Cultural and Linguistic Competence A Guide for the 21st Century Clinician

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Cultural and Linguistic Competence A Guide for
the 21st Century Clinician

• CSHA Diversity Issues Committee

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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 CCC-SLP, Ph.D.

• CSHA Convention
• Friday, March 28, 2014
• San Francisco, CA

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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 Whats 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)

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The Changing Face of CaliforniaSofia Carias

• Introduction
• Why are we here?

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Where have we been?

• Dramatic population growth decade after decade
• 1970 20 million people
• 80 identified as white on census data

Sacramento, 1860s
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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

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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

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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

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CSHAs Diversity Issues CommitteeSandra Gaskell

• Purpose, Roles, and Participation

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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_diversit
y_committee/ Facebook
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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

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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

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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, 185216. 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. 89102). Boston
Allyn and Bacon.
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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

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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, 2008136)

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.  
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Cultural CompetencyChristine Maul

• ASHA Documents

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ASHA (2011)

• Cultural Competence in Professional Service
  Delivery
• Position Statement
• Professional Issues Statement

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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

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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.

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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/malpractic
  e
• With all due to respect to ASHA, I would add. . .
  

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Professional Issues (cont.)

• . . . BECAUSE ITS THE
• RIGHT THING TO DO!!!

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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

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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 professionals
  interpretation
• Determine ways to adapt professional
  interpretations to the value system of the family
  through discussion and collaboration

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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

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Non-Biased Assessment ProceduresSofia Carias
Pam Norton

• Whats New

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Examiner Bias

• Defining English Language Learners
• Do you have a Bias? We all do!
• Educational?
• Cultural?
• Linguistic?
• How do we reduce examiner
• bias?

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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?

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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?

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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

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Types of Tests

• Norm Referenced

• Criterion Referenced

• Advantages
• Disadvantages

• Advantages
• Disadvantages

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Alternative Assessment Approaches

• Sherman-Wade Bader, 2013
• What are they?
• What does it include?
• Advantages?
• Disadvantages?

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Interpreting Scores

• Crowley 2009, 2011
• Parent Interview Information for report sections
• Evaluation of the Data
• Informed Clinical Judgment

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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 clients cultural views on Health,
  Disability, Religion, etc.
• Linguistic Universals?
• Again know your test!

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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 Administrators Guide
• Using Interpreters

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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

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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

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Bias Consciousness

• Awareness that bias is universal
• Acquiring knowledge for most accurate diagnoses
• Advocating best practices across disciplines
• Best placement

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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..

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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

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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

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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

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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)

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CA Practice Mandates

• When standardized tests areinvalid, 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

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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

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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?

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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

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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

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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

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Cultural Competence for CliniciansElisabeth Ward

• What Works

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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?

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VALUE DIVERSITY

• Do you accept and welcome cultural differences?
• Are you tolerant of those who look, speak, act
  differently from you?

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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?

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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)

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ADAPTING

• Can we adapt to the needs and preferences of our
  clients and patients that have a difference in
  values, beliefs, and attitudes?

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Defining Disorder

• Exploring the meaning of Illness
• Explanatory Model
•     What do you think has caused your or your
  childs problem? What do you call it?
•     Why do you think it started when it did?
•     How does it affect your or your familys
  life?
•     How severe is it? What worries you the most?
•     What kind of treatment do you think would
  work?

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Defining Disorder (cont.)

• The Patients 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

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CC Skills

• UNDERSTANDING
• RESPECT
• EMPATHY
• CURIOSITY
• APPRECIATION

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CC Skills (cont.)

• What qualities/ knowledge do you need to be
  qualified to work with clients from culturally
  and linguistically diverse backgrounds?

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Case StudiesDiversity Committee

• Putting Skills Into Action

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Gaining Support for Culturally Competent
PracticesDiversity Committee

• Where To Go