CSHA Diversity Issues Committee
Cultural and Linguistic Competence
A Guide for the 21st Century Clinician
CSHA Diversity Issues Committee
Co-Chairs
Pamela Norton CCC-SLP,
Ph.D., & Sandra Gaskell
CCC-SLP, D-ABD
Members
Christine Maul CCC-SLP,
Ph.D., Elisabeth Ward
CCC-SLP, M.A., & Sofia
Carias CCC-SLP, M.S.
Moderator: Betty Yu CCCSLP, Ph.D.
CSHA Convention
Friday, March 28, 2014
San Francisco, CA
Agenda
Introduction: The changing face of California (Sofia Carias) 10mins
What is the Diversity Committee: Purpose, Roles, &
Participation (Sandra Gaskell) 10mins
ASHA documents on Multicultural Practices (Christine Maul) 25mins
Non-Biased Assessment Procedures: What’s new
(Pam Norton &
Sofia Carias) 30mins
Break 10mins
Culturally Competent Clinical Skills: What Works (Elisabeth Ward)
25mins
Case Studies: Small Group Activity 40mins
Gaining Support for Culturally Competent Practices (All) 15mins
Questions & Wrap up (Until the end)
Introduction
Why are we here?
The Changing Face of California
Sofia Carias
Where have we been?
Dramatic population
growth decade after
decade
1970 – 20 million people
80% identified as white on
census data
Sacramento, 1860s
Where are we now?
2010 – 40 million people.
We doubled in 40
years!
Today, no race or ethnic
group has a majority
Fastest growing groups
are Asians & Latinos
Where are we going?
In next decade, Latinos
will be single largest
population
Large international
immigrant influx &
higher birth rates
Projected for next 10-20
years: 400,000 people
per year (size of Long
Beach!)
2030 – 1 in 5 over age 65
Implications
Changes in Public Policy
Transportation, water,
education, & healthcare
SLPs will need to keep up
with growing demand
for services to
multicultural groups
Diversity of skills,
interests, beliefs will
challenge our own
therapy practices
Purpose, Roles, and Participation
CSHA’s
Diversity Issues Committee
Sandra Gaskell
Purpose
Mission Statement
The mission of the
Diversity Issues
Committee is to assist
CSHA members in
increasing knowledge and
awareness of issues
related to cultural and
linguistic diversity in
speech-language pathology
and audiology
On the Web
http://www.diverscommcsha.org/
CSHA Websites
https://www.csha.org/diversity
Yahoo Group
http://groups.yahoo.com/group/_csha_
diversity_committee/
Facebook
Roles
• Attend all meetings
• Contribute and voice
objective opinions
• Share relevant info on
multiculturalism
• Respect ideas and conflicting
viewpoints
• Advocate on behalf of the
profession
• Participate in on-going
projects
• Agree to a two-year term/
can be extended to fouryears
• Chair (or co-chairs)
• Members
• A group representative of
the CA demographic trends
Newsletter
First Issue was in 2005
Available at every CSHA since
then
Projects updated in articles
Special Interest information/
Resources
Cultural Competence
Presentations: CSHA 2005,
2008, & 2014
Understanding Worldview
• Individualism vs.
collectivism
• Work ethic
• Event time vs. clock time
• Language and dialect
• Roles in kinship
• Beliefs-rituals-superstitions
• Class /status/ cast
• Values-”end states”
• Overt – what is seen on
the surface of a culture
• Covert-what lies under the
surface in a culture
Brislin, R. W. (1970). Back-translation for cross-culture research. Journal of Cross-Cultural Psychology, 1, 185–216.
Brislin, R. W. (1980). Translation and content analysis of oral and written materials. In H. C. Triandis & J. W. Berry (Eds.),
Handbook of cross-cultural psychology: Methodology. (pp. 89–102). Boston: Allyn and Bacon.
Cross-Cultural Skills
• Medical Anthropology & Ethnography in Speech
Pathology have common observation skills
• We use the terms
• “setting” and “characterized by” – we give “diagnostic
statements” based upon “observations.”
