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This is the free clinic located in Ragama, Sri Lanka. This clinic sees thousands of children from all around Sri Lanka and there are only 3 Speech Therapists here. They also offer a variety of other services like physical therapy, occupational therapy, and more.

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Day One - Summary of Clinical Observations  

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Day One - Summary of Clinical Observations  

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The population of the groups I observed during assessment on our first day at the clinic included children who are diagnosed with Cerebral Palsy (CP) and Cerebral/Cortical Visual Impairment (CVI). This was the first time I learned about CVI. CVI and visual processing is different for each child with CVI. Some kids prefer certain colors, have a visual field preference, or need an object to be moving in order for them to see and process it. These were some of the characteristics that the clinicians and graduate students were assessing. They used different colored objects and tested if the child could fixate and follow on it, which colors they preferred over others, latency, and augmentative and alternative communication (AAC) trials. They then created appropriate goals for each child depending on their needs. I also went to the AAC lab with some of the other undergraduate students to learn how to program on Board Maker. We created a low tech AAC device for a child whose goal was to learn more simple verbs using low tech AAC and pointing. I observed four different children during their sessions who all had CP and CVI and it was interesting to see how although each child had the same diagnosis, they all had differences in the visual processing and severity of their CP and CVI phase. Many of the children had color preferences, but their preferences all differed based on the child. One therapy toy that was a big hit for the kids was the pull apart vegetables that one of the other students brought. The kids loved to cut them with the pretend knife and put them back together. Another thing that was interesting to see firsthand was the testing of the threat and tap reflexes. Some children had both of these reflexes but others did not. This was something that I had never considered as part of speech therapy, but it was so fun to see.

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The first day at the clinic brought me so many different reactions and feelings towards the interactions that I had with members of this culture that is new to me. The first thing I noticed that surprised me is that everyone is barefoot. All of the parents come in to the therapy rooms without shoes, and they even take their kids’ shoes off sometimes. At times, it was hard to communicate with a lot of the parents and children due to the language barrier. However, I was expecting less English speaking families. A lot of the parents on the first day understood and spoke some English which alleviated a lot of the language barrier stress for the first day. I was shocked to learn how far a lot of the families have to travel to receive services. Many families were traveling for 2 or more hours and had to take off work to bring in their kids. This showed how dedicated a lot of the families were to helping their kids and their communication skills. My initial reactions to the families I had met were taken aback at how respectful they were to us and the clinicians. I liked this because in America, I would expect parents to dislike a ton of people in the room during therapy but I think the parents here handled it very well and were very respectful towards me even though I was only an observer.

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Day Two - Summary of Clinical Observations 

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Day Two - Summary of Clinical Observations 

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During our second day in the clinic, I observed 4 children during their sessions for assessment. Today was similar to our first day of CVI assessment. During each session, I watched the graduates ask the parents questions, interact with the kids, use objects to test the severity of their CVI, and create appropriate goals for the upcoming intervention sessions. They also trialed AAC for certain children. For example, one method of AAC that they tried was for the first client of the day. We used buzzers and recorded two choices for YouTube videos, and added a picture of each one to the top of the buzzers. Then, the graduate student would ask the child which one she wanted and played the recording for her. It was so cool to see her understand and utilize this type of AAC, and her mom loved that she was able to communicate her needs more. The next child had dark room modifications, so the grad students completed the tests there. They recommended providing the child with more wait time and sensory input to allow the child to respond, and giving sensory stimulation for eating and brushing teeth to prepare her more. She responded well to sensory input, which led them to refer her for an ASD diagnosis. The next child I observed had diplegic CP, which means that only the hands or arms move, and in this case, the child's hands were able to move but not her feet. This child was very independent, smart and very stimulable for learning. She knew how to differentiate Sinhala letters from one another and was able to use AAC to answer questions. Possible modifications for her included environmental modifications, reducing distractions, and reinforcing positive behavior and the use of AAC through learning for a few minutes and clips of YouTube videos as a reward.

