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Bolivia 2008

The Bolivia Project

Bolivia 2008

 
 
Catherine (Cate) Crowley, Director
Miriam Baigorri, Clinical Director and Clinical Supervisor
Elizabeth Ijalba, Bilingual Literacy Research Specialist and Clinical Supervisor
Lorena Diaz, Schools Specialist and Clinical Supervisor

Overview
  • For 3 ½  weeks (May 28 to June 20, 2008) eighteen students in the graduate program of Communication Sciences and Disorders at Teachers College offered free speech, language, and dysphagia services to children in Bolivia. The Teachers College students worked in three different sites and were supervised by three ASHA-certified native Spanish speaking clinical supervisors, and the project director.
  • At least 5 television programs and many radio broadcasts and newspapers carried information about the services offered by the Teachers College CSD Bolivian Project. The Chief Cabinet Minister of Evo Morales, the President of Bolivia, sent a letter to Cate Crowley acknowledging the work of the TC CSP students in Bolivia.
  • Each student accumulated an average of 54 clinically supervised hours that will go to meet their ASHA certification requirements.
  • Together the students provided a total of over 920 hours of free speech and language services to Bolivian children with disabilities and their families.
     
  • Students gave 11 different talks on a variety of topics related to children with disabilities at the national hospital for children and a school for the deaf in La Paz, and a school for children with developmental disabilities in El Alto. These charlas were attended by approximately 335  teachers, parents, medical professionals, and administrators.
  •  Clinical supervisors gave direct supervision at all three sites and provided daily feedback to the TC student about how to improve their work. They met as a group at least once a week.
  •  Ten students--the non-native Spanish speakers--arrived early for 5 days of intensive Spanish classes for 4 hours a day in groups of 2 or 3.
  •  Two times a week all met for a seminar on Bolivian language, cultures, politics, and educational systems. Articles came from a variety of fields including anthropology, U.S. congressional reports, comparative education, educational anthropology, linguistics, and sociolinguistics. The readings and discussions gave students insights into Bolivia that enhanced the quality of services they provided.
  •  On weekends students traveled throughout Bolivia to learn more about the country and its people.  

 The Media Blitz about our Campaña 

Our work in Bolivia this year was marked by a great deal of media coverage. Dr. Christian Fuentes, Director of the Hospital del Niño, and Catherine Crowley appeared on several television programs. In addition, the media department of the Hospital del Niño arranged for publicity on a number of radio stations and in the newspapers. This coverage was picked up and disseminated throughout the country. In response to this media coverage parents brought their children from all over Bolivia to receive the free speech, language, and feeding services we offered.  

Virtually all of these people brought their children to the Hospital del Niño where the students and supervisors worked diligently to meet the demand. Lorena Diaz was our clinical supervisor in the morning at the hospital along with six students. In the afternoons usually two of the supervisors went with a group of six to eight students.
 
Every child was evaluated first through a parent interview and then through clinical diagnostic methodology. During that very first first session, the students would begin with parent training on what the parents could do to stimulate language and communication in the homes. Virtually all children were scheduled for several additional therapy sessions where the families could learn more strategies and techniques.
Most of the children who came to the hospital for services had never seen a speech language pathologist (or fonoaudiologist) before. Many of the children came from very long distances. Some flew in from Santa Cruz, Sucre, and the jungle regions. Others came on 18 to 30 hour bus rides just to have the opportunity of receiving the services of a speech language pathologist.
 
One set of grandparents flew from Santa Cruz with their 8 year old grandson who had all the marks of a child with severe autism, but who had never received any services and had no diagnosis. The grandparents, in fact, had never heard of autism before. Our students began developing a communication system and a behavior modification system for this non-verbal, somewhat aggressive boy. The grandparents came to the charla on autism and then came to every charla that the students gave for the week they were in La Paz so they could learn as much as possible for when they returned to Santa Cruz.  
           
Another 4 year old girl was also nonverbal but only because she had moderate to severe cerebral palsy. She understood everything and her mother knew this and was searching for some help for her daughter. The students developed an expandable communication board for this girl that she began using almost immediately. For the first time in her life, she told her mother what she wanted by using the communication board.  
 
 
For some children, their language delays improved quickly and remarkably with parent education on how to stimulate language. Some parents learned by watching our students use communication temptations to draw the children into a communicative mode. One mother was in tears as her son uttered his first words during a therapy session with our students. 
   