• We analyze power structures which create human
behaviors.
• We identify behaviors between individuals for
problem solving.
• We analyze kinship models and determine who holds
the power in a human group in order to effect change
Fieldwork Data is…
Observation & Interview
“In contrast to an impairment or a delay, a language difference is
associated with systematic variation in vocabulary, grammar, or
sound structures. Such variations is ‘used by a group of individuals
[and] reflects and is determined by shared regional, social, or cultural
and ethnic factors’ and is not considered a disorder” (Prelock et. al, 2008:136)
Prelock, P., Hutchins, T., Glascoe, F. (2008). Speech-Language Impairment:
How to Identify the Most Common and Least diagnosed disability of childhood.
Medscape Journal of Medicine.10(6): 136.
ASHA Documents
Cultural Competency
Christine Maul
ASHA (2011)
Cultural Competence in Professional Service
Delivery
• Position Statement
• Professional Issues Statement
Position Statement
Providing competent services requires cultural
competence
To be culturally competent, individuals should:
• Value diversity
• Conduct cultural self-assessment
• Be conscious of dynamics of cultural interaction
• Have institutional cultural knowledge
• Adapt to diversity and cultural contexts of the
communities they serve
Position Statement (cont.)
Cultural humility
• Ongoing critical self-assessment
• Recognition of limits
• Ongoing acquisition of cultural knowledge
“In summary, culturally competent professionals must
have knowledge, understanding of, and appreciation
for cultural and linguistic factors that may influence
service delivery from the perspective of the
patient/client and his or her family as well as their
own.”
Professional Issues
Why should we be culturally competent?
• To respond to demographic changes
• To eliminate health status disparities
• To improve service quality and health outcomes
• To meet legal mandates
• To gain a competitive edge
• To decrease the likelihood of liability/malpractice
With all due to respect to ASHA, I would add. . .
Professional Issues (cont.)
. . . BECAUSE IT’S THE
RIGHT THING TO DO!!!
Cultural Dimensions
ASHA has adapted a framework suggested by research
conducted by Hofstede & Hofstede (2005) to describe
cultural dimensions
• Individual-collectivism
• Power distance
• Masculinity-femininity
• Uncertainty avoidance
• Long-term orientation
While somewhat useful in organizing our thinking, this
framework has had its critics, to say the least!
The framework may be of little use in attempting to understand
individual human beings
Cultural Reciprocity
Not mentioned in the ASHA (2011) documents
Proposed by Kalyanpur & Harry (1999) writing in the field of
special education
• Identify possible cultural bases for your interpretation of a
students’ difficulties
• Discover whether or not the family shares the bases for
this interpretation
• Acknowledge cultural differences that may be revealed
• Explain the cultural basis for the professional’s
interpretation
• Determine ways to adapt professional interpretations to
the value system of the family through discussion and
collaboration
Suggestions!
We recognize the limitations of a framework such as that
discovered by Hofstede & Hofstede (2009) in attempting to
understand cultural differences at the level of the individual
human being
We examine more thoroughly alternative models to “cultural
competency”
• Cultural humility
• Cultural reciprocity
We embrace a more holistic approach in educating SLP students
regarding lifelong self-examination and development of
appreciation of cultural variations
What’s New
Non-Biased Assessment Procedures
Sofia Carias & Pam Norton
Examiner Bias
Defining English Language Learners
Do you have a Bias? We all do!
• Educational?
• Cultural?
• Linguistic?
How do we reduce examiner
bias?
Examiner/Test Bias
Sherman-Wade & Bader, 2013
CONSIDER THIS
• WHAT IS THE PURPOSE OF THE TEST?
• Who is requesting the evaluation?
• WHO ARE THE RESULTS FOR?
• What will the results be used for?
• WHO IS PAYING FOR THE EVALUATION?
• Legal guidelines?
Test Bias
Racial and cultural biases in assessment materials =
disproportionate representation of minority children
in Special Ed. – HOW?
Activities of daily living, vocabulary exposure, idioms,
socialization practices, etc.
