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My first day at the Ayati Clinic, the pro bono center located in Ragama Sri Lanka. I was introduced to Cerebral Palsy and Cortical Visual Impairment (CVI), CVI is a diagnosis I had never encountered in such depth until the first assessment at the clinic. I learned that CVI involves multiple defining characteristics including, visual field preference, latency, movement, light sensitivity, and visual complexity. During the first sessions clinicians emphasized distinguishing between developmental goals and functional goals, prioritizing skills that improve daily participation. AAC was frequently integrated as a core communication support. As I was observing on the first day, I began understanding our place as undergraduates and graduates students for the clinical experience. Our first day we almost met the dean of the university!

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I was immediately struck by how beautiful and well-organized the clinic is. As the clinic serves nearly 40,000 patients while only having 3 Speech Language Therapist I was shocked. Through the sessions, I was surprised that both parents consistently attended sessions and were deeply engaged or that there was always a second person there supporting if it was not both parents. In my observation hours in the states, I never saw two people attending the session, only one family member. It was nice to see how attentive they were. The kindness and hospitality of the clinicians, students, and staff created an environment that felt collaborative and supportive which led me to feeling welcomed for the upcoming days.

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On day two, we explored the clinic’s services, including speech-language therapy rooms, a sensory room, audiology rooms, dark rooms specifically for CVI, early intervention rooms and even saw students in class learning. The tour of the clinic gave us students knowledge on how the clinic came to be with the funding and strength of numerous partners and the military. I observed the clinicians interviewing the parents before each session to certify if the medical history was up to date. I was glad to contribute clinically by helping create an AAC board, reinforcing AAC as a practical, immediate communication tool rather than a last resort with simple verbs. Out of the numerous sessions held on the second day, the client which stood out to me the most was a child seen diagnosed with CVI and Diplegic Cerebral Palsy. For the 12 year old client the clinicians attempted to have the child communicate through a big lettered keyboard in Sinhala letters.

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I was surprised to learn that the military built the Ayati Center, which challenged my expectations of who provides disability-related healthcare infrastructure. Families were receptive to AAC and therapy strategies, demonstrating trust in the clinical team. With the session that stood out to me the most of the 12 year old client, it was challenging to see there was a lot of potential in the child’s growth but little motivation. It leaves me questioning to how the clinician will move forward in sessions to motivate the client.

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The session began with the background and medical history interview led by the clinician. It included vaginal delivery questions, seizure questions and current therapy received including feeding therapy, physical therapy, occupational therapy, and speech-language therapy. The child follows simple directions inconsistently and communicates through gestures, vocalizations, and reaching. It was addressed that the child was described as a picky eater, preferring crunchy foods such as cheese, biscuits, and rice. Meals were reported to take up to one hour, with irritability during feeding. Parents identified feeding challenges as a combination of sensory and motor factors.

Oral–Motor Examination:

The child demonstrated labial retraction during smiling, intact palate, absence of oral residue, and age-appropriate oral cavity size. Lingual movement was difficult to fully assess because of client cooperation.

Feeding Trials:

Trial 1
The child demonstrated avoidance behaviors, including pushing away and turning away the water in the cup. Improved interest was noted when a pinch cup was paired with a flashlight underneath.

Trial 2 –
Initial refusal behaviors included screaming and head turning. With gradual exposure, the child demonstrated intermittent biting and munching to soft mashed cheese. The food was allowed to melt, with limited mastication and lingual movement. Fatigue signs were observed (eye rubbing). By the third bite, acceptance improved with adequate hyolaryngeal excursion and safe swallow observed. Approximately 10% bolus loss was noted, likely related to pacing and oral control.

Trial 3
The child independently self-fed a cracker, demonstrating bite, tear, and munching patterns. The child consumed yogurt independently with a spoon, demonstrating appropriate pacing, containment, and no signs of aspiration. Increased enjoyment and engagement were noted.

Recommendations:

Suggested feeding aversion with sensory components, rather than structural swallowing impairment. Mastication skills were there but inconsistent. Continued gradual exposure, offering preferred textures alongside novel foods.

Client 2

The next client demonstrated a complex medical history. This child was born at 40 weeks and required prolonged oxygen support due to lung infections related to aspiration. Medical history included NG tube placement, PEG feeding, multiple orthopedic surgeries, low muscle tone, and neurologic involvement. The child receives PT, OT, SLT, and neurology services. Caregiver goals included transitioning from tube feeding to increased oral intake.

