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

1. CSHA Diversity Issues Committee Cultural and Linguistic Competence A Guide for the 21st Century Clinician

2. 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

3. 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 Break10mins Culturally Competent Clinical Skills: What Works (Elisabeth Ward) 25mins Case Studies: Small Group Activity40mins Gaining Support for Culturally Competent Practices (All) 15mins Questions & Wrap up (Until the end)

4. Introduction Why are we here? The Changing Face of CaliforniaSofia Carias

5. Where have we been? Dramatic population growth decade after decade 1970 – 20 million people 80% identified as white on census data Sacramento, 1860s

6. 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

7. 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

8. 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

9. Purpose, Roles, and Participation CSHA’s Diversity Issues CommitteeSandra Gaskell

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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.

16. ASHA Documents Cultural CompetencyChristine Maul

17. ASHA (2011) Cultural Competence in Professional Service Delivery • Position Statement • Professional Issues Statement

18. 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

19. 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.”

20. 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. . .

21. Professional Issues (cont.) . . . BECAUSE IT’S THE RIGHT THING TO DO!!!

22. 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

23. 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

24. 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

25. What’s New Non-Biased Assessment ProceduresSofia Carias & Pam Norton

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

27. 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?

28. 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?

29. 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

30. Types of Tests Norm Referenced Criterion Referenced Advantages Disadvantages • Advantages • Disadvantages

31. Alternative Assessment Approaches Sherman-Wade & Bader, 2013 What are they? What does it include? Advantages? Disadvantages?

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

33. 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!

34. 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

35. 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

36. 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

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

38. 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..”

39. 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

40. 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

41. 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

42. 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)

43. 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

44. 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

45. 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?

46. 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

47. 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

48. 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

49. What Works Cultural Competence for CliniciansElisabeth Ward

50. 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?