Chapter 12 Assessment of multicultural and international clients with communication disorders
The case history interview
The speech and language assessment process with clients from international culturally and linguistically diverse (CLD) backgrounds is the same as that for any client. According to Meitus and Weinberg’s (1983) model of clinical service delivery, there are four functions associated with the diagnostic evaluation process: investigative, analytic, utilization, and accountability. Part of the investigative function involves the collection of historical information about a client and his or her communication status through case history interviews, referral reports, and testing.
A guiding principle in CLD assessments, as delineated in the American Speech-Language-Hearing Association (ASHA; 2004) knowledge and skills document for CLD populations, is the importance of determining “what is typical speech/language development in the client’s/patient’s speech community and communication environment” through interview with a parent or caregiver “on how the client’s/patient’s speech/language development compares to peers in his/her speech community.” In addition, according to Battle (2000), culturally competent clinicians use “the case history for obtaining information about a client’s culture, communication, speech history and life history” (p. 20).
The process of obtaining information through the case history interview, however, is a sensitive one. It is important to establish a positive information gathering and sharing climate by working to establish rapport and an atmosphere of mutual trust and respect (Haynes & Pindzola, 2008). This can be challenging when working with clients and families from differing cultural backgrounds because what is perceived as trust and respect in one group can differ from that in another group. The strategies and type of discourse interaction that are most useful for accomplishing this task can also vary.
One additional consideration when assessing bilingual and multilingual clients is the importance of using case history interview questions that provide a clear overview of (1) comprehensive language system and use patterns within and across all languages spoken, (2) relative communication strengths and weaknesses within each language spoken, and (3) the impact of any perceived communication difficulties on that client’s ability to “communicate effectively in his/her speech community or family” (Battle, 2000, p. 21).
Establishing rapport
The communication strategies that are most useful for establishing rapport and trust can vary across different individuals and families. Individuals and families vary in preferred cultural communication style. Cultural beliefs regarding what is most appropriate to discuss or disclose can also vary. Finally, differences in family structure and roles can determine who is to be involved in the information sharing process, what roles different individuals play in the family, and who is given the primary responsibility for making decisions.
Culture and the case history interview
Personal, social, and cultural identity
Personal, social, and cultural identity are factors that affect the overall communication process with clients and families. According to Ting-Toomey and Chung (2005), personal identity includes those unique attributes that are associated with one’s “individuated self in comparison with those of others” (p. 87). Social identity includes various other forms of identity such as cultural or ethnic membership identity, gender identity, disability identity, or professional identity. Cultural identity is defined as the “emotional significance” that individuals attach to their “sense of belonging or affiliation with the larger culture” (Ting-Toomey & Chung, 2005, p. 93) and reflects the extent to which one identifies with a larger cultural group. All cultures and cultural groups have not only “shared rules for appropriate behavior” but also shared “values and beliefs” that help “to regulate interaction with other members of the community and with individuals form cultural backgrounds different from their own” (Saville-Troike, 1986, p. 48). This can include common beliefs about how, when, where, and with whom they should use certain types of language and communication styles.
Cultural identity continuum
Families and individuals differ in their cultural or group affiliation even when they come from the same racial or ethnic background. Individuals will also differ in their degree of cultural identity salience (Ting-Toomey & Chung, 2005), which includes the strength of one’s cultural group affiliations, allegiance and loyalty to a given group, unique individual personal identities, and differences in the degree of acculturation. Individuals within the same cultural community “may differ in the extent to which they chose to adhere to a set of cultural patterns” (Hanson, 2004a, p. 4).Some people identify more strongly with a particular cultural group, some identify less strongly, and others identify with more than one group.
As a result, it is important not to make generalizations about a given individual or family as a result of their cultural background. Individuals and families from the same cultural and ethnic background will not always assume or display the cultural practices and beliefs generally associated with that group. For example, Gushue and colleagues (2010) caution that although the primacy of the family (a concept referred to as familismo) may be an important feature of Mexican culture in general, one has to consider the extent to which it is true for a particular family.
Acculturation
The level of acculturation plays a role in a person or family’s social identity. Acculturation is the process by which individuals assume and adopt the values, beliefs, and norms of a more dominant, mainstream culture (Battle, 2002; Gushue et al., 2010). As individuals interact with and begin to spend more time with a new or different culture, they can move along a continuum as they adopt, adapt, and accept more mainstream cultural group norms and practices.