Oral–Motor and Sensory Observations:

The child demonstrated heightened sensitivity to oral stimulation, wet vocal quality, increased respiratory rate, anterior bolus loss, and fatigue during trials. Oral findings included overbite, tight lip tie, low tone, and limited head control.

Feeding Trials:

Melted ice:
The child tolerated small amounts without distress; coughing was observed, indicating possible airway compromise.

Purée/Yogurt trials:
The child accepted minimal amounts with open mouth posture. Limited bolus control and delayed swallow were observed. No overt signs of aspiration occurred during the session; however, respiratory changes suggested the need for caution.

The session prioritized safety over volume. Positive responses to cold stimulation were seen, suggesting potential for future skill development. Continued slow exposure, monitoring respiratory status, and maintaining a safe feeding plan were recommended.

Client 3 – Down Syndrome

Background and Session Reflection:

The child with Down syndrome demonstrated strong engagement and positive rapport throughout the session. The child was able to self-feed and showed increased comfort and interest during feeding tasks. I was unable to take too much data on the last client as the child took a liking to me so I had to keep her entertained with vegetable play.

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Day three both groups switched, my group as we had been under Dr.Muttiah observing CVI switched to Mrs.King's group to now observe Dysphagia. Prior to the trip I did not know much of Dysphagia aside from completing observation hours which allowed me the chance to see two sessions. I went in excited to learn more. The day prior Mrs.King had given us a review on Dysphagia which was helpful in introducing new vocabulary so the undergraduates and myself could understand what was being talked about. (Bolus, anterior loss, residual/minimal clearing, mastication). The day ended on a great note when the mother of the Down syndrome client expressed significant emotional relief and satisfaction with the session and cried to us overwhelmed with relief. She had previously been told her child would not be able to live a normal life and the session proved otherwise with the child’s ability to self feed, ability to communicate and the child’s joy! There were tough moments throughout the day especially with the client who had a PEG tube, as it was my first time seeing that, I had a heavy heart for the families difficulties.

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Once again the background and feeding history of the client was taken by the clinician. The caregiver reported a normal birth history with no history of choking. The child is able to self-feed, though meals take longer. The child sometimes gags with food.

Oral–Motor Examination:

Findings included a high palatal arch, reduced maxillary structures with peg-shaped incisors, a missing right mandibular incisor, and generalized dental decay on molars. The child demonstrated lip pursing, functional bilabial range of motion, and adequate oral cavity closure.

Numerous food and liquid trials:

Trial 1
The child demonstrated a good labial seal, adequate pacing, and sufficient hyolaryngeal excursion with a water cup. No signs of distress were observed. The child accepted liquid appropriately and swallowed safely.

Trial 2
The child shook their head “no,” squished the food (papaya) , and swallowed without adequate oral preparation, indicating reduced oral processing.

Trial 3
The child did not accept the food (rice). Tongue movements suggested sensory aversion to texture.

The child demonstrated sensory-based feeding challenges, particularly with textured foods. Recommendations included offering foods that melt easily in the mouth and mixing soft solids into purées to gradually increase texture tolerance.

Client 2

Background history was taken per usual. The child has a history of CVI and cerebral palsy, was born at 34 weeks via C-section due to maternal hypertension, experienced neonatal distress requiring NICU admission, and had seizures shortly after birth requiring medication. The child receives OT, PT, and SLP services. The child communicates primarily through vocalizations and facial expressions and demonstrates good tolerance for liquids. Preferred foods include bun, biscuit, and gravy.

Oral–Motor Examination:

Findings included slightly reduced lingual retraction, intact palate, adequate jaw inclusion, and overall functional oral structures for feeding.

Food and Liquid Trials:

Trial 1
The caregiver manually opened the child’s mouth and presented liquid (water). The child demonstrated licking of lips, adequate swallow initiation, stable vocal quality, and appropriate hyolaryngeal excursion.

Trial 2
The child accepted spoon fed liquid with an open mouth posture. Mild anterior loss (~10%) was observed, likely related to fast pacing. The child swallowed a teaspoon of liquid without signs of aspiration.

Trial 3
When positioned laterally, the soft potato remained on the palate, and the child did not demonstrate a munching or chewing pattern.

