Work Setting: Schools Work Setting: Health Care Work Setting: Private Practice
When visiting a village school and outpatient rehabilitation clinic in the Democratic Republic of the Congo (DRC), a team of professionals from the United States worked with their local counterparts to provide training and help patients. One patient was a 6-year-old boy with a complaint of severely reduced expressive language. The team – comprising both US and DRC medical professionals – worked together to create an assessment and treatment plan for the boy. They also provided education and strategies to the boy’s mother.
The Centre for Education and Community Based Rehabilitation (CERBC) is a school and outpatient rehabilitation clinic in Aru, a rural village in the Ituri Nord province of DRC. The school wing of CERBC provides primary, secondary, and vocational education for children who are blind, deaf, and/or have physical and cognitive disabilities. Many of them are unable to attend traditional day schools. The majority of the students have hearing loss caused by meningitis or malaria. Other diagnoses include cerebral palsy, genetic syndromes (including Down syndrome), burn contractures, macular degeneration, and polio. The clinicians at the rehab center also diagnose and treat adult and pediatric patients.
Following two visits to CERBC, an interprofessional practices (IPP) team assembled to target previously identified areas of need. The team consulted with CERBC faculty, teachers, and medical professionals within the community and selected topics for training sessions in a variety of disciplines. The result was a 10-day training clinic. Each morning of the training, all CERBC faculty and visiting clinicians attended a 1-hour lecture presented by members of the visiting IPP team. Afterwards, the visiting clinicians traveled with their CERBC counterparts to the clinic to see patients together.
During this time, a 6-year-old boy named Etumbu arrived at the clinic after a 3-hour moped ride from their remote village with his teenaged mother. Etumbu presented with a complaint of severely reduced expressive language.
Obtaining an adequate medical and developmental case history was challenging, as his mother responded to most questions with one-word answers or stated that she had forgotten. She described a “difficult” birth with labor lasting 2–3 days. She reported that she believed he had functional hearing at birth, and the audiologist confirmed this by conducting oto-acoustic emissions (OAE) testing. Etumbu had not been enrolled in primary school due to his lack of speech.
The IPP team consisted of the following professionals:
The IPP team met to discuss what types of assessments Etumbu needed. Given the mother’s concerns, the team began with speech and hearing evaluations and were assisted by translators.
The audiologist‘s assessment found that Etumbu’s hearing was within normal limits. However, while demonstrating how to assess the patient’s receptive language skills with a picture-pointing task, the SLPs and the rehab aide observed that Etumbu struggled to point to a picture with his right (dominant) hand. By pointing with his left hand, Etumbu revealed comprehension of a good deal of functional vocabulary. However, Etumbu did not follow commands such as “Put the ball next to the elephant.” His expressive language was limited to “Mama,” “Baba,” and “Du-doe” (his sister). Etumbu also displayed significant difficulty copying movements modeled by the rehab aide.
The visiting SLPs and the rehab aide worked with Etumbu by modeling the pronunciation of his name. Then, the team asked his mother to copy the clinician’s use of cues to practice with her son. She was reluctant and shy at first. However, with encouragement from the aide, she successfully used the strategies that she observed.
Following the consultation, the team met again to discuss the assessment findings and create a treatment plan. The PT said that a physical evaluation may be required due to the observed upper-extremity weakness, and the team agreed. The PT evaluated Etumbu and provided caregiver education via a translator. The PT also demonstrated to the CERBC physiotherapist specific strengthening and flexibility exercises that were appropriate for Etumbu (e.g., throwing a playground ball). After a team discussion, the CERBC physiotherapist agreed to do a trial with Etumbu to see how he progresses with the exercises.
Due to regional cultural beliefs regarding handedness, caregiver education was required to ensure that Etumbu’s family and future teachers understand that functional use of his right hand is unlikely. The team encouraged his family and teachers to support and accept Etumbu’s use of his left hand.
The IPP team recommended that Etumbu return to the clinic for continued speech-language therapy and physical therapy services.
Due to the family’s extreme poverty and remote location, ongoing therapeutic services were not possible. The team met with Etumbu’s mother to provide education and strategies and to inform her of the likely diagnosis of cerebral palsy.
Most important, Etumbu’s mother understood that her son could hear and comprehend spoken language and that he may also be able to learn to read. She acknowledged that he should begin attending the local primary school. She confirmed that she understood the team’s explanation for allowing her son to use his left hand and stated that she planned to continue practicing single-word speech with him.
At the conclusion of the 10-day clinic, the visiting clinicians and CERBC faculty reviewed successes and areas for improvement. The CERBC Board of Directors requested that the team plan for similar clinics every other year and recruit two additional members of the IPP team—an occupational therapist (OT) and an ear, nose, and throat surgeon.
Due to civil unrest in eastern DRC, a planned trip has been put on hold. The inability to follow through with the next planned visit highlights the problem of sustainability in this type of setting. However, technology is helping to bridge the gap. The CERBC director is in touch weekly with one of the American SLPs via text message. This communication often revolves around specific cases.
The CERBC director and resident medical director routinely reach out to all of the American team members for case questions. The IPP team members regularly discuss telepractice and teletraining options, but they are unable to implement them due to the unreliable Internet connection on the CERBC campus. Team members continue to participate in fundraising initiatives that specifically target sustainable development of the CERBC.