Multiple cultural identities
In today’s global world culture, there are growing numbers of individuals who balance multiple cultural identities because of their multiracial heritage (Choi-Misailidis, 2010). These individuals may display a cultural affiliation that differs from that of individuals within each of their cultural affiliation groups. Their cultural affiliation may differ dependent on the extent to which there is congruence and disparity between their internal mixed race identity and their external multiracial heritage. For example, an individual who is both African American and Hispanic may affiliate with African American culture and cultural groups for some functions but with Hispanic culture for others. There may be some biracial African American and Hispanic individuals who identify almost completely with African American culture. Others may identify almost completely with Hispanic culture. Still others may identify with neither.
Another example of individuals who have to balance more than one cultural identity are those who self-identify as lesbian, gay, bisexual, or transgender (LGBT). They may identify not only with LGBT culture but also with the cultural identity linked to their ethnic-racial background. There is also the struggle for some LGBT individuals who are CLD to balance multiple or conflicting cultural norms, values, and beliefs—those of the LGBT community and those of the CLD community with which they affiliate (Wilton, 2010).
New emerging global identities
One additional category that deserves some attention is that of today’s young adult generation of “e.net’ers” (Ting-Toomey & Chung, 2005). According to Ting-Toomey and Chung (2005, p. 314), e.net’ers represent a new generation of individuals who are attempting to create a third identity. Their identity involves a fusion of individualism and collectivism and embraces both individual privacy and a longing for a sense of global belonging and connection that transcends traditional ethnic-cultural boundaries. They have a sense of communal belonging on a global level. A key contributing factor to this new emerging identity is the Internet, which allows users to develop relationships across the barriers of time, space, geography, and ethnic-cultural boundaries.
Although some e.net’ers retain some degree of loyalty to their traditional ethnic groups, they are more likely to have a more connections with their technoglobal social networks. Ting-Toomey and Chung (2005) explain that one of the outcomes is a generation that differs from that of their parents and grandparents with respect to traditional cultural values and norms. This can create culturally based communication tensions and challenges across the generations within families as well as in interactions between individuals who are more technology oriented and those who are not. Part of the tension can be attributed to differing perceptions between family members (e.g., teens and adults) of one’s attentiveness and one’s desire to interact socially with others when using technology (e.g., texting) in the presence of others (Jayson, 2010-2011).
Impact of culture on the communication style and interaction
High-context versus low-context communication
Cultures differ in the amount of information that is transmitted through words vs. nonverbal contexts and communication (Lynch, 2004). These differences have often been described in terms of high-context and low-context communication. High-context communicators place more emphasis on the expression of meaning and intention through “explicit verbal messages” (Ting-Toomey & Chung, 2005, p. 169). They give less emphasis to the spoken word and pay more attention instead to nonverbal cues and messages as conveyed by facial expression, body movement, gestures, environmental clues, and other body language cues or subtle “vibes” (Hecht, 1989, cited in Lynch, 2004). Pause, silence, and tone of voice are other examples of nonverbal communication devices used to convey meaning and intent. There is also a greater expectation placed on the listener to “read between the lines” (Ting-Toomey & Chung, 2005). According to Crystal (1989, as cited in Chan & Lee, 2004), there are some communities where pride and value are placed on one’s ability to “know” intuitively what others are thinking and feeling without the benefit of words. For example, in the Korean community, nun-chi (reading the eyes) is an affective sense by which one is able to use external cues to assess genuine attitudes and emotional reactions about a given topic, proposal or situation.
Low context communicators, on the other hand, focus more on the use of explicit verbal messages (Ting-Toomey & Chung, 2004) and precise, direct, verbal communication with less processing of nonverbal cues and movement and explicit verbal messages (Lynch, 2004).
Asian, American Indian, Arab, Latino, and African American communities are examples of cultures that have typically been characterized as using high context in communication style (Lynch, 2004). Persons from European countries such as Germany, Switzerland, Denmark, and Sweden tend to be at the more extreme ends of low-context communicators. Persons from countries such as the United States, Canada, Australia, and the United Kingdom, although less extreme, also tend to be on the low-context end on this continuum of communication, perhaps because of their European roots. In some cultures, such as American culture, males also tend to be low-context in communication style, whereas females tend to be high context (Ting-Toomey & Chung, 2004).
