uruguay; some had lived in Spanish-speaking countries; some grew up in other countries such as Japan, Korea, Italy, Canada, and Morocco. For some, this was their first trip abroad; others had traveled extensively. This diversity resulted in a wealth of perspectives that led to challenging and dynamic discussions during class and throughout the program.

Program Goals

Our group had several specific goals:

  • Provide and model activities that parents, teachers, school administrators, clinicians, and health professionals would continue to implement after we left
  • Use activities or materials that were accessible and easily duplicated in Bolivia
  • Be sensitive to culturally appropriate communications between parent and child
  • Encourage clients, parents, teachers, and other professionals to interact freely with us so that we could learn about their difficulties and offer solutions
  • Encourage self-sustaining activities so that the work could continue after we returned home

Speaking Spanish

Each student received two free weekly Spanish lessons, which they could supplement at their own expense. At meals, students could choose to sit at the Spanish-speakers-only tables or at the one English-speakers table. Most days, the Spanish tables were full, with only a few students at the English table—and they were often speaking Spanish. By the end of the month, even those students with fairly weak Spanish skills were using Spanish regularly within the group.

The students' morning clinical placements were in monolingual, Spanish-speaking settings. In these placements, students with weaker Spanish skills were generally paired with students who spoke Spanish well. All students, even those with weaker Spanish skills, participated in the charlas (presentations), which were given in Spanish.

Academic Course

The core of the Bolivian program is the academic course, which focuses on the cultures, education, health systems, history, and politics of Bolivian society. Living in close contact with Bolivian families and working daily with clients and Bolivian professionals facilitated this understanding. Students read a variety of information—from a January 2007 congressional report on the current state of Bolivia and its relationship with the United States to a book chapter by an anthropologist on child-rearing practices in an Aymaran village.

As part of the course requirements, students chose a specific disability to research. Before the trip, they researched the current theory and practice in the United States on causation, prevention, identification, and treatment of their chosen topics. Once in Bolivia, the students communicated with parents and professionals to gather information for a paper on these same areas in Bolivia.

Clinical Experience

Students in the program provided bilingual speech and language services under the supervision of SLPs who are native Spanish-speakers, licensed in New York, and ASHA-certified.

Some students worked at Camino de Sordos, a school for the deaf. About half of the 2006 TC group had worked there, developing an oral program for preschoolers to enhance the sign language program already in place. This year's group found that the school had expanded the oral program into the upper grades and were using it to enhance literacy instruction; the students expanded it further and left materials and support for continuing the program.

Our students also worked at CEREFE (Centro de Rehabilitación y Formación), a 20-year-old special-education school and rehabilitation center outside La Paz in El Alto, the most rapidly growing city (about 950,000 people) in Bolivia. El Alto is home to a growing population of indigenous people (mostly Aymara- and Quechua-speaking); it is very poor economically, but rich in culture and community. CEREFE began as a school for children with cognitive impairments and now includes children who are deaf and children with multiple disabilities who are cognitively age-appropriate. It provides services for children from birth through young adults in their mid-20s.

Our third placement was Hospital de Niños, the national children's hospital in La Paz. It is a full-service hospital with an active outpatient clinic, a well-baby clinic for birth through 6 years, and inpatient facilities. The TC students screened outpatient children for speech-language impairments and provided individual treatment two or three times a week. They worked closely with parents to explain how they were stimulating language.

The TC students also worked with inpatient children who needed speech-language treatment or feeding therapy. Many of these children had traumatic brain injuries; a number of very young children were failing to thrive. Few of the medical professionals had training in stimulating sucking and swallowing responses, or proper positioning and feeding.

In the afternoons, all the students generally worked with young inpatients in the hospital. Each student generally had one child to work with each afternoon. Students with limited Spanish skills tended to work with the young children, many of whom were malnourished or failing to gain weight appropriately. The TC students gave these children stimulation and attention, holding, touching, and massaging them; giving them eye contact and verbal stimulation; and feeding them. During the time we were there, we watched these children begin to gain weight and increase their responsiveness as the results of our work.

Charlas: Interactive Presentations

Students and supervisors gave 15 interactive talks, called charlas. The charlas on feeding and swallowing and on Down syndrome were the most popular and were requested repeatedly. Charlas were also given on cerebral palsy, autism, hearing loss and deafness, and current research on bilingualism for children with disabilities. We presented another to parents and teachers at Camino about implementing the oral program at home. The charlas generally began with a 20-minute presentation; TC students would then demonstrate specific techniques and approaches on each child in the room.

One of the presentations for parents of children with Down syndrome at CEREFE had more than 80 parents and teachers and 30 children. Often at the end of the charlas parents would stay to talk with one another, and we used that opportunity to help begin two support groups, one for parents of children with Down syndrome and one for parents of children who need to use alternative means of communication, such as a picture symbol system.

The charlas had a ripple effect—parents passed on the information to one another by word of mouth and modeling. For example, one of our students witnessed a mother assisting another in feeding her very young child according to the guidelines discussed in the parent presentation. They were following the suggestions exactly, even though neither parent had been present at the charla—the information had already been successfully passed on to them by someone else. We also observed nurses helping each other and informing other parents/caregivers on ways to help their children eat more and more healthfully.