Examples from commonly used tests
What does IDEA 2004 say?
Know Your Test
IDEA 2004 says…
VALIDITY - Does the test actually test what it is meant
to test?
RELIABILITY - Quality of test scores. Degree of
inaccuracy of measurement due to errors. Stability of
scores. Consistency with which a test measures a
given behavior.
CONFIDENCE INTERVAL - This analysis assumes the
test is valid, reliable, and has no significant cultural or
linguistic biases
Types of Tests
Norm Referenced
Criterion Referenced
• Advantages
• Advantages
• Disadvantages
• Disadvantages
Alternative Assessment
Approaches
Sherman-Wade & Bader, 2013
What are they?
What does it include?
Advantages?
Disadvantages?
Interpreting Scores
Crowley 2009, 2011
• Parent Interview Information for report sections
• Evaluation of the Data
• Informed Clinical Judgment
Bilingual & Multicultural
Considerations
Normal Second Language Acquisition – Simultaneous?
Sequential?
Factors influencing bilingual development –
Interlanguage, Silent period, Language loss, Exposure to
dialects, Exposure to code-switching
Know the client’s cultural views on Health, Disability,
Religion, etc.
Linguistic Universals?
Again – know your test!
Modifying A Std. Test
Sherman-Wade & Bader, 2013
• Give instructions in the first language and in English
• Rephrase confusing instructions
• Give additional examples and demonstrations
• Provide extra time for the student to answer
• Repeat items when necessary
• Check the Administrator’s Guide…
Using Interpreters
Report Writing
This is the basis for all we do! Eligibility, Tx goals,
frequency, dismissal!
Be descriptive – do not rely solely on the numbers
• Hologram Method (Crowley)
• Difference v Disorder – data description
WHY DOES ANY OF THIS MATTER??!!
• Ethical Conisderations
• Educational Impact
• Cultural Impact
• Societal Impact
African American Students
Dialectal Variations & Bias
Linguistic bias is universal
 Habitus: notion of an actor's 'best interest'
through attention to the cultural definition of
'best' (Pierre Bourdieu, 1991)
Mainstream American English (MAE) is “best”
• Stakeholder
positions
Bias Consciousness
Awareness that bias is universal
Acquiring knowledge for most accurate diagnoses
Advocating best practices across disciplines
Best placement
Clinical Competency
ASHA
•
Social dialects position paper (1986)
“no diialectal variety of English is a disorder
or pathological form of speech or language.”
•
Cultural and linguistic competence (2013)
“The professional must recognize that
differences do not imply deficiencies or
disorders..”
Diagnostic Error Types
Type 1 and Type II errors (Peters-Johnson, 1986)
•
Type 1: False-positive
•
Type II: False-negative
• Typically developing student identiied as disordered
• Speech/language disordered students not identified
Understanding AA Risk
80-90% of African American students speak African
American English to some degree varying by
environment
- Dialectal patterns emerge at 2, established at 4-5
- AAE features decrease in 5-8 year olds
- More AAE at 9 years and above due to peer
influence, peaking in teens
- Higher in boys, lower in language-impaired
- AAE features overlap with MAE disorder features
What about Standardized Tests?
CONSTRUCT VALIDITY
CASL, CELF-5, EVT, OWLS, PPVT,
ROWPVT, TAPS-3, TELD: construct validity
by correlating with IQ tests (Kaufman, WISC)
or with other tests that correlate with IQ
CELF - Expert bias panel and alternative rubrics but
inconsistent in application
ARTICULATION TESTS are strongly MAE-based
*All demonstrate linguistic bias
Standardized Tests
NORMATIVE SAMPLE
- averaged normative population samples are not valid
- valid tests should demonstrate population subgroup
means and standard deviations
-- all ethnic subgroups should perform “similarly”
TWF-2, TAWF, TWFD, but not CTOPP or TOPS-3
Diagnostic Evaluation of Language Variation – Screening Test
(DELV-ST)
Diagnostic Evaluation of Language Variation - Norm-Referenced
(DELV-NR)
CA Practice Mandates
“When standardized tests are…invalid, expected language
performance level shall be determined by alternative
means”. (CDE, 1989)
- Assessment plan must include description of alternative
means
- Evidence that assessment will be comprehensive
- not discriminatory
- no IQ tests or tests CORRELATED with IQ tests
- result in inclusive written reports
How will tests vary from standard conditions
Increasing Assessment Repertoire
From Technician to Researcher
1 – Gathering information on student across
environments
a – Referral information: interviews with teachers
b – Historical information: interview with parents
c – Observations with peers (Wyatt, 1995)
2 – Alternative assessment protocol
 a - informal assessments
 b - alternative use of standardized tests : quantitative,
descriptive
3 – Report writing with caveats
Triangulating Information
Gathering information on student across
environments – agreement?