Greetings
Shaking hands is a common form of greeting and departure and is an important part of social etiquette in many places throughout the world (Kulwicki, 2003). Even though handshaking may be used as a typical form of introduction, it may not be as “hearty” in some places in the world as it is in the United States (p. 63). For example, among the Navajo, the handshake is lighter than one would expect elsewhere and is “more of a passing of hands” (Lynch, 2004; Still & Hodgins, 2003).
In contrast, shaking hands as a way of greeting may be uncomfortable to Southeast Asians. In India, for example, individuals are greeted with a handshake known as wai, in which one brings the palms of the hand together and raises them to the chest or tip of the nose while lowering the head (Lynch, 2004). In Japanese culture, the traditional greeting is a bow with the “depth of the bow, its duration, and the number of repetitions” reflecting “the relative status of the parties involved and the formality of the situation” (Sharts-Hopko, 2003, p. 220).
The order and manner in which greetings and introductions are made can also be important. According to Matsuda (1989), when greeting and making introductions in many Asian cultures, it is important to know the client’s status and position. When meeting Asian parents for the first time, professionals should identify themselves and their title and position through formal introduction. Chan and Lee (2003) recommend greeting members of Asian families in order of age beginning with the oldest. It is also typical to greet male members first.
Terms of address
When meeting a client and family members for the first time, terms of address can also be equally important to establish rapport. Although the use of first names is often used in contemporary American culture as a way of establishing rapport with clients, there are a number of cultural groups with whom the continued use of a person’s last name or the use of a title (e.g., Mr., Mrs., or Dr.) with a first or last name would be the best social protocol. For example, it is best not to address African American family members by their first name “unless given permission” to do so (Glanvillle, 2003; Willis, 2004). A common practice for addressing persons within Appalachian communities is through the use of a title with the first name, such as “Miss Elizabeth” or “Mr. William.” Zoucha and Zamarripa (2008) also emphasize the importance of formality when addressing elderly members of Mexican families and state that being overly familiar by “using first names may not be appreciated early on in the establishment of a professional relationship with the families.”
One additional consideration related to the use of terms of address are the various ways throughout the world to refer to married women. In some French Canadian communities, such as Quebec, married women are required by law keep their maiden name throughout their lifetime. It is therefore not uncommon for children of French Canadian parents to have differing surnames. One child may carry the mother’s surname, another may have the father’s surname, and others may have hyphenated or nonhyphenated combinations of both names in any order (Couto-Wakulczyk et al., 2003). In some Chinese and Korean cultures (except in Hong Kong and Taiwan), women also do not take on their husband’s name after they marry (Chan & Lee, 2003; Wong, 2003). In some Hispanic cultures, the naming practice for married women is complex. According to Purnell and Paulanka (2003), in Hispanic communities married women are likely not only to take on their husband’s surname but also to retain both of her parent’s surnames, resulting in an extended name such as La Senora Roberta Rodriguez (husband’s surname) de Malena (mother’s maiden name) y Perez (father’s surname).
Beginning the interaction
Once initial greetings have been made, professionals need to consider how they will begin the interview. There are some cultures in which clients may be ready to begin fairly quickly after some brief preliminary introductions and greetings. For example, according to Jezewski and Sotnik (2005), in American culture after a brief greeting, conversations immediately move to the primary business at hand. In other cultures, there is a great value placed on establishing a personal relationship first. In Arab cultures, for example, greetings, inquiries about well-being, pleasantries, and a cup of tea or coffee precede business (Kulwicki, 2003). When interacting with individuals of Mexican origin or heritage, Zoucha and Zamarripa (2008) suggest engaging in social talk before proceeding with the usual business as a means of encouraging open communication and sharing and establishing trust Similarly, Joe and Malach (2004) suggest that when beginning a conversation with American Indians, it is important first to engage in social talk. Doing such helps families get to know you as a person and are important as a means of establishing rapport.
Conversational directness
Cultures can vary in the amount of directness used and expected during conversations. In some cultures, there is emphasis placed on directness and honesty with opinions expressed in a very open and direct manner. In others, where there is an emphasis on preserving group harmony and preserving face, a more indirect communication style may be used and valued (Chan & Lee, 2004; Hanson, 2004).