Recommendations given by the clinician:

The child would benefit from small bite sizes, gradual exposure to textured foods, and increased opportunities to explore sensory input. Caregivers were encouraged to continue offering preferred foods while slowly introducing new textures, such as larger spoonfuls of yogurt and varied sensory experiences.

Positive reinforcement was provided and caregivers were encouraged to continue exposure-based feeding strategies.

That was the day for clinic and then we got to listen to Mrs. Kings talk!

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The first client participated in structured speech-language therapy sessions focusing on choice-making, yes/no responses, AAC use, visual discrimination, receptive language, and early expressive communication.

Session 1: Choice-Making and Yes/No Responses (Buzzers & Preferred Items)

The session began with the use of buzzers to support engagement and choice-making. Choices were repeatedly presented using preferred characters (Miss Rachel, Hey Duggee), the client consistently selected Hey Duggee, demonstrating clear preference and intentional choice-making across multiple trials.

Yes/no responses were targeted using colored buzzers (green for “yes,” red for “no”). The client demonstrated understanding of yes/no concepts by responding appropriately to questions such as:

Wanting or rejecting specific items (milk cookie, TipiTip, Hey Duggee)

Identifying people (responding “yes” to identifying mom)

Indicating intent and refusal

Session 2: AAC, Expressive Vocalization, and Picture Identification

A video-based activity targeting expressive vocalization was introduced. Client made choices between motivating items such as ball and bubbles, using AAC with single-picture displays. Client successfully selected “bubbles” multiple times and demonstrated functional requesting (“more ball”) using AAC.

Receptive language skills were targeted through object and action identification, including:

Identifying items by function (“Which one drives?” → car)

Identifying sounds/actions (“Which one quacks?” → duck)

Identifying categories (drinks, brushes)

AAC-based simple verb identification (reading, clapping, singing, talking, eating, drinking) was attempted; however, the client showed limited responsiveness at this level. When six-picture AAC displays were introduced, comprehension decreased, suggesting that reduced visual complexity supported better performance. I noticed the client consistently demonstrated understanding of “drinking”, often responding by grabbing their bottle.

Session 3: Receptive Language and Two-Step Directions

The next section focused on receptive language targeted using two-picture choices and two-step commands. The client successfully identified items such as:

Duck

Banana

Strawberry (with some initial errors followed by correction)

Successfully demonstrated understanding of daily routines (e.g., drinking, brushing hair) and was able to follow two-step directions, particularly when picture supports were provided. Right-hand dominance was observed, and required support to maintain attention.

Session 4: AAC, Visual Discrimination

High-tech AAC was introduced using two-picture and later more complex picture displays. Successfully made choices between toys and songs (teddy, bubbles, slide). Visual discrimination tasks were completed using increasingly complex scenes, where client correctly identified items such as dog, ball, bird, elephant, giraffe, though errors increased as visual complexity increased. These findings reinforced the need for high-contrast, simplified visual layouts.

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It was a great day. I was able to obtain clear data on the client giving me exposure to how data and professional jargon is expressed. The sessions ended positively with clear recommendations given to the caregivers. Mrs. Kings talk offered recommendations for intervention and therapy for those at the clinic. One of the observers mentioned a difference between clustering in the Sinhala language and English language that I would not have thought of prior. This gave me more of an insight into the complexities of speech in languages.

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Today has been one of my favorite days. It was interesting to see how different clients can respond when they are diagnosed with the same diagnosis. The sessions varied in intensity, focus and goals. I noticed a greater need for flexibility throughout the sessions to ensure the activities were tailored to that specific child’s needs. For instance, the client who was selecting yes or no on the buzzers did not do well with printed paper and the mother commented laminated is better. With this Dr. Muttiah had me go to the AAC lab and with the help of the workers at the clinic, they laminated the papers to work on during the session. The mother however was already prepared knowing her child’s needs which was awesome to see. Today I got confused by the Sri Lankan head nod and had to ask for more clearance about what it meant!

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These clinical sessions provided a meaningful look into the role of Early Intervention (EI) in speech-language pathology and its impact on children with Down syndrome. Early Intervention in speech therapy focuses on supporting communication, cognitive, sensory, and social development during the earliest stages of life, when the brain is most adaptable. The purpose of EI is not only to address delays but also to coach caregivers, embed strategies into daily routines, and support functional communication across environments.

