cultural and linguistic competence a guide for the 21 st century clinician
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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 - PowerPoint PPT PresentationTRANSCRIPT
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