A number of other parents brought 3 and 4 year olds whose speech was unclear. Our students used developmental guidelines to advise the parents on whether their child’s speech was delayed or acceptable for the child’s chronological age. Many of these parents simply did not have the information to know what normal development sounded like. A number of these parents were in tears when they learned that their children were doing fine and were likely to develop normal speech just in the process of growing older.
 
These and many, many other stories allowed our students to understand the value of their work as speech language pathologists. It was moving to watch our Teachers College students work with their first “clients” and make such extraordinary contributions to the lives of the children and parents they touched.

Sustainability
   
 One of the most important goals of the Bolivia Project is that our work continue after we leave. Over this past year we were able to stay in contact with all of our sites through the internet. In this way, we identified what particular topics the placement sites wanted for the student talks and learned of any significant changes in the sites. The internet also facilitated a closer relationship with the people who work in the sites so when we we arrived in May 2008 we were prepared to get to work.
 
Sustainability  through parent education and training
 
Parents were always included in the speech and language sessions. At first parents watched while the TC students modeled what they were expected to do. The TC students talked to the parents about what they were doing and seeing. As soon as possible the parents were encouraged to take the lead in the therapy sessions, with the TC student providing support and shaping the parents’ skills.
 
Most of these parents also attended the charlas (see below) where the TC students provided information on how to facilitate communication for a particular disability. 
 
 
 
 
Sustainability of individual therapies  

 Our work was focused on training parents, teachers, medical professionals, and administrators on how to continue on with the work when we returned to New York. We wanted to establish a level of understanding on what we were doing; what our goals were for individual clients; and what methodologies would be most effective in meeting the needs of the children.
 
Students spent many late nights in the hotel creating therapy materials for the children. Parents attended therapy sessions and the TC students modeled how to use the materials effectively. They also showed parents how to create, expand and adapt the materials as the children’s communication skills improved. 
                                                                                                                                                                                                         
Many parents were given packets of materials to use when we left. One example is the shown at left. where Linden created all these materials for the boy she worked most closely with in Bolivia. The materials are designed to be used at home and in his classroom.
 
One 15-year-old boy with cerebral palsy at CEREFE had taught himself to read but could not communicate verbally in a way that could be understood. Natalia, at right, took him as her client and created his first communication book. Most of the entries were written words. She took him out with his classroom teacher, and he used his communication book to order lunch. The TC student and his teacher collaborated on this book. In doing so the teacher developed her own skills so that she can  support him in expanding his communication capacity. 

Sustainability in the classrooms 

At both school placements--Camino de Sordos and CEREFE--the TC students spent about half their time in the classrooms. There they worked with the teachers to incorporate language-based activities that would stimulate language development for the children in the class.
 
At CEREFE the TC students selected on one or two classrooms to focus on for the month. In one of the classrooms most of the students needed some form of Augmentative and Alternative Communication (AAC). The TC students created classroom activities that incorporated a strong AAC component, such as when the students had to make choices, state their preferences, or make decisions on what would happen next. The TC students created the activities for the classroom, demonstrated to the teacher how to do it, incorporated her suggestions, and then stepped aside so the teacher could develop full mastery of the activity (photo at left). Over the month the teacher saw the benefits to her students and learned the skills needed to continue to use AAC effectively in her classroom as a communication bridge for many of her students (photo above right).
 
One of the classrooms in particular was very small with about 10 children who were mostly diagnosed with moderately-severe autism or Down Syndrome. One woman was in charge of this classroom. Few of the teachers that the TC students worked with had any teacher education preparation, and even fewer had any coursework on special education. Yet, even with good training and several teacher assistants this would have been a very challenging classroom.
 
The TC students worked in that classroom every day modeling language- and literacy-based activities. The teacher was always present and always participated. To support the group activities the TC students generally did pull-out therapy sessions with many of the children. This created a teachable environment in the classroom.  
 
Before they left, the TC students created theme-based folders, each centered around a particular book. Each folder contained a number of different activities that the teachers could do with the children in her classroom (photo above right). After the month in Bolivia, the TC students had a good sense of what the children liked and what activity level would be appropriate for that class. They also collaborated with the teacher to make sure they were creating materials that she would feel comfortable using. 
 
Sustainability of Literacy activities: The Magic of Books--And Musicals!
 
Literacy-based activities were not apparent in most of the classrooms. The TC group had brought approximately 60 books in Spanish. Throughout the month, the TC students read books to the children and created many literacy-based activities that expanded upon the stories moving into vocabulary development, development of syntax and morphology, story grammar, character development, and learning reading and writing skills.
 