This difference can have a very important impact on how topics are addressed and on the types of responses given to questions. Individuals who use a more indirect style of communicating may, for example, sometimes say “yes” and use a negative head nod indicating “no” (i.e., telling the speaker what he or she wants to hear rather than giving a truthful answer). They may also be noncommittal or hesitant to respond to a direct question if they are reluctant to do what is being asked or there is some form of disagreement with what is being expressed or asked. Such responses can be misinterpreted or evaluated as being evasive, devious, and dishonest by individuals who use a more direct conversational style (Chan & Lee, 2004).
Listener acknowledgement, agreement, and disagreement
While nodding one’s head up and down typically is a sign of understanding and agreement in mainstream American culture, the same gesture may mean that the listener understands the message (e.g., “I hear you speaking”) but does not suggest agreement in some Asian, American Indian, Middle Eastern, and Pacific Island cultures There can also be differences in how individuals also signal what they have heard. For example, individuals from India signal that they have heard what is said by moving their head in a quick, horizontal, figure-eight pattern (Lynch, 2004).
Listener agreement or disagreement can also be signaled verbally through the use of words such as “yes” and “no,” but there can be cross-cultural differences in how these two terms are used. According to Santos and Chan (2004), even when Filipino Americans are privately opposed to an issue or question at hand, they may still say “yes” instead of “no” despite of their feelings, or use more ambiguous responses such as “maybe” or “I don’t know,” especially when conversing with someone they consider to be superior or when they feel that the truth may offend or embarrass.
Eye contact
The interpretation and use of eye contact is another communication behavior that can vary during conversation. In mainstream American, Irish and Cuban cultures, in which direct eye contact during conversation is valued, a person who does not maintain eye contact may be perceived as not listening, not being trustworthy, not caring, or being less than truthful (Purnell, 2003; Purnell & Paulanka, 2003). In Irish culture, not maintaining eye contact can be interpreted as a sign of disrespect, guilt, or evidence that one cannot be trusted (Wilson, 2003).
On the other hand, in some communities, the use of direct eye contact may be considered disrespectful. For example, in American Indian and Asian communities, respect for others, such as elders and individuals with knowledge, authority, or status, is shown by not making direct contact (Lynch, 2004).
There can also be situational variables that dictate whether or not direct eye contact is appropriate. Among the Amish (Wegner & Wegner, 2003), avoidance of eye contact and an overall demeanor of general reserve is most appropriate during interactions with non-Amish in public situations. In one-on-one contacts, however, Amish clients are more likely to display more openness and candor with unhesitating eye contact.
According to Purnell and Paulanka (2003), sustained eye contact in some communities (e.g., Mexican, Cuban, Puerto Rican, Iranian, Egyptian, Italian, and Greek) may bring on the “evil eye” or “bad eye,” which is considered a contributing cause of disability.
Silence
The use of silence can vary across cultural communities (Jezewski & Sotnik, 2005; Ting-Toomey & Chung, 2005). In some mainstream American cultures, a little silence is tolerated during conversation, but prolonged silence is often viewed as “empty pauses” or “ignorant lapses.” In Eastern Asian cultures, silence is viewed as “a sign of thoughtful respect, affirmation or cooperation.” The Navajo stress the importance of providing sufficient time for elderly people to respond to questions through silence. Failure to provide sufficient time can lead to an inaccurate response or no response at all (Still & Hodgins, 2003).
Silence can also be used as a tool during conversation to establish formal distance as is done with the French and many Native American cultures with strangers. In contrast, talk is often used by mainstream Americans to “break the ice,” with silence being reserved for use in intimate relationships (Ting-Toomey & Chung, 2005).
Facial expression
Facial expressions can vary in use and interpretation. In traditional Chinese families, facial expressions, such smiling, are used extensively among family and friends but may be limited in formal situations (Wang & Purnell, 2008). Smiling can also be used by Asian communicators as an expression of apology for minor offenses, deference to authority figures, to mask difficult feelings and emotions (e.g., pain, distress, discomfort, anger, disapproval, disappointment), and to avoid conflict when insulted, threatened, or otherwise provoked (Chan & Lee, 2004). In the Vietnamese community, silence or the use of a “reluctant” smile can be used as an expression of negative emotion (Nowak, 2003, p. 329).
In German culture, smiling is reserved for friends and family and may not occur during introductions. In settings (e.g., work) and situations that are considered to be serious (e.g., dealing with illness), the most appropriate response is one that is reserved, with no smiling (Steckler, 2008).
