Cultural Competence in Clinical Practice

• Cultural competence involves possessing the knowledge and skills necessary for effective care of clients from diverse cultural groups.
• This can be achieved through continuous self-assessment and broadening one's understanding of different cultures.
• ASKED is an acronym that covers different aspects of cultural compentence, where :
  • A = Awareness
  • S = Skill
  • K = Knowledge
  • E = Encounters
  • D = Desire

Pre-Assessment Knowledge

• Before an evaluation, clinicians should know about the client's culture, associated communication development, and personal history.

Cultural Considerations

• Cultures have distinct social rules influencing communication.
• These include views on disability, a woman's role, familial authority, using names/titles, comfort with case history/interview questions, and traditional testing practices.
• Views on individual achievement, child behavior around adults, eye contact, time perception, expressing disapproval, personal space, small talk, and trust in other groups also vary.
• Ethnography, the scientific study of culture, is a way to increase one's cultural knowledge.

Gathering Cultural Information

• Cultural information can be collected by:
  • Interviewing community members.
  • Observing in natural settings.
  • Asking the client.
  • Consulting professionals from the same cultural group.
  • Reading literature.
  • Researching through online resources.

Normal Communicative Patterns

• Knowledge of communicative patterns tied to various cultural groups is a must.
• Sources:
  • Speech-language pathologists.
  • Interpreters.
  • Teachers.
  • Family and community members.
• A dialect isn't a disorder, but understanding a client's dialect is key.

Second Language Acquisition

• Transfer: Behaviors transferred to the second language.
• Fossilization: Persistent second-language errors.
• Silent Period: A 3-6 month phase of primarily listening.
• Interlanguage: Development of a unique linguistic system.
• Language Loss: Reduced first-language proficiency.
• Code-switching: Alternating between languages in the same utterance.
• Acquiring a second language depends on consistent first-language development.
• Proficient second language acquisition:
  • BICS (Basic Interpersonal Communication Skills): Social communication in context, develops in 2-3 years.
  • CALP (Cognitive Academic Language Proficiency): Academic language for school, takes 5-7 years.

Assessment Considerations

• Standardized tests are often unsuitable for culturally and linguistically diverse clients due to bias.
• Modifying standardized tests by direct translation is not appropriate.
• Authentic assessment, which is a desirable alternative, evaluates behaviors in real-life situations using a dynamic approach.
• Learning basic vocabulary can be advantageous.
• Speaking in the client's primary language is helpful and shows effort.

Conducting a Culturally Sensitive Assessment

• Steps include:
  • Using culturally appropriate materials.
  • Testing in both the client's dominant language and English.
  • Collecting speech-language samples.
  • Using narrative assessment.
  • Focusing on the ability to learn.
  • Being ready to adjust the assessment approach.
  • Consulting with professionals and interpreters.
  • Being sensitive in interview situations.
• Differentiating communicative disorders from communicative differences is important when making a diagnosis.

Analyzing Assessment Data

• Examine aspects of the client's language in both English and their primary language.
• Determine the client's language use in various contexts.
• Note participation level and appropriateness.
• Note ability to follow directions.
• Note whether the client's discourse is logical and organized.
• Determine the ability to:
  • Describe events.
  • Make predictions.
  • Use contextual cues.
• Determine difficulty in learning new skills.

Evaluating Speech-Language Samples

• Look for:
  • Inappropriate nonverbal language.
  • Inadequate expression of needs.
  • Rare peer interaction.
  • Sporadic responses.
  • Reliance on gestures.
  • Difficulty understanding.
  • Inappropriate responses.
  • Difficulty organizing thoughts.
  • Poor topic maintenance.
  • Word-finding difficulties.
  • Failure to provide context.
  • Difficulty taking turns.
  • Prolonging topics.

Working with Interpreters

• Interpreters should be proficient in both languages, trained in cross-cultural communication, and knowledgeable in speech-language pathology.
• Children, family, or friends should not be used as interpreters.

Briefing, Interaction, Debriefing (BID)

• Briefing: A pre-meeting between the clinician and interpreter to review the agenda, discuss technical information, and train the interpreter.
• Interaction: All parties are present; the client is introduced to the interpreter, the assessment process is explained, and the clinician observes both the client and interpreter.
• Debriefing: A post-meeting between the clinician and interpreter to discuss encountered difficulties, impressions of the meeting, and review assessment information.
• Follow-up meetings and additional training should be planned as needed.

Pre-Assessment Information

• Primary sources:
  • Written case history.
  • Interviews with the client or caregivers.
  • Information from other professionals.
• Limitations of Case History:
  • The terminology on the form may not be understood by the respondent
  • Insufficient time may be provided
  • Vague recall
  • Time passed since the onset of the problem
  • Other life events
  • Cultural differences.
• There is no standard case history form for speech-language pathologists.

Intake Interviews

• The 3 phases of the intake interview include:
  • Opening Phase: Introductions and meeting purpose explained.
  • Body of the interview: Core content covered.
  • Closing Phase: Summary of key points.

Interview Questions

• Use both open- and close-ended questions during the interview.
• Start with open ended questions
• Examples:
  • Describe your concern.
  • When did you notice this?
  • How did it begin?

Specific Communicative Disorders Questions

• Questions for articulation:
  • What is your native tongue and what language do you speak most?
  • How long have you been concerned about the way your speech sounds? Who brought the problem to your attention in the first place?
  • Which sounds are particularly challenging for you?
  • What have you tried in the past to improve your speech?
• Questions for children's language issues:
  • Can you describe what worries you regarding your child's use of language?
  • What language is often spoken at home? At school, at daycare?
  • How much of what your child says can you comprehend?
  • Does your child establish and keep eye contact?
• Language questions for adults with language issues:
  • Do you have a problem with your native language and in English?
  • Do you read? If so, how often? What are your preferred book genres?
  • Have you been in an accident of suffered illnesses that impacted your language?
  • Have you ever had your hearing checked? What was the duration, where did it occur, and what were the outcomes?
• Questions for Issues in Stuttering:
  • How has your stuttering changed over the years?
  • When was the first indication of stuttering?
  • Is the stuttering bothersome to you? If yes, in what way?
  • In which settings do you stutter the least.?
  • Are there settings do you typically avoid? What causes these scenarios to be avoided?
• Questions related to vocal issues:
  • What exactly are problems you are having with your voice?
  • How long have you been experiencing the voice? Who first made you aware of voice issues?
  • Do you ever get out of breath while speaking? Then try describing the situation.
  • What speaking settings cause the greatest level of intensity for your voice issues?
  • Under the ideal circumstances, how exactly does your voice sound when it's at its best?

Information from Other Professionals

• Information from other professionals:
  • History or etiology of a disorder
  • Associated or concomitant medical, social educational and familial problems
  • Existing speech language diagnosis, and goals
  • Treatment histories
  • Prognostic implications
  • Treatment options and alternatives
• It's important to maintain an objective position because information obtained from other professionals can lead to bias.
• HIPAA Privacy Rule dictates legal constraints on requesting client information or providing to others.
• You must obtain written authorization from the client or caregiver before contacting other professionals.