At Camino de Sordos the TC students focused on developing literacy and language skills using a Big Book version of  El Pez Arco Iris (The Rainbow Fish). They first read the book to the children with one student reading the Spanish, another signing the story, and a third acting it out as it was being read. At the end, when the Rainbow Fish gives his beautiful scales away, the student  acting out the story gave each child a brightly colored paper in the shape of a scale. The TC students knew that these children really understood this book about sharing and community when the children spontaneously stood up and with huge smiles on their faces made a giant "group hug" that they made sure included everyone in the classroom!
 
The Rainbow Fish story was told and acted out in different ways several times over the next week--a fish was created which the children decorated, the students drew pictures about it, and they talked about sharing things they loved. The children also drew chalk outlines of themselves and showed where their clothes would go, similar to where the scales would go on the fish. At the end of this--the only literacy activity the students observed in the school during the month--the TC students gave the school The Rainbow Fish Big Book, several other Big Books, and a variety of other books that would lend themselves to this type of literacy exploration and fun.
 
The TC students at CEREFE incorporated literacy in a different way. Ever the New Yorkers, these students brought Broadway to El Alto and turned the book Donde Viven Los Monstros (Where the Wild Things Are) into a musical! They created masks for costumes, a boat, a sea, monsters, the mother, and Max. There was even a starring role for "the warm smell!"  They spent two weeks rehearsing the play with the CEREFE students. The TC students created songs, with input from the CEREFE students, that the entire cast sang. These songs incorporated and emphasized main plot developments.. The cast included a class of teenagers with developmental disabilities and autism, the TC students and their supervisor, a mother, and the classroom teacher.
 
After two weeks of rehearsal, they performed the musical for for the CEFERE community--parents, fellow students, teachers, and administrators. Before the TC students returned to New York, they gave this and many books to the teacher that would lend themselves to dramatic adaptations. The teacher enthusiastically accepted this gift, ready to create new musicals with her class.  
 
Clinical Supervision and Clinical Hours
 
The Clinical Supervision
  
All three clinical supervisors were ASHA certified, native-Spanish speakers with their New York State license and bilingual extension certificate, and with many years of clinical experience.

Miriam Baigorri, MS, CCC-SLP, is the Clinical Director of the Bolivia Project and Clinical Supervisor of CEREFE. Miriam works at Bellevue Hospital as a Bilingual Speech language pathologist. She graduated from Teachers College SLP program. She is on the faculty of the Bilingual Extension Institute at TC and co-teaches the cleft palate course there. Miriam is of Spanish descent.  

Elizabeth Ijalba, Ph.D., CCC-SLP, Bilingual Literacy Research Specialist and Clinical Supervisor at Camino de Sordos, recently completed her doctorate focusing on bilingual literacy at CUNY Graduate Center. She is an Assistant Professor at Queens College and is on the faculty of the Bilingual Extension Institute. Elizabeth is originally from Uruguay
          
 Lorena Diaz, MS, CCC-SLP, Schools Specialist and Clinical Supervisor at the Hospital del Niño, is a bilingual speech language clinician in the New York City Department of Education. Prior to joining the NYCDOE two years ago, Lorena worked for YAI’s Grammercy Preschool. Lorena is of Puerto Rican descent.
 
At each site there was at least one clinical supervisor present at all times. The supervisors provided direct supervision--they answered questions, gave suggestions, and any additional support that the students needed. In the evenings at the hotel, students prepared materials for their therapy sessions. Even there, the supervisors were available for questions, suggestions, and feedback.
 
The supervisors provided daily feedback to the students. The supervisors were to build upon the students’ strengths and constructive criticism was provided. At least once a week the group met for a larger session when students spoke about the work they were doing with their clients. These larger group sessions were very useful to share innovative approaches that could then be replicated at other sites or with other clients.  

Students were required to write goals and S.O.A.P. notes for one client that they followed throughout the month. Here again, the supervisors gave feedback on the quality of the written work which the students incorporated into their next submission of the written work. Students developed goals and prepared sessions for all the clients they saw on a regular basis, but they only had to write goals for one client that they saw everyday or two or three times a week. 

Clinical Hours 
      
On average students accumulated 54 clinical hours that can be attributed towards their supervised clinical hours needed for ASHA certification. Over the 3 ½ weeks, the TC students provided over 920 hours of services to Bolivian children with disabilities and their families. 
 
At the hospital student clinical hours were divided primarily among autism, developmental disabilities, cerebral palsy, and language delays under 4 years old. In addition, about 5% to 10% of the cases at the hospital were fluency and cleft palate. At CEREFE most of the clinical hours were for children and adolescents with autism, developmental disabilities, and cerebral palsy. All the children at Camino de Sordos were either deaf or severely hearing impaired, although a few had a secondary diagnosis.  