During the first EI session with a 6-month-old infant, intervention focused on foundational communication skills such as labeling objects, modeling language, and repetitive shared book reading (e.g., “duck, duck, duck”). Distractions were intentionally reduced so the child could focus on one stimulus at a time, and positioning was carefully adjusted to support attention and engagement. These strategies are developmentally appropriate and help build early receptive language and joint attention skills. An occupational therapy referral was recommended to further support sensory and motor development, highlighting the importance of interdisciplinary collaboration in EI.

In a second EI session with a child with Down syndrome, both parents were present and actively involved. The child demonstrated strong joint attention and was able to visually track objects, which allowed clinicians to target early language goals. Therapy focused on labeling objects (e.g., “fishy”) and expanding language by pairing objects with actions (e.g., “fishy swim”). Positioning during book reading was used to maintain engagement and maximize visual access. The parents bringing a blanket for their child emphasized the importance of comfort and regulation during sessions and reinforced the family-centered nature of EI services.

Another session with a child with Down syndrome focused on AAC, sensory processing, and emerging language skills. The child showed high levels of vocalization, engagement in play, and understanding of routines, such as recognizing that a banana is used for eating and responding to their name. Receptive and expressive language skills were present, including body part identification. The child demonstrated consistent choice-making using AAC with four pictures, and successfully expanded to eight-picture AAC, supporting increased communication independence. Clinical observations such as impulsivity, open mouth posture, overbite, and sensory behaviors contributed to the recommendation for a CVI assessment, demonstrating the importance of holistic clinical observation.

In a session with a 7-year-old child with Down syndrome, AAC was used to support functional communication, literacy, and sentence development. Despite significant dental challenges, the child successfully identified fruits using AAC, worked on producing “I want” requests, and demonstrated the ability to combine simple words into sentences at home. During book reading, clinicians modeled breaking language down and asked comprehension-based questions, such as identifying what a character was doing and how the child arrived at the clinic. The child responded accurately through AAC, showing growing expressive language and comprehension skills.

The final session involved dysfluency and narrative development in a child with Down syndrome communicating across Sinhala and English. The child demonstrated single-syllable repetitions and primarily one-word utterances, but was able to answer “why” questions, label vocabulary, count in English, and describe events such as “Father is running because of the rain” in broken words. Intervention focused on building narratives using mind maps, graphic organizers, and the story retelling rope, targeting story structure (beginning, middle, and end) and increasing utterance length.

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These sessions reinforced the importance of Early Intervention, AAC, and family-centered care when working with children with Down syndrome. They highlighted how individualized, functional, and culturally responsive approaches can support communication development at every stage. It was impactful hearing the last clients story from their mother. The child demonstrated potential growth in the areas of expressive and receptive language even through the diagnosis and life challenges they have experienced. This experience deepened my understanding of how speech-language pathologists support not only children, but also families, through intentional, evidence-based intervention.

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The last day of clinic was a half day. The morning was spent working on a three clients previously seen the week before for Dysphagia. For the first session, after the graduate student spoke with the mother in regards to what has changed since the last time they were seen the session began. I recorded six trials of what was done during the session that demonstrated steps to desensitization to food

Trial 1

A vibrating brush was introduced to support sensory desensitization. The stimulus was first applied to the client’s hand to familiarize the child with the sensation. The clinician then gradually progressed proximally to distally, applying the brush to the arm, cheek, mouth area, lower lip, and upper lip. Lip puckering was facilitated by the clinician, followed by attempts to encourage independent lip puckering by the child. This sequence was repeated 10 times to promote tolerance and consistency.

Trial 2

A toothbrush was used to provide oral stimulation to the lips, with the goal of eliciting independent lip puckering. The clinician modeled the movement and waited for the child to initiate the response. This trial was also repeated 10 times, with data collection completed by multiple observers.

Trial 3

The client was spoon-fed yogurt to assess anterior bolus loss and oral control. Several variables were modified during this trial to observe differences in performance, including, seating position and feeding location whether the middle of the mouth (midline) or the side (lateral)

Trial 4

The vibrating brush was reintroduced while the clinician used the opposite hand to apply pressure to the lateral cheek, encouraging a chewing response on one side. This dual input provided both sensory and motor cues.

Trial 5

A non-vibrating brush was presented with the expectation that the child would bite down independently. When this did not occur, the clinician manually massaged the external cheek to stimulate jaw movement and chewing behavior.