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Day Three - Summary of Clinical Observations 

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Day Three - Summary of Clinical Observations 

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During the first day of the dysphasia clinic, I observed four pediatric clients with complex medical and developmental history, including CP, CVI, Down syndrome, and global developmental delays. Throughout the sessions, feeding evaluations focused on assessing the child’s oral motor skills, sensory preferences, ability to control food in their mouths, airway protection, and strategies for caregivers. One child had food aversions and oral holding. He only ate biscuits and some yogurt, however he demonstrated sensory based food aversions and oral holding to soft solids. He showed no signs of aspiration and showed good mastication skills when eating a biscuit. The clinicians recommended the family to not force feed him any foods, and to create a positive feeding environment so that he can be more open to trying new foods. Another child with a feeding tube came in to be evaluated and showed poor posture, significant inability initiating swallowing, and wet respiration and cough which led the clinicians and students to strongly advise the parents against feeding their child due to it being unsafe. The next child also had trouble with swallowing and respiration, and experienced occasional gulping of air. While he was also not safe to be feeding solids to, his mom was looking for help with his respiration, and was referred to see a regular doctor instead. Lastly, I observed a child with Down syndrome. She showed no feeding concerns, and was able to eat cucumbers and crackers on her own with adequate oral clearing. Her mom was so happy to see that she was on the right track. All of the clients I was able to observe today showed how important it is to educate caregivers on proper feeding posture, sensory awareness, and pediatric dysphasia in general because not many people know how dangerous swallowing can be.

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Day Four - Summary of Clinical Observations 

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Day Four - Summary of Clinical Observations 

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During today’s clinical sessions, I was able to observe two pediatric dysphasia sessions. The sessions included children with complex medical history and development. The first child I observed had CP and CVI, and a developmental delay. He participated in experimental feeding trials of spoon fed purées and liquids such as yogurt and water, in which he demonstrated intact dentition and palatal formation, clear vocal quality, and adequate laryngeal excursion. However, feeding required support from his caregiver and the clinicians. Another child we saw was diagnosed with Sanjad-Sakai Syndrome. This was the first time I had ever heard of this syndrome before. I learned that it is associated with hearing and vision impairments. This child showed safe swallowing abilities with purées and liquids like yogurt and water. He showed a good labial seal when drinking from an open water cup, a good swallow initiation, and good bolus clearance, as well as no signs of aspiration or distress. He accepted some solid mashed foods like mashed potatoes, but demonstrated oral holding when distracted or distressed. Overall he needed extra meal time to complete swallowing tasks. During both of these sessions, the clinicians focused on emphasizing the importance of safe feeding strategies, pacing during mealtimes, gradual texture progression, and caregiver education. They provided strategies to the parents, allowing them to understand how they can better support their children during meals. Some strategies included making sure their positioning was upright, feeding slow and not rushing , allowing them to fully swallow before giving them the next bite, and continuing to gradually and slowly introduce new food textures into their safe foods to allow them to be more comfortable exploring. They also recommended that the clients come back for swallowing intervention to start therapy strategies.

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Day Five - Summary of Clinical Observations

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Day Five - Summary of Clinical Observations

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Today I was observing the CVI unit during intervention services. The first child I observed practiced using high tech AAC devices. She used buzzers to indicate what videos and snacks she wanted. The grad students asked her A question and she answered with the buzzer. I then observed another child with CVI (not pictured). The grad students tested his visual preferences such as colors and visual fields and seeing if he could fixate and follow the objects by using a flashlight in the dark room. The next client practiced identifying a picture when presented with two. He was able to do this, and they made it more fun by asking him where he should park his toy car for each item they wanted identified. They also asked him to play with the toy vegetables, and then asked him to cut a certain one, for example "cut the corn." he was able to identify the correct ones. The last child I observed also used a high tech AAC device and practiced choosing between 4-15 different toys, fruits, and songs he wanted. He was able to choose between up to 15 different choices. With the use of this AAC ahead can communicate his needs and wants with others while developing his communication skills.