 Is there a history of medical concerns/family
disorders?
 Does child seem to be developing differently from
other child family members or typically developing
peers in their community?
 Is the child experiencing obvious difficulty
communicating with peers?
 How does child follow directions, problem solve in the
classroom?
Alternative Assessment Protocol
Sampling and analysis – deep vs. surface structure
• Speech - 20 utterances:
- understood by familiar family listener?
- understood by unfamiliar, community listener?
Language – naturalistic – 50 utterances
Communicative competence, complexity,
pragmatics
Dynamic assessment
Portfolio assessment
Diagnostic Evaluation of Language
Variation
DELV Screening Test (4 – 12)
Mild to strong variation from MAE
Low to high risk for disorder
DELV Norm-Referenced (4 - 9)
Language universals
Syntax, pragmatics*, semantics, phonology
Diagnosis of disorder not related to dialect
Least Biased Report Writing
 Indicate when test modifications have been used
 Use cautionary statements when reporting potentially
biased test data
 Provide detailed analysis of language strengths and
weaknesses vs. standardized scores
 Delineate aspects of speech and language that result
from disorder that are not dialect specific
 Recommendations based on clinical judgment citing
CDE
What Works
Cultural Competence for Clinicians
Elisabeth Ward
SELF-AWARENESS
Are you aware and mindful of
your own cultural beliefs,
values, and behaviors?
How do your own beliefs
affect your interactions
with your patients and
clients?
Do you refer a client to a
colleague if you cannot
manage your biases?
VALUE DIVERSITY
Do you accept and
welcome cultural
differences?
Are you tolerant of
those who look,
speak, act differently
from you?
DIFFERENCES
Do we understand the
dynamics of
differences when
making decisions?
If we believe in one
treatment but the
client does not, do we
fit the client into what
we think is best or
respect their
decisions?
ASSESSING OUR OWN CC
Do we interact with culturally diverse people and then
integrate the lessons that we learn?
Are we aware of our limitations in this area?
Do we know when to seek additional knowledge,
understanding, and sensitivity?
How do we know what we do not know?
Do we assign motivations to people based on our own
culture?
Do we stereotype one culture of people to be “all the
same.” (they do this or that)
ADAPTING
Can we adapt to the
needs and preferences
of our clients and
patients that have a
difference in values,
beliefs, and attitudes?
Defining Disorder
Exploring the meaning of Illness
Explanatory Model
What do you think has caused your or your child’s
problem? What do you call it?
Why do you think it started when it did?
How does it affect your or your family’s life?
How severe is it? What worries you the most?
What kind of treatment do you think would work?
Defining Disorder (cont.)
The Patient’s Agenda
How can I be most helpful to you?
What is most important for you?
Illness Behavior
Have you seen anyone else about this problem?
Have you used non-medical remedies or treatment for
your problem?
Who advises you about your health?
NIH, Ped Review, 2009, February 30 (2)57-64
CC Skills
UNDERSTANDING
RESPECT
EMPATHY
CURIOSITY
APPRECIATION
CC Skills (cont.)
What qualities/ knowledge
do you need to be
qualified to work with
clients from culturally
and linguistically diverse
backgrounds?
Putting Skills Into Action
Case Studies
Diversity Committee
Where To Go
Gaining Support for Culturally
Competent Practices
Diversity Committee