Aural Rehabilitation Telepractice International Project Links NY Student Clinicians, Bolivian Children World Beat
World Beat  |   June 01, 2009
Aural Rehabilitation Telepractice
Author Notes
  • Carol Polovoy, production editor of The ASHA Leader, can be reached at
    Carol Polovoy, production editor of The ASHA Leader, can be reached at×
  • Catherine J (Cate) Crowley, MA, CCC-SLP, JD, founder and coordinator of the Teachers College Columbia University Bolivia project and director of its Bilingual Extension Institute, can be reached at
    Catherine J (Cate) Crowley, MA, CCC-SLP, JD, founder and coordinator of the Teachers College Columbia University Bolivia project and director of its Bilingual Extension Institute, can be reached at×
Article Information
Hearing Aids, Cochlear Implants & Assistive Technology / Audiologic / Aural Rehabilitation / Telepractice & Computer-Based Approaches / International & Global / World Beat
World Beat   |   June 01, 2009
Aural Rehabilitation Telepractice
The ASHA Leader, June 2009, Vol. 14, 20-21. doi:10.1044/leader.WB.14082009.20
The ASHA Leader, June 2009, Vol. 14, 20-21. doi:10.1044/leader.WB.14082009.20
On any given Tuesday, Wednesday, or Thursday afternoon, speech-language pathology graduate students at Teachers College (TC) Columbia University in New York are providing aural rehabilitation services to 10 children with hearing loss—a scenario common to just about every communication sciences and disorders graduate program in the country. What makes the TC program unique, however, is that the graduate students are seated at computers—not in treatment rooms—and the young clients are almost 4,000 miles away in La Paz, Bolivia.
This innovative telepractice project is part of an effort to enrich and enhance the bilingual/bicultural focus of the TC speech and language pathology program, which has a strong commitment to educating students to work effectively in a multilingual world. In addition to coursework and clinical experience in New York, the program offers its students several international opportunities to provide speech and language services to children with disabilities.
Bolivia Program
In one such opportunity, students receive academic credit for providing free speech and language services in Bolivia. For the past three summers, 17 TC graduate students have spent a month in La Paz, working with children and their families in the national hospital for children, a school for students with developmental disabilities and autism, and a school for the deaf (The ASHA Leader, Oct. 16, 2007). The program is directed by Cate Crowley, coordinator of TC’s bilingual/bicultural program emphasis and its Bilingual Extension Institute, and supervised by Miriam Baigorri, clinical coordinator, with the assistance of additional ASHA-certified bilingual speech-language pathologists.
At Camino de Sordos, a school for the deaf with an enrollment of 45 students ages 4–20, less than a handful of the students have ever had hearing aids.
“Our students worked at the school and we maintained Internet contact with the school and some of its families,” Crowley explained, “but we knew that if the students were going to acquire spoken Spanish, they needed hearing aids and intensive aural-verbal habilitation. We shared this need with our colleagues.”
Putting the Pieces Together
One colleague who heard of the need for hearing aids was Melissa Inniss, a Panamanian-born audiologist and SLP enrolled in the TC Bilingual Extension Institute for SLPs. Inniss offered to obtain donations of hearing aids and molds for the children at Camino and to go to Bolivia to test their hearing.
Providing hearing aids was only the beginning. These were not very young children being amplified for the first time—they were 4–16 years old. In addition, there were no Bolivian professionals available to work with the students. “I noticed that in all the Internet cafes in La Paz people were using Skype [videoconferencing software] to communicate with their friends,” Crowley explained. “It occurred to me that with computer access, we could provide real-time aural habilitiation from the TC speech and hearing clinic to the school for the deaf in La Paz.”
In addition to an audiologist and SLPs, the project needed technological expertise. It arrived in the form of Ray Diaz, a technology expert and husband of one of TC’s clinical supervisors in Bolivia. On a visit to Camino, he was so taken by the school and its students that he volunteered to help; he located a financial company willing to donate computers to this project.
Funding for the project came from a grant from the Downey Family Foundation (SLP Stephanie Downey is a recent graduate TC graduate), which focuses on education. With that funding, Inniss and Diaz went to La Paz in August 2008. Inniss tested the hearing of all the students, made ear mold impressions, and supplied hearing aids to 10 students for the first time in their lives. Diaz installed three computers at Camino with the capacity to use Skype, and three more in TC’s Mysak Speech and Hearing Clinic.
Program Launch
With the technology in place and 10 Bolivian students with hearing aids, seven Spanish-speaking graduate students in the TC speech-language pathology program are providing aural habilitation from their on-campus clinic to the 10 Bolivian students.
Each Bolivian student receives treatment two or three times a week for 20–30 minutes. Students accompanied by a classroom teacher receive treatment in the Catalina Crespo Computer Center. Each session begins with Daniel Ling’s Six-sound Test from a purely auditory perspective. The Bolivian students raise their hands if they hear the sound. The test is repeated with visual and auditory input for the sounds the students cannot hear, and the students are then asked to repeat the sounds. The TC students are working on developing the Bolivian students’ ability to detect, discriminate, and produce sound and words. Some of the students are working on just hearing sounds; others are learning about and producing the plural /s/ marker in Spanish; an older student is able to understand full sentences in Spanish (see sidebar).
Benefits and Obstacles
In addition to providing treatment, this project reveals some of the strengths and weaknesses of international telepractice for aural habilitation and speech-language treatment. The major benefit is simple—Bolivian students receive services otherwise unavailable to them (there are very few SLPs or audiologists in Bolivia and only a few of the Bolivian students had ever had an audiological evaluation).
“Having teachers in Bolivia accompany the student is a great benefit because the teachers see what we are doing and carry it over into the classrooms,” Crowley said. “So, in a way this situation is better than traditional treatment.”
Other benefits come directly from the technology itself. For example, the camera can be shifted away from the speaker to provide only auditory stimuli. Also, pictures and reinforcement materials used in treatment are small—only 6 inches by 3 inches—and rather unexciting across a treatment table. But, held close to the camera, the pictures appear much bigger, filling the 19-inch computer screens in Bolivia. “The Bolivian students view the computer screens as similar to television,” Crowley said, “and are very interested in watching the ‘show’ that comes their way from New York City.”
Technical problems do occur. “Sometimes there is no audio, and other times no video, but the technology works well about 85% of the time,” Crowley said. “Also, we don’t have control over the volume of sound, but the teachers accompanying the children in La Paz during the Skype sessions give us the feedback we need.” Flexibility is the key—with flexibility and phone support from Diaz, virtually all technical glitches are overcome, worked around, or resolved.
The groups on both sides of the equator have benefited from the project. Even though all Bolivian schools closed for summer vacation in mid-November, the administration arranged to open the school for telepractice; parents continued to bring their children to school two or three times a week for treatment and teachers came in from their summer vacation to work on this project. The Bolivian students display intense concentration and participation during their sessions.
“This project works because we have the support of our chair and program director,” Crowley said. “It is fully integrated into our clinical training with the assistant director of the TC clinic, who supervises the current group of eight TC students.” The telepractice hours count toward the 400 minimum needed to graduate.
“For the TC students and their supervisors, this project has proved to be an opportunity to experiment in a new medium and to see the positive impact of their skills on people thousands of miles away,” Crowley said.
“As a result, we plan to maintain the program as an ongoing opportunity for our master’s students in speech-language pathology.”
Case Studies: Alexia and José
Case #1