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Day Six - Summary of Clinical Observations 

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Day Six - Summary of Clinical Observations 

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Today, I observed my group of grad students and our clinician working with children for early intervention services. The main purpose of the early intervention sessions is to evaluate the child's language skills and to provide the family with helpful strategies they can use at home to help continue the child's language development. One of the grad students would interact with the child by using toys, books, and sounds to stimulate language. The other student asked the parents questions about their child's language to gain a more comprehensive understanding of their development. Some of the questions they asked included, does your child babble, use gestures, point, use facial expressions, or words? Does your child look and engage with you when you talk to them? This helps the students and clinicians understand what stage the child is in their language development. A lot of the children that we saw today did not have too many communication concerns, and were very developmentally on track. The grad students explained that even though a child isn’t talking yet, if they have good joint attention and engagement, they are developmentally on track. One strategy the grad students gave to the parents was to always talk to their child about what they are doing and what their child is doing so that they are exposed to more language. Another strategy was to read books and point to parts in the book while describing what is happening. Even if they don’t understand it yet, their children will be exposed to more language and will continue improving joint attention, which can help their language development. The next strategy was labeling objects you see using repetition and simple language and modeling labeling objects to help to expand vocabulary. This will help the child to continue to develop and learn language since they are prerequisites for learning language.

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Group Excursions and Cultural Experiences 

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Group Excursions and Cultural Experiences 

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Outside of the clinic, our group went on so many different exciting activities. Some of them included an elephant orphanage, donations to a church in Kandy to help with Cyclone relief, going to the beach, and a visit to a turtle hatchery! Going on these different excursions helped our group learn more about the culture of Sri Lanka. There was a parade for the holiday Perahera, which is a cultural and religious celebration that honors religious figures and relics, seeks blessings, symbolizes the Sri Lankan culture through song and dance. Being able to learn and immerse myself in the Sri Lankan culture was such a memorable experience, and one that I never would have gotten elsewhere. Getting to live these new cultural experiences is the true purpose of studying abroad, and I am so grateful to have had the opportunity.

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Today, I was able to see so many children with CP and CVI, and their parents were super supportive. One child's mom told us how she supports her child by being in the classroom with her daughter. Another mom is an online advocate for her daughter and other children with cerebral palsy. I loved being able to see how supportive these parents were of their kids and their disabilities, and wanting to make the world a better place for them. This was so special for me to see as a young student in the therapy field since this is also my first clinical experience and my first experience with children with CP. im grateful for this experience to be able to learn more about these disabilities and how I can integrate what I have been observing into my future practice as an SLP.

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Being able to observe the pediatric dysphasia assessment sessions has helped me so far to understand how complex swallowing can be when there are so many impacting factors. What was especially informative to learn from observing was how certain signs of swallowing difficulty can be so subtle. Some of the children held the food inside their mouths for a long time, had wet vocal quality, or had changes in their laryngeal excursion, which are all subtle details you need to look for during a swallowing assessment. It was so helpful to see how a swallowing assessment is done on children and what the key aspects are to look for during assessments of dysphasia. These are definitely helpful tips I will remember and take with me for future graduate classes, medical placements, and as a future SLP.

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Observing these dysphasia assessment sessions showed how there are so many connections between a child’s medical and developmental history, sensory needs, and their swallowing skills. I gained a better understanding of how a dysphasia evaluation runs, and I learned so much about the mechanics of swallowing as well. I also learned how even the smallest changes can be beneficial for a child’s swallowing progress. Small adjustments in building foundational skills for swallowing, such as strengthening oral muscles, bolus management, oral exploration, and a positive mealtime experience are all ways that a child can progress, even if they aren’t eating new foods and textures right away. This is something that the clinicians highlighted to the parents. They made it clear that although their child may not be earning what they want them to, they are still making small steps for feeding. I also noticed how a lot of parental beliefs are culturally intertwined. a lot of parents have different views on their children's disability. In the feeding clinic, I noticed how some parents felt upset that their children did not want to eat the foods that are so important in the Sri Lankan culture, such as rice and curry or potatoes. For me, coming from a culture where food is celebrated instead of rejected, I can understand how a lot of parents might feel discouraged and confused as to why their child won’t eat the foods that they provide them with. However, it is also important for parents to understand that creating a negative mealtime experience for their children will only deter them even more from wanting to try new things.