Trial 6

The final trial involved placing mashed potato laterally in the mouth while the clinician manually massaged the child’s cheek to model chewing. A small amount of yogurt was then introduced to assess bolus clearing and swallowing efficiency following mastication.

The last session of the day while the child did not interact consistently with the food or accepted it, the clinicians and parents were flexible in meeting the child where he was at. The parents clinicians and even the clients toys interacted with the food through touch, licks and smell to motivate the child.

We then said goodbye to the clinicians and staff who had welcomed us into the clinic handing off gifts and hugs!!

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My final day at the Ayati Clinic felt especially meaningful. Overall, this experience was incredibly rewarding, and I am deeply grateful for the opportunity to have gone to the Ayati Center. It was powerful to help support a clinic connected to my professor’s former students and to witness firsthand how speech-language pathology is practiced in a multilingual and multicultural setting. Seeing the differences in how speech, language, and communication are supported across languages reinforced how adaptable and universal our field truly is.

During the first session of the day, I was struck by how accepting the child was of the vibrating brush. Watching him tolerate and engage with the sensory input was exciting, especially knowing how challenging sensory-based interventions can be. What stood out most was the mother’s response—she shared that since the last session, she had been actively trying the recommendations at home. Seeing her confidently and lovingly hold her child while implementing strategies demonstrated her strength, dedication, and trust in the therapy process. It was a powerful reminder of how impactful caregiver education and carryover can be.

In the second session, it was heartwarming to see both parents present and actively involved in therapy. When the animals were being “fed,” not only did the child participate, but the parents also touched the food and modeled engagement to motivate their child. Their involvement transformed the session into a shared experience rather than a clinician-led task. This level of participation reinforced how therapy is most effective when families feel empowered and included.

Reflecting on this final day, I realize how much this clinic experience has shaped my understanding of family-centered care, cultural responsiveness, and the importance of collaboration. The acceptance, resilience, and commitment demonstrated by the families reaffirmed why I am pursuing speech-language pathology. I will carry these experiences with me as I continue my journey, both as a future clinician and as a person.

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Sri Lanka was breathtaking in ways I never expected. The people, the culture, and the sense of community that surrounded us everywhere we went welcomed us like one of their own. One of the most meaningful moments of the trip was helping donate sneakers and socks to the children at the Methodist church—black sneakers for the boys, white for the girls. Seeing the children receive them with such joy and gratitude was incredibly moving even if they couldn’t understand what we were saying they were so happy. The way they bowed and expressed thanks to us was humbling. It was a reminder that small acts of service can carry deep meaning, and this experience would not have been possible without the students coming together to raise support funds.

Another highlight was visiting an autistic school which was damaged during the recent cyclones. We were yet again welcomed with open arms. One woman even showed us a broken radio that had been damaged due to the water. An old radio I think it was a boombox. The moment stood out to me so much as I am so blessed to have all that I do I should never forget to give freely to those in need.

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During this trip we had the opportunity to meet the U.S. Ambassador and learn about the scope and responsibility of her role. Hearing firsthand about her work and the way she represents the United States abroad was both inspiring and eye-opening. She mentioned she was from Texas and to see her have such an important job reminded me the power it is to be an American and how we can use that for the good of others.

The trip also brought us closer together as a group. Visiting the tea estate and the Buddhist cultural temple allowed us to experience Sri Lanka’s history, spirituality, and natural beauty. Walking through the tea fields and learning about the process behind such an important part of Sri Lankan culture was grounding and peaceful. My professor even shared with us the sweeter the tea is when you have it in someone’s home represents their appreciation. This is something I plan to do moving forward as it was so thoughtful!

The cultural immersion and shared moments made this experience far more than a clinical opportunity but rather a way to reflect on my decisions moving forward both academically and professionally.

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These are a few of my favorite pictures from the trip. They show me beauty and peace. From the botanical garden, to my professor and her family and the history of Sri Lanka. All show beauty and history. The picture on the river holds reminder of what Sri Lanka has experienced in invasion and trading while the elephants symbolize the strength and sacredness of their beliefs. Again I can not stress enough how much I learnt on this trip not only clinically but culturally. I hope it can be done again in the future and that this first trip gave hope to the professors and clinicians in Sri Lanka of the unity we can all have!