Cultural and Linguistic Competence

A Guide for the 21st Century Clinician

CSHA Diversity Issues Committee

CSHA Diversity Issues Committee

Co-ChairsPamela Norton CCC-SLP,

Ph.D., & Sandra Gaskell CCC-SLP, D-ABD

MembersChristine Maul CCC-SLP,

Ph.D., Elisabeth Ward CCC-SLP, M.A., & Sofia Carias CCC-SLP, M.S.

Moderator: Betty Yu CCC-SLP, Ph.D.

CSHA ConventionFriday, March 28,

2014San 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)

The Changing Face of CaliforniaSofia Carias

IntroductionWhy are we here?

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

ImplicationsChanges in Public PolicyTransportation, 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

CSHA’s Diversity Issues Committee

Sandra Gaskell

Purpose, Roles, and Participation

Purpose

On the Web

http://www.diverscommcsha.org/

CSHA Websiteshttps://www.csha.org/diversity

Yahoo Grouphttp://groups.yahoo.com/group/

_csha_diversity_committee/ Facebook

Mission StatementThe 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

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 four-years

• Chair (or co-chairs)• Members • A group

representative of the CA demographic trends

Newsletter

First Issue was in 2005Available at every CSHA

since thenProjects updated in

articles Special Interest

information/ ResourcesCultural 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. 

Cultural CompetencyChristine Maul

ASHA Documents

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 DimensionsASHA 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 ReciprocityNot mentioned in the ASHA (2011) documentsProposed 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

Non-Biased Assessment Procedures

Sofia Carias & Pam Norton

What’s New

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 BiasSherman-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 BiasRacial 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?

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

Know Your Test

Types of Tests

Norm Referenced

• Advantages

• Disadvantages

Criterion Referenced

• Advantages

• Disadvantages

Alternative Assessment ApproachesSherman-Wade & Bader, 2013

What are they?

What does it include?

Advantages?

Disadvantages?

Interpreting ScoresCrowley 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. TestSherman-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 WritingThis 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 & BiasLinguistic 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 universalAcquiring knowledge for most accurate

diagnosesAdvocating best practices across

disciplinesBest placement

Clinical CompetencyASHA• 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 IQCELF - Expert bias panel and alternative rubrics but inconsistent in applicationARTICULATION TESTS are strongly MAE-based*All demonstrate linguistic bias

Standardized TestsNORMATIVE 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 RepertoireFrom Technician to Researcher

1 – Gathering information on student across environmentsa – Referral information: interviews with

teachersb – Historical information: interview with parentsc – Observations with peers (Wyatt, 1995)

2 – Alternative assessment protocol a - informal assessments b - alternative use of standardized tests :

quantitative, descriptive3 – Report writing with caveats

Triangulating InformationGathering 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 utterancesCommunicative competence, complexity, pragmaticsDynamic assessmentPortfolio assessment

Diagnostic Evaluation of Language Variation

DELV Screening Test (4 – 12)Mild to strong variation from MAELow to high risk for disorder

DELV Norm-Referenced (4 - 9)Language universalsSyntax, pragmatics*, semantics, phonologyDiagnosis 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

Cultural Competence for Clinicians

Elisabeth Ward

What Works

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 IllnessExplanatory 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?

Case StudiesDiversity Committee

Putting Skills Into Action

Gaining Support for Culturally Competent PracticesDiversity Committee

Where To Go