“I made it back to the US on December 15th after 22 hours in flight. Jet lag and the holidays followed quickly! My colleagues, (known affectionately as Dr. Brad and Dr. Kie by the Bhutanese) were able to stay on another week or two after my departure. We will be meeting up January 16th to reflect on “lessons learned” and plans for the future.
The most lasting legacy of this trip for me was an appreciation for all that we have here in the US (and may take for granted). This includes a variety of materials we use as speech therapists, but also basic requirements of a therapeutic-learning environment, e.g. adequate heating, lighting, a workable table/chair set-up for adult-child interaction, and reduced distractions/interruptions when trying to assess children and counsel parents. I also appreciated having taken Maret Wilson’s seminar on “Culturally and Linguistically Diverse Populations” right before I left, which prepared me for working with interpreters and how to use more alternative assessment methods. There are approximately 12 different languages spoken in Bhutan given its isolated, mountainous topography. Most children before the age of five speak one of these twelve “mother tongues”. Upon entrance into “PP” (the equivalent of kindergarten or the first year of school), children learn both the national language (Dzongka) and English. Most typically developing children are thus trilingual by the age of 7 years and most professionals whom I worked alongside spoke several languages, including Nepali, Hindi, English and at least 3-4 Bhutanese languages.
The country is considered “developing” and they have many world-wide agencies helping them in areas of health, education, economic growth, and environmental and cultural preservation. One of the more active agencies includes UNICEF which is involved in establishing early intervention centers. During our stay we met with UNICEF staff, and Dr. Berman toured one such center. Future efforts to bring speech therapy to the country will likely involve collaboration with such agencies and with the Ministry of Education, which together can plan and deliver service across the many different regions of Bhutan.
My role this year was more of information gathering and to expose Bhutanese professionals to our field of speech therapy. In addition to presenting to about 75 people over a three-day conference (many of whom had to ride buses for 2-3 days to get to our location), my team was observed and videotaped by teachers, para-educators, and hospital staff during consultations at the country’s only developmental clinic and at a newly formed agency supporting parents of children with special needs: Ability Bhutan Society. We also met Ministers of Health, Education, and even the current queen of Bhutan. Future efforts will likely include fund-raising in 2013 and a return trip in 2014. Given many children whom I assessed were severely impaired communicators with neurologically-based problems or syndromes, future efforts will need to specifically address alternative-augmentative communication, and parent education with respect to realistic goals of intervention.”
Hello from Bhutan! We have started our work at the capital city’s main hospital and also at the newly formed Ability Bhutan Society. The day starts with packing up materials for the trip (developmental checklists, wordless picture book for language sampling, PLS-4 pictures and objects, an oral mechanism kit, and the clinic’s audiometer.) I also use items from the Bailey Test of Infant Development at times brought by Dr. Johnson. Also needed are basic provisions for working at the hospital (Power Bars, toilet paper) as there is typically no lunch break and the hospital staff bathroom is bare bones. On the hospital wall you see signs “Thank you for not spitting” as this refers to the local betelnut chewing/spitting habit of many Bhutanese.
The children arrive at the hospital’s clinic every hour on the hour starting at 9am. Dr. Berman and I saw 6 children today at the hospital and then 3 each after that at the Ability Bhutan office, so a total of twelve consultations from 9-6pm. The primary complaint is often “speech impairment” but in fact, usually the kids are globally delayed with seizure disorders and CP of various types. After talking with parents and doing some basic assessment, often the kids are functioning at 25-50% of their chronological age. We also have seen a few cases of autism (youngest today we agreed was “at risk” at age 2-9). After doing two days of consultations, it is clear the main goals are to 1) support parents in voicing their concerns, 2) document need for the country to develop speech therapy options for its population, 3) give at least 3 practical tips for parents to carry out at home, 4) demonstrate some basic speech therapy techniques for para-educators/technicians who will continue to see the children after we leave, and 5) provide parents with computer access helpful websites, e.g. Hanen.org.
There is a big problem of children watching too much television in the country. Oftentimes children are left to watch cartoons all day and display some aggressive behaviors they have probably seen on TV. Another problem is lack of proper nutrition/protein poor diets. To the positive, local preschools are beginning to become more available, and there is currently a big effort on the part of UNICEF to open more “Early Childhood Centers”.
There is one deaf school in nearby Paro with 73 students ages 4-25. I met with one of their teachers who gave me several videotapes of her efforts to teach speech to HOH and deaf children.
There are a few special education classrooms throughout the country. Unfortunately students are off on winter break for several weeks so it has not been possible to view them during this trip.
The physio department (equivalent to Physical Therapy) is staffed with one dedicated therapist and two technicians. This one person is responsible for all developmental needs: orthopedic therapies, orthotics, fine-motor dexterity, feeding and speech issues. The room has a mattress on the floor, a bed, a few large toys, a make-shift paper mache chair or small plastic lawn type chairs for child seating, and stools for parents. There are no appropriate child chairs for postural support or to facilitate testing for more active children (Gosh! How much I wished for a cube chair today!) Test materials have to be locked up at night as mice will chew up various items. This was the fate of one reinforced, makeshift cardboard chair with mice teeth marks all over it.