Body language
The use of body language (i.e., the extent to which it is publicly evident) can also vary across different cultural communities. Those from certain cultures can be very expressive in their use of body language during conversations, such as African Americans and Puerto Ricans (Juarbe, 2003; Willis, 2004). Others can be more reserved. For example, in Irish culture, a high degree of value is placed on humility and emotional reserve, which are considered virtues. Public displays of emotion and affection are also typically avoided (Wilson, 2003). In traditional Japanese culture, value is placed on control over body language, making it difficult for some service providers to detect and interpret emotions such as anger and dismay (Sharts-Hopko, 2003).
Self-disclosure
Cultural socialization influences can also impact the extent to which an individual self-discloses personal information to others. According to Ting-Toomey & Chung (2005), verbal self-disclosure of personal information involves some degree of “trust-risk.” For example, in some African American families and communities, individuals “openly” express feelings to trusted friends of family; however, in others, what happens within the family is viewed as private and is not appropriate for discussion with strangers (Glanville, 2003). African Americans may be suspicious and cautious with health care practitioners that they do not know As a result, clinicians may find that some African American clients and families may initially be a little less willing to share personal information openly with health care practitioners that they do not yet know.
It can also take nontribal health care providers a long time to get Navajos to self-disclose because they “generally do not share inner thoughts and feelings with anyone outside of their clan” (Still & Hodgins, 2003). According to Wegner and Wegner (2003), people of Appalachian culture and heritage and who reside in that region of the United States do not easily trust or share their thoughts or feelings with outsiders.
In Filipino culture, the group status membership of an individual plays a significant role in determining the amount and type of sharing done. The degree and the nature of the sharing are dependent on insider or outsider status (Pacquiao, 2003).
The establishment of a personal relationship with service providers is equally important in Middle Eastern communities where a high value is placed on privacy. There may be a resistance to disclosing personal information to strangers, especially when it relates to familiar disease and conditions. As a result, persons from the Middle East “need to develop personal relationships with a health care provider before sharing personal information” (Kulwicki, 2003).
The history of a community can also play a role in the extent to which individuals disclose personal information with others. In Haiti, institutions that provide services for children with disabilities are often viewed as places of refuge from the public scrutiny and societal abuse that can occur against children with disabilities. Nongovernmental, religious, or foreign organizations that provide services are institutions in which Haitians place their faith owing to an expectation that these institutions will provide “miracles” because of stories of miraculous recoveries passed on by friends (Jacobson, 2005).
As a result of the long history of foreign invasions in Iran, people from Iran may hold a general suspicion of foreigners. The disclosure of personal information to strangers is generally perceived to have detrimental consequences. Not verbalizing one’s thoughts to strangers is customary (Hafizi & Lipson, 2008).
Personal life experiences can play a role in any community. There will always be some individuals within communities who have witnessed or experienced personal life events that affect their overall willingness to trust. According to Short and associates (2010), a number of immigrants and refugees throughout the world, including those seeking asylum in the United States, have either survived, witnessed, or experienced acts of torture and abuse in their home countries. For example, according to statistics stated by Short and associates (2010), approximately one third of the world’s refuges are survivors of torture, and more than 80 percent have experienced torture. Such experiences will obviously affect a family or individual’s willingness to disclose during the case history interview, especially when individuals are coming from countries where issues such as war, violence, torture, poverty, imprisonment, and poor living conditions have been an issue.
Attitudes toward disability and disorder
Perceived causes
A key issue that can affect disclosure of information is the cultural beliefs about disabilities that can exist across communities. In many places of the world, such as Italy, various beliefs about the role of the “evil eye” in causing disability continue to exist (Hillman, 2003). Some cultural communities believe that disabilities are the result of punishment for past sins (Miller, 2005). In Samoa, a child born with a disability may be attributed to a poor relationship with God within the family (Mokuau & Tauili’ili, 2004). A summary of possible beliefs about the causes of disorder, disability, and illness can be found in Table 12-1.
