Before our speech-language pathology team at Teachers College (TC) Columbia University introduced augmentative and alternative communication (AAC) to students with intellectual disabilities in a Ghana school, we asked parents what they wanted their children to be able to do. The parents had a quick and unanimous request: They wanted their children to shop for the family in the local open-air market, a traditional role for a Ghanaian child.
Speech-language pathologist Brooke Linden works on Spanish production with two students at Camino de Spordos, a school for children who are deaf in La Paz, Bolivia.
So, with the parents and teachers, we created AAC boards with drawings of food items. We laminated the boards, showed them how to use them, and returned home. The next year when we returned and asked about the boards, the parents pulled them out in pristine condition. It was obvious they had not been used.
We clearly had more work to do: We needed to find out how we could improve the AAC system so the students would use it each day in the local market. This experience, and what followed, encapsulates our philosophy of ensuring effectiveness of our services—a philosophy that has guided our seven years of international work in Bolivia and Ghana with Teachers College speech-language pathology master's students. We provide speech-language services and share knowledge and skills with patients, families, and colleagues (Crowley & Baigorri, 2011).
We use ASHA's Code of Ethics as a guide in our international work, with the following rule particularly relevant: "Individuals shall evaluate the effectiveness of services rendered and of products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected" (ASHA, 2010, Principle I, Rule I).
In this article, we ask and answer questions that sharpen our focus so that we provide services that are beneficial and ensure that we maintain an ethical approach. We hope that these questions, and our answers, can provide insight to others interested in international work.
Why am I doing international work?
Both of us work at TC Columbia University in the speech-language pathology program. As part of the bilingual/bicultural program focus, we wanted to develop international opportunities for students to deepen their understanding of cultures and linguistic diversity, which they do through the clinical experiences and the in-country academic seminar. We also wanted our Teachers College speech-language pathology master's students to provide services in Spanish in Bolivia and through colleague-interpreters in Ghana. We hope that through these experiences the students develop a sense of themselves as global citizens with shared responsibilities.
In identifying what we set out to accomplish, we ask ourselves how to structure our work so it can have an enduring effect on services for people with communication disabilities. We think small. We focus on how to share our knowledge and skills with clients and their families, other professionals, and, wherever possible, other SLPs and audiologists. We consult with our in-country colleagues on cultural issues and on the realities of available supports (Crowley et al., in press).
What materials should I bring?
We use materials that are easily available and relatively inexpensive in the country where we are working. In this way, we know that the work can continue.
Our use of straws with cleft palate patients is an illustration of this approach. We use straws to identify nasal air emissions and to teach the difference between oral and nasal sounds with patients who have cleft palate. Straws are cheap and generally readily available. Other approaches, such as special tubing or marketed devices, are more expensive, often not available, and no more effective. Straws can be discarded after use, eliminating the need for cleaning, which can be challenging with limited hot water and in warm climates where bacteria build quickly.
We bring materials that are not available locally only if they enhance and support what is already in place. For example, in Ghana and Bolivia the special education teachers ask us to bring more books such as Big Books and early-reading books, and classroom educational materials such as sight-word bingo and math games and manipulatives. We work in the classrooms and therapy rooms with our colleagues and the clients and their families, modeling how to use the new materials, and together we problem-solve on any modifications. Each year we look to see whether the materials have been used and, from that, decide what additional materials to give the schools.
When we do introduce a new approach to communication, we make sure that the approach can be continued and expanded by families and our colleagues after we leave. For example, for clients who benefit from an AAC approach to communication, we do not use technology to create the system. Rather, we draw the AAC boards with the teachers, students, and families. We generally use card stock paper, colored pencils, and clear packing tape, all of which we buy in-country.
What technology should I bring?
We generally do not bring technology. Few of the people and institutions we work with internationally have the funds for regular battery replacement or for color ink, computers, and printers. Electricity is often very expensive and subject to regular power outages. None of the places we work has adequate temperature controls, and extreme temperatures and humidity easily damage equipment.
We do, however, provide audiological services and hearing aids to the students at CAMINO, a school for the deaf in La Paz. Over the past seven years we have developed strong collaborative relationships with the administrators, teachers, parents, and students of CAMINO. Melissa Inniss, a dually certified SLP and audiologist and member of the TC team, secures donations of new digital hearing aids, custom molds, audiometers, and batteries. The companies that make these donations know that she returns each year and trains students, teachers, and parents how to maintain the hearing aids.