Alexia, a 5-year-old girl, was born with profound bilateral sensorineural hearing loss. In August 2008, she received amplification for the first time. Initially she seemed very serious, almost bewildered, by the sounds she was hearing and the faces she saw via the Internet, yet she actively participated in every session with complete focus. It soon became apparent that, despite her profound hearing loss, she has a great deal of potential to function in the hearing world. In just one 20-minute session, she progressed through two stages of aural habilitation: detection of nonverbal and verbal (animal) sounds, and identification of animal sounds. We put pictures of two animals on the screen and she could identify with 100% accuracy the animal that made the sound we were making off-camera. Since then she has moved to minimal pairs, which she identifies with 80% accuracy. She has begun to hear and produce Spanish morphemes indicating plurality and verb tenses. Even after 10 weeks of individual treatment three times a week, she remains focused through every session. Alexia has lost her bewildered look and her face has relaxed into a confident smile.

Case #2

José is a 15-year-old boy who is fluent in Bolivian Sign Language, which is used at Camino. José received a hearing aid in August 2008; he has made so much progress so quickly that he now understands questions and sentences in Spanish. He continues to respond in sign but he understands what is being asked of him. After watching his comprehension skills improve so significantly, we wanted to learn what José thought about his newly acquired skills. José said that he had hearing aids when he was a young boy, but he could not make sense of the sounds that he heard, so he took his hearing aids off and never used them again. José said that he felt he could acquire Spanish as a second language because he has acquired Bolivian Sign Language at Camino. At 15, José may continue to use sign language as his main form of communication, but now he is able to understand Spanish spoken by his hearing family and community.

—Cate Crowley

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June 2009
Volume 14, Issue 8