TABLE 12-1 Traditional Beliefs about Perceived Causes of Disorder, Disability, and Illness
| Belief | Culture | References |
|---|---|---|
| Punishment for past sins, transgressions in a previous life, bad deeds or sins committed by ancestors | Arab | Kulwicki (2008) |
| Guatemalan | Ellis & Purnell (2008) | |
| Thai | Ross & Ross (2008) | |
| Chinese | Liu (2005) | |
| Jamaican | Miller (2005) | |
| Mexican | Santana-Martin & Santana (2005) | |
| Vietnamese | Hunt (2005) | |
| African American | Willis (2004) | |
| Filipino | Santos & Chan (2004) | |
| Southeast Asian | Jacob (2004); Groce & Zola (1993) | |
| Trial that builds strength or cleanses past sins or wrongs | Arab | Ebrahim, as cited in Kulwicki (2008) |
| God’s will or fate | Mexican | Santana-Martin & Santana (2005) |
| Filipino | Santos & Chan (2004) | |
| Appalachian | Huttlinger & Purnell (2008) | |
| Blessing or gift from God | Israeli Arab | Kulwicki (2008) |
| Filipino | Pacquiao (2008) | |
| Doing something wrong or improper self-care during pregnancy | Korean | Kip-Ripnow (2005) |
| Filipino | Santos & Chan (2004) |
Reactions and acceptance
Where there is the belief that a disability is the result of punishment for past wrongs or sins, families may conceal family members with a disability (Miller, 2005). In Samoa, for example, because of the possibility of public embarrassment and guilt and possible public scrutiny and ridicule, some families hide their children with a disability from the public (Mokuau & Tauili’ili, 2004). In Korea, children with disabilities are often stigmatized and kept out of the public or abandoned because of the lack of support services and prohibitive cost of care (Purnell & Paulanka, 2003).
Attitudes about language use
Clinicians should also be sensitive to the fact that some parents believe or have been counseled that their use of more than one language or a language other than the majority language has contributed to a child’s language delay. It is still the case that some professionals continue to counsel families against using more than one language even when research such as that cited in Kohnert (2008) clearly shows that learning more than one language does not confuse children and that children with language delays are just as capable as their monolingual peers of learning more than one language.
Family structures and networks
Types of family structures and networks
In recent years, there have been changes in the types of family structures and networks around the world. The traditional family unit in the United States has typically been the nuclear family, consisting of a married man and woman with one or more unmarried children. This traditional family unit, however, is changing in the United States. (U.S. Census Bureau, 2009). Families are becoming more varied, including married and unmarried couples, both men and women living alone or living together with or without children; single parents with children; and blended families consisting of two parents who have remarried or who are not married to each other, with children from their previous marriages or relationships, and male and female same-sex parents. Along with these changes has been an increased acceptance of divorce, non-marital cohabitation, unmarried parenthood, permanent non-marriage and voluntary childlessness.
In many other parts of the world as well as with some cultural communities within the United States, the typical family unit has been the extended family unit, typically consisting of grandparents, aunts, uncles, cousins, nieces, and nephews (Ting-Toomey & Chung, 2005, p. 88). In extended family households, it is very common for family members across two or three generations to live within the same household or within close proximity of each other. According to the U.S. Census Bureau (2009), in the United States 3.6% of families are multigenerational. In some cultural communities, the extended family unit also included nonbiologic kin. For example in Hispanic communities, the extended family can include “biological relatives and non-biological members who may be considered brother, sister, aunt, or uncle” (Purnell & Paulanka, 2003, p. 20).
Gender and family roles and decision making
During the past couple of decades, there has been a significant shift in perspectives on gender equity and equality in some countries such as the United States. As a result, males and females are more likely to have equal status in the child-rearing or elder care. Despite these changes, there are still many parts of the world where the male continues to serve as the primary family representative for any matters concerning the family. For example, in Iran, where the traditional culture is still patriarchal and hierarchical, the father has the greatest authority for all family decisions. In the absence of the father, the oldest son has the primary authority. Older male siblings also have the authority to make decisions for younger siblings even with the father present (Hafizi & Lipson, 2003, p. 181). In more acculturated families, the roles are more flexible (Hafizi, Sayyedi, & Lipson, 2008). In other cultures, it will be the female. In still others, the decision will be shared equally between the males and females. In some communities, it is the grandparents rather than the parents who have this primary responsibility. In Haitian communities, when an individual has a disability, decisions regarding the most appropriate type of intervention or rehabilitation plan are made by the entire family, with each member of the extended family being consulted before a final decision is reached (Jacobson, 2005).