At CAMINO our goal is for the students, whose first language is sign, to develop their Spanish skills and become bilingual in Spanish and sign. It is a long-term and year-round commitment. Throughout the year we provide Spanish audiologic habilitation via telepractice, in real time, from our TC on-campus clinic to CAMINO (Polovoy & Crowley, 2009). Two years ago, we began an inclusion program in which CAMINO students attend afternoon sessions in hearing schools, supported by CAMINO teachers; with our colleagues at CAMINO, we have provided professional development for the inclusion teachers.
Am I doing something that is beneficial?
Sometimes even good work cannot be sustainable and may have negative effects. Our first year in Bolivia, we worked in an institution for "orphaned and abandoned" children. Each day for five hours, the TC team worked with a group of children with severe disabilities. After a month, some of the children were speaking single words for the first time, choosing songs or activities using AAC pictures, and making small but significant gains.
During that month, however, even with our best efforts, none of the employees at that institution spent any time learning how to continue the work after we left. We were also concerned that by establishing such strong relationships with these children and then leaving them—in a sense abandoning them again—we were doing more harm than good.
Although it was very hard to walk away from the children, we did. We then found a different placement site—CEFEFE, a school for students with intellectual disabilities—where we collaborate with the administration and the teachers to share and build capacity. We have continued at that site for the past six years.
Can I make a long-term commitment?
Quality international work is very difficult, if not impossible, without a long-term commitment. In Ghana we work to share strategies and build capacity in a number of areas. One area is the special education teachers in the "unit schools," which are two or three classrooms of students with intellectual disabilities within general education schools. These teachers are graduates of the University of Education at Winneba in Ghana and they are extremely open to learning new approaches and methods to implement in their classrooms. We recognized that these unit school teachers did not know about AAC.
Initially, we worked in a single classroom at one unit school. Then we began to share information on AAC with several teachers. One teacher, Belinda Bukari, attended the 2011 International Society for Augmentative and Alternative Communication conference and received support to be a teacher-in-residence at an AAC school in South Africa. Another teacher, Clement Ntim, learned about AAC communication passports through written materials. In January 2012, the Teachers College team, Bukari, and Ntim led a professional development retreat, sharing AAC strategies for 40 unit school teachers from throughout Ghana representing 1,000 students with disabilities.
This fall, Ntim will attend an AAC conference in England and spend three weeks as a teacher-in-residence at Capability Scotland, a school in Scotland that specializes in AAC. In January 2013, when we return to Ghana, we will participate in another professional development retreat for the unit school teachers, and Ntim will share what he has learned and how he is using AAC with his students in Ghana. This capacity building is only possible with a long-term commitment to the work.
How can I be more effective?
To be effective we must be flexible and open to learning how to improve our work. We do this by honestly appraising the value of our work. We also ask our colleagues to give us feedback, which is more possible as our collaborative relationship deepens, gathering information informally and through pre- and post-trip evaluations. We prepare needs surveys to gather information from our colleagues. We review these data and then implement modifications as needed.
Returning to our earlier example of the Ghanaian students and families who weren't using AAC boards to shop at the market, our Teachers College group went to the market with the students, parents, and teachers to observe. We saw we had to develop a system that identified the common food items and also represented the three price points used in the market.
We created AAC card sets of three copies of the same item with different prices on each of the three cards.
The next day we role-played in the classroom, with the parents giving the students the set of cards that was the shopping list, and our master's students playing market sellers and helping the students understand how to use the AAC cards. Then everyone walked to the local market and the unit school students bought the items for their families.
The following year when we returned and asked whether they continued to use the AAC cards, we were delighted to learn that, yes, they did. Parents, teachers, and students had introduced the AAC cards to new students and families. One of the teachers made more cards for additional needed items, and had replaced those that had worn out. Most gratifying, when we went into the local market, the market women knew the unit school students by name and easily accepted the AAC cards as the students' ways of communicating what they wanted to purchase (Dwoskin, 2010).
Perhaps the greatest strength of our international work is that we continually "evaluate the effectiveness of services rendered and of products dispensed" (ASHA, 2010). Through this framework we are most likely to provide services reasonably likely to benefit the Bolivian and Ghanaian people with whom we are privileged to work.
The authors thank their Bolivian and Ghanaian colleagues and Teachers College students, as well as the Wyncote Foundation, Downey Family Foundation, Central Coast Children's Foundation, Rotary International, Teachers College Columbia University, Hal-Hen, Widex, and Northeastern Technologies Group.