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CSHA Diversity Issues Committee. Cultural and Linguistic Competence A Guide for the 21 st Century Clinician. CSHA Diversity Issues Committee. Co-Chairs Pamela Norton CCC-SLP, Ph.D., & Sandra Gaskell CCC-SLP, D-ABD Members

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Csha diversity issues committee

CSHA Diversity Issues Committee

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

Csha diversity issues committee1

CSHA Diversity Issues Committee


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


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



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


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)

Introduction why are we here


Why are we here?

The Changing Face of CaliforniaSofia Carias

Where have we been

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

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

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



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

Purpose, Roles, and Participation

CSHA’s Diversity Issues CommitteeSandra Gaskell



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

CSHA Websites

Yahoo Group




  • 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



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

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

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

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

ASHA Documents

Cultural CompetencyChristine Maul

Asha 2011

ASHA (2011)

Cultural Competence in Professional Service Delivery

  • Position Statement

  • Professional Issues Statement

Position 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

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

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

Professional Issues (cont.)



Cultural dimensions

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

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



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

What’s New

Non-Biased Assessment ProceduresSofia Carias & Pam Norton

Examiner bias

Examiner Bias

Defining English Language Learners

Do you have a Bias? We all do!

  • Educational?

  • Cultural?

  • Linguistic?

    How do we reduce examiner


Examiner test bias

Examiner/Test Bias

Sherman-Wade & Bader, 2013



• Who is requesting the evaluation?


• What will the results be used for?


• Legal guidelines?

Test bias

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

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

Types of Tests

Norm Referenced

Criterion Referenced



  • Advantages

  • Disadvantages

Alternative assessment approaches

Alternative Assessment Approaches

Sherman-Wade & Bader, 2013

What are they?

What does it include?



Interpreting scores

Interpreting Scores

Crowley 2009, 2011

  • Parent Interview Information for report sections

  • Evaluation of the Data

  • Informed Clinical Judgment

Bilingual multicultural considerations

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

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

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


  • Ethical Conisderations

  • Educational Impact

  • Cultural Impact

  • Societal Impact

African american students

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

Bias Consciousness

  • Awareness that bias is universal

  • Acquiring knowledge for most accurate diagnoses

  • Advocating best practices across disciplines

  • Best placement

Clinical competency

Clinical Competency


  • 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

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

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

What about Standardized Tests?


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

Standardized Tests


- 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

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

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

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

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

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

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

What Works

Cultural Competence for CliniciansElisabeth 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?



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)



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

Defining disorder

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

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

CC Skills






Cc skills cont

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

Putting Skills Into Action

Case StudiesDiversity Committee

Where to go

Where To Go

Gaining Support for Culturally Competent PracticesDiversity Committee

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