Word is getting out in the community that we are here, thus our schedules are getting more and more jam packed. Dr. Berman is also called to do consults for very sick children in the ICU. Kie and I go have gone with him and have met very dedicated doctors who explain complicated cases (Saddest was of a 12-month-old on 21 medications, suffering from tuburcular meningitis; nonresponsive and will probably will be hospitalized for a year, with high risk of severe brain damage/neurodevelopmental problems).
Several high governmental officials and well-known Bhutanese actors are requesting that their children be seen before we leave. Tomorrow we are seeing a child of someone “very important” and our credentials/CVs have been checked and we have been “Googled” thoroughly. The pace is getting a bit frenetic here, but I remind myself that this is coming to an end for me this Friday. Dr. Berman and Dr.Johnson will continue on for another week or two.
As I wind up the next few days, I will start to generate a needs list with the help of ABS and the physiotherapist at the hospital. Dr. Berman will likely return in the Spring of 2014, and I’m sure would appreciate more speech help. We are also considering inviting one to two Bhutanese professionals to train/shadow SLPs (perhaps at SPG?) in the next year or two.
More to follow! Lisa
Today I delivered the last of three presentations to 70 professionals from Bhutan. Most were “Physiotechs” or Physical Therapists, Special Educators, and a few Ministers and hospital doctors (pediatrics, psychiatry). Many people commented afterward how much they appreciated the videotapes of clinic clients in therapy sessions, so thanks to SPG clinic staff and clients’ families who contributed to these efforts. We asked the audience about what they learned which was most surprising, and some of the comments were that they didn’t realize that therapy with children would be play-based and that parent training would be so important. Dr Berman and I also role played administering the PLS, with Dr. Berman taking the role of a “difficult to test, three-year-old child with ADHD and language issues,” with the audience clearly enjoying his antics and my efforts to contain him and get him to cooperate.
The visit to the local hospital was an eye-opener. I spoke with Dr. Philip, a US pediatrician on a two year contract, and he has as many as 28 patients with acute illness whom he cares for on a daily basis. He is on a rotating weekly on-call status 24/7, so in emergencies, has to get to the hospital at any given hour. His rounds are pretty much non-stop, 9am-3pm. Given the terrain is so mountainous and thus it is difficult to travel to the capital city’s hospital, most kids are in severe distress when they arrive.
I also met the hospital’s only audiologist. He was trained in India and has both speech and audiology degrees, but he described minimal duties as a speech pathologist. Once diagnosed with hearing impairment, children do have access to some hearing aids. There are no children fitted with cochlear implants at this time (in fact, he laughed when I asked this question)! He did have access to a sound-proof booth, also had an “audio tech assistant”, and told me his training in India took 5 years to complete. Next door to his suite was an office titled “speech therapist” but there was no one there providing ANY speech therapy given the country’s one and only therapist left several months ago.
Next week we will be doing multidisciplinary consults at the hospital Monday-Thursday. We will also be meeting with our sponsors, Ability Bhutan Society, to discuss ways in which we could be most helpful in future efforts. Finally, we will be touring the capital city’s Special Education School, and meeting with the Director there, Madam Chimi. We will also tour the school for the deaf in Paro. There are currently efforts with Unicef spear-heading efforts to provide Early Intervention Centers in key areas of the country. Dr. Berman and his wife, Shiva, are trying to ascertain how future missions could help support these efforts with respect to fund-raising efforts back at home in the US.
Tomorrow will conclude our trainings with Dr Brad Berman and Dr. Kie Johnson discussing more on assessment methods for neuropsychological and overall developmental issues.
More later! Lisa
Queen consort of Bhutan in 2011
Here is a picture taken in Paro, Bhutan (not far from the little airport).
On December 2nd Lisa arrived in the capital city of Bhutan, which is much more populated, about 80,000 people, but the landscape is still pretty spectacular. On Saturday, Dec 2nd there was an all day marathon with Ability Bhutan Society’s community events honoring people with special needs. There was something like the Special Olympics with disabled kids participating in races and such, and the Queen of Bhutan actually attended and gave out trophies to the kids. Very sweet. She then stopped by our tent and shook our hands which was quite a moment.
The afternoon ended with a forum/discussion of issues facing kids with special needs, with about ten community leaders presenting on various obstacles. They have a lot to tackle as just their infrastructure is so challenging for people with physical disabilities. There was also a lot of discussion about their special education system, practical issues of inclusion vs. special schools, how to get the government ministries more involved, etc. Dr. Berman presented on how the US has tried to tackle issues with various laws, e.g. American with Disabilities Act, IDEA and Free and Appropriate Public Education, IEPs/504s, importance of early intervention, etc.
On Dec 3rd, Lisa visited the hospital with Kie Johnson while Dr. Berman toured an early intervention center in another town.
Today, Dec 4th the team starts their presentations! We wish them the best of luck!