On my first volunteer trip to the Bahamas, I met 3-year-old "Cara." She had never spoken, she cried if you came too close and she refused to be touched. I remember turning to her mother and asking if she had ever received a speech and language evaluation ... or any evaluation, for that matter. Her mother replied, "She has never been tested; we have been on the waiting list for services for eight months. I just want to hear her say 'Mommy.' Can you stay? We need help." During my trip back to the United States, I couldn't get this beautiful little girl and her mother's words out of my head. Something had to be done; I had to find a way to be in two places at one time.
Over the course of several trips to the Bahamas, the dearth of speech-language services was soon apparent: Only seven trained and licensed speech-language pathologists are available to serve more than 2,804 children (5 percent of the school-age population) experiencing disabilities affecting the mind and/or body (see census [PDF] for population estimates). Wait lists extend for months and sometimes years. Services typically occur just once or twice a year and, in some areas, speech-language services are not available at all.
In 2009, a child psychologist in the Bahamas invited me to provide speech and language services to disadvantaged children. That first volunteer visit expanded into visits every holiday, and then monthly. However, after a year of functioning this way, it was soon clear that my monthly travel to the Bahamas wasn't enough—and was costly, as I was funding my travel personally.
I went back to the drawing board—and developed the idea to offer telepractice speech and language services that would be accessible and affordable to the families in the Bahamas and eliminated my airline and housing expenses. In the summer of 2011, I introduced more than 40 parents of students in private schools for children with special needs to the idea of online services. I screened and re-evaluated (as needed) more than 25 children to determine their speech and language needs and the severity of their disorders. All screenings were free; evaluations were paid for by the school. At the end of this nine-day process, 15 families agreed to try the Divine Intervention Rehab Tele-speech program.
How it works
Telepractice in the United States can be difficult to navigate because of varying laws, individual state guidelines, and licensure requirements. It can be even more challenging across oceans because of limited and sometimes nonexistent Internet service in Bahamian homes. I offer telepractice services during the school day, with the option to add services on Saturdays at the school so that parents can participate. I also enlisted communication assistants—college graduates and college students—to provide onsite assistance. I trained the assistants, who are employed by the schools, to serve as communication assistants/facilitators during telepractice sessions. The communication assistants:
- Provide a comforting presence to parents because they know the island's culture and educational practices.
- Ease the service-provision burden on schools.
- Eliminate the need for parents to take time off work to attend sessions.
- Facilitate activities and redirect the child as needed.
- Help ensure consistency of service delivery.
I elected to provide services using Skype because I can create separate accounts for each family or school and have one central Skype number the families can call to reach me via a secure transmission incorporated to protect the privacy of the users.
A system was set up to offset the cost of services to families who can't afford them. Families that could not afford the full cost of services receive assistance from the school, which elected to cover the remaining balance each month (as needed). Licensing was another challenge, but after considerable research I determined the island has no documented laws for the provision of telepractice. However, the Bahamas Ministry of Health requires noncitizen professionals who work solely on the island to maintain a work permit and a Medical Health Professions license. As my telepractice is based in the United States, and Divine Intervention Rehab clients sign a contract detailing the stipulations of telepractice and entering into an agreement with my practice, I do not need to obtain a work permit or be licensed as a medical health professional in the Bahamas. I am certified by ASHA and licensed in Washington, D.C., where my sole proprietorship was established.
Providing services to children with special needs in the Bahamas has been a continuous lesson and has involved cultural challenges. In the Caribbean islands, some people believe that having a child with special needs is a punishment for something that a parent or relative did wrong, and the child is unacceptable to society. Also, lack of awareness of communication disorders and/or misdiagnosis of a disorder can cause parents to balk at receiving services. In the past two and a half years of providing services, I have found the two biggest barriers to providing telepractice services in the Bahamas to be:
- A lack of treatment materials that support the children's environment and day-to-day interactions. To solve this, I spoke with teachers and parents and created a list of culturally relevant vocabulary and material to make intervention more effective. I modified communication books for nonverbal children to include, for example, beaches, sand, bread fruit, conch and guava duff. I eliminated items like coats, because there generally is no winter.
- Missed services because of unpredictable Internet connections. The entire island relies on one electric company and generator and one Internet provider. At times, electricity and phone connections go down for hours and days, with no warning.
Although providing telepractice services in the Bahamas has not been easy and continues to be a work in progress, the benefits to the island are undeniable. My costs are reduced (because I don't have to travel) and so are the costs for families. In addition, because of the ability to reach more than one child in rural areas of the island and within private educational sectors, I can provide treatment to children who do not have readily, consistent access to an SLP. In addition, I:
- Can provide services in the child's least restrictive environment as needed.
- Increase family and educator participation.
- Reduce barriers to specialized expertise.
- Reduce waiting lists and increase the number of children on the island receiving speech-language services.
Of course, being able to provide speech-language services to children who previously had limited access outweighs the challenges of implementing telepractice services internationally. Seeing their faces on my computer screen and watching them improve daily is ultimately my biggest reward. Thinking back on Cara's mother's statement, I have not only answered her request (Cara is now able to express her wants and needs with ease and is an avid user of the word "Mommy"), but I also have found a way to be in two places at one time.