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Today I was able to observe three early intervention sessions. I was able to learn so much about early intervention and early language development for children. After watching these sessions, I was able to better understand the roles intentional play, caregiver involvement, and daily language interactions, can have on a child's language development. I also liked how the students and clinicians were able to use the information provided by the parents about their child's language use, combined with direct and intentional interaction with the child to gain a better understanding of where their language is at developmentally. Through the observation of early intervention therapy techniques, I was able to pick up on some key components of language development. One part of language development that was highlighted to the parents was joint attention. This is a prerequisite for learning language. If a child shows good joint attention, it likely means that they are on the right track developmentally for language. This is why it is important for parents to talk and read to their babies, even if they don't yet understand what is being said. The most important part is making sure the child is engaging with what the parent is saying or reading, this way they are continually exposed to more language. This emphasized how important caregiver education is, and making sure to provide them with the strategies to continue using at home to support their child’s language development. Overall, today’s observations deepened my appreciation and interest for early intervention as a family-centered and preventative approach, strengthening my interest in working with young children and their families as a future SLP.

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Today, one of the child's mom talked to us about why she is such a passionate advocate for CP for children in Sri Lanka. She said that many parents are not as accepting of their children's disabilities and might hide them from society because of the cultural stigma surrounding disabilities. It shocked me to learn that there is such a strong cultural stigma about disabilities and that some parents hide their kids from the world. This will help me as a future clinician to be able to encourage parents that a disability is not always a negative thing, and to help shift their mindset towards a more positive outlook.

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Day Seven - Summary of Clinical Observations 

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Day Seven - Summary of Clinical Observations 

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Today was our last day at the Ayati clinic. I was observing in the feeding and dysphasia unit. Since it was a half day, we only saw three children. We saw some of the same kids that saw for days 3 and 4 for feeding assessment. The first child was one with feeding aversions. They started with play, using stuffed animals to imitate feeding and touching food with rice and water, and the child touched the food. They also modeled feeding with his family members. Then they began to trial oral sensory input to familiarize him with the sensations using different tools such as toothettes and vibrating tools. He was open to exploring oral sensory experiences with these objects which is a step towards food. The second child I observed had CP and CVI, but did not really struggle with any food aversions. They first started by provided oral sensory input with the vibrating tool and toothette on his cheeks and lips. He accepted this sensory input multiple times with both objects. Then they began trialing different foods, and the grad student modeled what it should look like for the mom. She showed her how to give him small bites by placing a small amount in the center of his mouth and closing his mouth after to help him keep better control of the bolus. This method helped decrease the child’s anterior bolus loss although it didn’t eliminate it completely. They also modeled smacking the lips to help the child try and chew the food on his own. He also handled the oral mechanism stimulations very well which is to help strengthen his chewing. Then they moved on to trialing with food while still modeling the chewing process. They had him switch between small bites of potato and small bites of yogurt to help him learn to mash and chew food, and clear the bolus. For the last child, the session began similar to the other two, modeling feeding with stuffed animals, then introducing familiar foods the child likes and modeling over exaggerated mashing and moving it around in the mouth. He then took a bite, and the grad student massaged his cheeks to model chewing. All of the kids today made really good progress and worked towards accomplishing many of their goals.

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Today I learned so much about feeding therapy. I learned how many steps it takes to get children more familiar with food and feeding. It is important to move slow with the child and get them more familiar with touching and playing with the food. This is the first step towards feeding. I also learned about sensory stimulations which helped the kids with sensory aversions to be more open to eating eventually. I learned that feeding therapy includes more aspects than just food. You have to heighten the child’s sensory experience so that they feel more comfortable, have a more positive feeding experience, and eventually feel open to eating food.

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We got the opportunity to meet the US Ambassador of Sri Lanka! We were able to talk to her about our experiences in the clinic as well as outside of it in Sri Lanka

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Our group of graduate and undergraduate students and our two professors. We also got to meet the Dean of the university !