Books

We brought about 80 Spanish-language children's books with us, and used them regularly with the children, modeling for the parents and teachers. At the end of our stay, one of our great joys was giving away all the books, especially to the children who loved particular stories.

One mother who had been bringing her child in for treatment at the hospital asked one of our TC students for specific instructions for how many times a day to read the book to her child. For this mother, the book was like medication—she wanted to make sure that she knew the daily dosage so that her child would get better.

The TC student gave her specific guidance on using the book—and then gave her two more, knowing she would definitely put them to good use.

Catherine Crowley, is a distinguished lecturer and coordinator of the bilingual/bicultural program focus, the Bolivian program, and the Bilingual Extension Institute in the program of speech-language pathology at Teachers College Columbia University. Contact her at crowley@tc.columbia.edu.

cite as: Crowley, C. (2007, October 16). Gaining Cultural Sensitivity : Student SLPs Work and Learn in Bolivia. The ASHA Leader.

Honoring Cultural Differences in Speech-Language Treatment

by Catherine Crowley

Students in the Teachers College Columbia Univeristy (TC) program in Bolivia learned to provide treatment in the context of Bolivian culture and tradition, especially the traditional dress of many mothers. Many women wear an awayo, a large woven fabric that women place on their backs and use for carrying potatoes, corn, and, of course, their children.

The supervising physical therapist at the Hospital de Niños and the education director at CEREFE encouraged mothers to take their children out of the awayos. The physical therapist was concerned that children carried in the awayo until 2 or 3 years old were not learning to walk, crawl, and support themselves sooner. The educational director was concerned that in the awayo, the children only saw the backs of their parents' necks and did not receive visual stimulation. Consistent with language socialization practices in the Aymara and Quechua of El Alto, mothers did not converse with their children in the awayos.

We wanted to respect the Bolivian cultures, and we struggled with how to approach parents of children with disabilities. Without daily stimulation from the parents or siblings—in addition to professional treatment—these children would not reach their potential. We spoke to a mother about how she had to be the eyes for her blind daughter so her daughter could learn about the world. We also noticed that parents did not talk to children who were not able to talk. For those children whose ability to understand language was greater than their ability to speak, such as those with cerebral palsy or Down syndrome, we wanted the parents to see how these children could understand and communicate.

Although we never asked a mother not to use her awayo, we did provide training on parent-child interactions that varied from the cultural norms that are perfectly appropriate for typically developing Bolivian children. We showed the mother of a 13-month-old child who had moderate developmental delays some interactive and enjoyable activities, such as anticipation games, a Bolivian version of peek-a-boo, and cause-and-effect games.

Jorge was an 18-month-old who was nonverbal from the effects of cerebral palsy. His mother did not speak to him because he could not speak to her. Jorge was a very bright boy; within two sessions he had begun to make choices and express his wants using eye gaze. Consistent with our cultural practices and preferred clinical practice, the TC students did a great deal of talking, asking Jorge questions, and verbalizing what he communicated through his eye gaze. When his mother saw his eyes light up with the interactions with the TC students, she began to talk to him in the same way that the TC students did. Several students made a communication book for Jorge. They shared the process with the mother, and showed her how to expand the book as Jorge's interests and abilities developed. Both the mother and Jorge picked up this new system of communication very quickly.

At 11 years old, José was nonverbal and diagnosed with mental retardation and cerebral palsy. He never communicated his wants or needs except to indicate that he needed to use the bathroom. The students developed a simple communication board for José that allowed him to communicate basic wants and needs such as hunger or thirst or fatigue. The students also helped the classroom teacher and the parent to use and expand the book. The students went to class with José and helped him and the teacher integrate the communication book into the classroom activities.

Two students worked with Salome, a 6-year-old girl with Down syndrome. Salome could communicate in simple sentences and quickly learned the activities that the students taught her. The students spoke with Salome's mother about Salome's potential and the language-based activities the mother could do with Salome. The mother took Salome to her kiosk where she sold corn every day, and the students demonstrated how the kiosk interactions could be great language-based situations.

One of the main ways of teaching and working with students with disabilities in Bolivia is having them color, write, or paste on sheets of paper. Children generally were not encouraged to interact with one another or with the teacher. At the school for the deaf, the TC students worked on promoting more social interactions among the children, including taking turns, using signed language, vocalizing, and following directions. The TC students suggested that the teacher have the children sit in a circle and participate in group-oriented activities that focused on communication, including songs, fine and gross motor movements, auditory discrimination, early literacy experiences, attention to the lips and articulatory gestures, etc. This non-traditional way of teaching was highly successful with the children, who were eager to sit on the floor, communicate with one another, and participate in the songs and games. We left instructions and detailed goals for the teacher to continue the circle activities during the rest of the year.

With the Internet, we can maintain contact with the clinical sites, the parent support groups, and even individual parents and children to provide support until we return in 2008. 



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