The individual who represents the family publicly in certain settings may not be the one who is charged with the primary responsibility of decision making in private. For example, in Middle East cultures, the man’s status as head of the family is evident in public even though in private the wife typically wields tremendous influence in matters pertaining to home and children (Kulwicki, 2003). Although decision making about health care–related matters is egalitarian among many Hispanics at home, the male in the family is usually the spokesperson for the family in public (Purnell & Paulanka, 2003).
Clinical implications
There are a number of clinical implications for clinicians conducting the assessment with clients from different cultural backgrounds given some of the issues addressed in this chapter. One of the best strategies for addressing some of these differences is being prepared for the case history interview by researching in advance some of the possible communication and other cultural issues that may potentially affect the process using some of the resources provided at the end of this chapter. Professionals can also work closely with interpreters, translators, and other professionals who can serve as cultural brokers that are familiar with the communication norms of the community of the families served. A summary of other suggestions for communicating effectively with families from diverse cultural backgrounds around the world are presented in Box 12-1.
BOX 12-1 Strategies for Communicating Effectively with Families from Diverse Backgrounds
• Use a communication style that is likely to be valued and/or used by the family (e.g., indirect vs. direct, with more silence and pause vs. talk).
• Be attentive to how one’s own nonverbal and verbal communication style is likely to be perceived.
• Pay attention to others’ nonverbal communication signals but be careful with interpretations of signals that can vary in meaning cross-culturally.
• Be sensitive to the ways in which questions are worded; review wording and topics with interpreters/translators or some other type of cultural broker in advance.
• Do advance readings on possible cultural communication style differences and health care beliefs, but keep the diversity that exists within communities in mind.
Case history interview with bilingual and multilingual clients
A key component of the case history interview with CLD clients involves the types of questions that are used and the ways questions are worded. The types of questions used with clients who speak more than one language are also key to determining important issues, such as the primary languages for assessment and intervention. Obtaining input from significant others also helps clinicians determine how well a client is able to communicate according to the standards of his or her community. The purpose of this section is to provide an overview of key considerations to be taken into account when interviewing bilingual clients.
Interviewing primary caregivers of bilingual and multilingual children
There are a number of key topics and questions that should be addressed when interviewing caregivers of bilingual child clients. The following section contains a summary of key topic and question considerations for the case history interview with caregivers. A list of possible questions can also found in Appendix 12-1.
Nature of communication difficulties observed in all languages spoken
A key focus of any case history interview is the types of communication difficulties observed and experienced. The same information should be obtained for bilingual children. The difference from monolingual language speakers is that whatever is asked about one language should be asked about any others spoken. Identifying areas of difficulty in more than one language helps to support a diagnosis of true impairment. There is an interdependent relationship or common underlying proficiency between the L1 and L2 in bilingual speakers (Roseberry-McKibbin, 2008). As a result, difficulties in one language are likely show to be similar in the second. This suggests that true disorders are likely to be evident in all languages spoken. Although there can be differences in the way in which an underlying disorder is expressed owing to language-specific characteristics of each language, the underlying nature of the difficulties is likely to be the same. As a result, the bilingual Spanish-English speaking child who uses velar fronting in English (e.g., “tat” for “cat”) is likely to display the same problem in Spanish (e.g., “tortuda” for “tortuga”).
Perceptions of family and other speech community members
Being familiar with community standards for identifying individuals at risk for articulation/phonology, resonance, voice, fluency, swallowing, and hearing/balance disorders is emphasized in ASHA’s (2004) Knowledge and Skills Statement for Providing Culturally and Linguistically Appropriate Services. Understanding the communication standards of the community are helpful for distinguishing true disorders from speech and language differences, particularly when there are no existing published norms or standards for that child’s language. Obtaining information about the perceptions of others close to the child helps to provide information about the expectations and standards of the client’s language community.
Interviews with bilingual and multilingual adult clients
The types of questions that should be asked of bilingual and multilingual adult clients with suspected communication disorders are similar to those that should be asked when evaluating child clients with a few exceptions and additions. (See Appendix 12-2 for sample bilingual adult topics and questions.) In addition to those questions recommended in Appendix 12-2, clinicians may also review questions that are included in the Language Experience and Proficiency Questionnaire (LEAP-Q) for assessing the language proficiency, profiles, and background of adult multilingual speakers (Marian et al., 2007).
Language use across communication environments and partners
Determining the extent to which languages are used for social activities is also relevant. If a key aspect of a client’s social life is church, the clinician needs to identify the language that is most often used as a part of church activities. Practicing words, phrases, and functional sentences that are used within that context using the language used most in that setting is a good strategy for promoting functional and relevant communication skills.