Spanish language skills

At the hotel and in the clinical placements the students were immersed in Spanish. Students who were not native Spanish speakers studied Spanish at Instituto Exclusivo in La Paz. In groups of two or three they received 4 hours a day of intensive Spanish for five days before they began the clinical placements.

All students were required to participate in the charlas (talks). So every student had to learn some Spanish that they could use during the part of their charla where they presented. This meant that all students had to work on their Spanish skills to be at a level where they could communicate and be understood by parents, teachers, medical professionals, and administrators. 

At the clinical placements, students who had weak skills in Spanish paired with a strong Spanish speaker. Each student had a different client they followed and wrote goals on. This teamwork allowed the students with weaker Spanish skills to learn more Spanish and to give students direct services. Those with weaker Spanish skills had to learn enough Spanish so they could work with their identified client. Students with weaker Spanish skills generally chose children who needed AAC so that the TC student could provide services to them.
 
 
The Charlas (The Talks)  
                                                                            
Prior to coming to Bolivia, students worked in small groups to research and understand current thought in the U.S. on the topic of their charla. They needed this background on identification, causation, prevention, and treatment on their charla topic so they could have enough expertise to answer questions from parents and professionals. (At least one supervisor went to each charla to support the students if they had trouble answering any of the questions.) Also students had prepared powerpoint presentations in Spanish for parents, teachers, and other professionals on their charla topics.  
 
In developing their charlas, the TC students worked to ensure that their charlas were interactive and they planned significant time for questions and answers. In addition to the powerpoint presentation, students prepared handouts that the audience members could bring home and could implement with a child with that disability. For example, the Down Syndrome charla presenters prepared a handout describing various communication methodologies that have been effective for children with Down Syndrome. The handout for the charla on children under 4 years old with language delays included a simple chart of normal language development and examples of how to stimulate language in various situations.  
 
Altogether, the students prepared and gave 11 charlas on 7 different topics. Most of the charlas were given twice—at the Hospital del Niño in La Paz and at CEREFE in El Alto. Approximately 335 parents, teachers, administrators, medical professionals, and others attended the 11 charlas. The following is a list of the charla topics and the numbers of people who attended:  
  1. Literacy and the Deaf
  2. Autism. Attendees: 1) 60; 2) 15
  3. Hearing aid benefits.  Attendees: 36
  4. AAC.  Attendees: 1) 15; 2) 45
  5. Lang Delays for children under 4 years old.  Attendees:  1) 60; 2) 30
  6. Down Syndrome.   Attendees: 1) 20; 2) 30
  7. Dysphagia (Feeding). Attendees: 25.


Future Plans 

Hearing Aids for the Children in Camino de Sordos

One major project that we have committed to is to provide hearing aids and follow-up aural habilitation therapy for the children at Camino de Sordos (some are pictured above). Melissa Innis, Au.D., a dually certified bilingual SLP and Audiologist, plans to go to Bolivia in September 2008 to test the hearing of all the children in Camino to determine which children will benefit from hearing aids and to make mold impressions for those children. Melissa is currently working to secure donations of the hearing aids and molds.
 
To benefit from these hearing aids, the children need aural habilitation to learn how to 1) make sense of the amplified sounds they will hear with the hearing aids and 2) produce these new sounds in oral communication. Ray Diaz, husband of Lorena Diaz and technology expert, spent time at Camino de Sordos in June 2008 to see what was needed to set up telepractice between the TC clinic in the school in La Paz. We are working with Ray so that the computers are in place when the Camino students get their hearing aids.

We can use lots of help on this project. Any donations or support for this project will be very welcome. We hope to have the hearings aids and telepractice set up before we return to Bolivia in May 2009.
Contact Cate Crowley crowley@tc.columbia.edu
 
The Bolivia 2008 TC Students
 
CEREFE -- Jenny Brown, Ingrid Curniffe, Natalia Martinez, Ileana Perez, Linden Prickett, Jamy Rodriguez.
 
Camino de Sordos -- Jules Csillag, Elina Eydlin, Dora Katsnelson, Chris Lebron, Diana Posadas, Courtney VanBuskirk.
 
Hospital del Nino -- Emily Bernath, Cate Bradford, Sara Carmody, Mahreen Daruwala, Angie Livingston, Natalie Eisenberg, and Caitlin Ruderman (honorary).
 
 
 

Bolivia Program