The process
Current assessment models and frameworks
Assessment models and frameworks
Culturally and linguistically diverse child populations
A number of models, assessment frameworks, and principles have been proposed for assessing child CLD clients. A brief overview of some of the most recent can be found in Box 12-2.
BOX 12-2 Culturally and Linguistically Diverse Assessment Models and Frameworks
“Riot”*
• R___________________________________eview relevant documents (e.g., school and medical/health records), client background information (e.g., cultural, language, family, social), and previous therapy/testing results.
• Interview___________________________________ the client and/or significant others (e.g., family members, teachers, peers) about the client’s communication skills and abilities.
• Observe___________________________________ the client in multiple contexts with multiple partners.
• Test___________________________________ the client using multiple forms of assessment (e.g., formal and informal, language sampling, classroom-based authentic assessments, dynamic assessment).
“Grasp it!”†
• Gather:___________________________________ Gather the necessary information.
• Review:___________________________________ Examine what you find and determine what else is needed.
• Ask:___________________________________ Interview teachers, family members, and/or members of the community to provide you with information to help you determine the significance of the assessment results.
• See:___________________________________ Observe the student in multiple settings with different partners.
• Proceed:___________________________________ Determine the next step (e.g., information to help design effective instruction, need for additional English language development support).
• Integrate:___________________________________ Analyze the data and integrate all of the relevant data that has been reviewed.
• Test:___________________________________ Undertake formal and informal assessments to complete the picture.
“Ecologically valid assessment”‡
• Thorough case history interview
• Formal assessment in L1 and L2 using standardized tests as appropriate
• Informal assessments in L1 and L2 using checklists, criterion-referenced assessments, language sampling, authentic performance-based assessments
• Observation in naturalistic environments (e.g., classroom, recess, lunch, library, home)
• Proficiency testing in L1 and L2 to determine level of language ability in both (e.g., BICs and CALP)
†Data from Lewis, N., Castilleja, N., Moore, B. J., & Rodriquez, B. (2010, July). Assessment 360°: A Panoramic framework for assessing English language learners. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 17, 37-56.
‡Data from Roseberry-McKibbin, E. (2008). Multicultural students with special language needs: Practical strategies for assessment and intervention (3rd ed). Oceanside, CA: Academic Communication Associates.
Although each of the frameworks presented in Table 12-1 varies slightly in terms of specific recommended considerations, each framework emphasizes the importance of a comprehensive assessment that generates a variety data, uses a variety of procedures and measures, is conducted in each of the languages spoken or understood by the client, and includes the case history interview, review of written documentation, observation, and both formal and informal measures. They all emphasize a move away from sole reliance on standardized tools for determining the presence of disorder and a growing reliance on dynamic, process-based procedures. They also emphasize the importance of assessing all languages spoken and understood.
Culturally and linguistically diverse adult populations
To date, there have been relatively few proposed models and frameworks for assessing adult CLD clients. Those that have been proposed have focused primarily on adult populations with cognitive-communication impairments resulting from neurologically based conditions such as stroke, traumatic brain injury, and Alzheimer disease. They have also stressed the importance of using approaches that are similar in many ways to those used with children. For example, when working with clients with neurologically based cognitive-communication impairments, Langdon (2008) recommends a comprehensive case history interview that includes information about a client’s language use, exposure, and preferences. According to Langdon, the interview also helps to provide a “sociocultural appraisal” (p. 221) of clients and family concerns, beliefs, attitudes, and desires as they relate to the clinical service delivery. This enables clinicians to identify some of the underlying cultural beliefs that may affect how clients and families respond to recommended treatment plans and approaches resulting from the assessment process.
Langdon (2008) also emphasizes the importance of conducting assessments in all languages spoken and understood by the client using culturally and linguistically appropriate assessment measures (e.g., those that are adapted for or normed on the populations with which they are to be used). Medical data and records from relevant radiologic and technologic tests (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) are also recommended to help substantiate the presence of a disorder. Using medical information helps minimize the possibility of misdiagnosis owing to possible underlying cultural-linguistic differences.
According to Kohnert (2008), when assessing CLD adults, a holistic disability framework, such as the International Classification of Functioning, Disability, and Health (ICF) developed by the World Health Organization (2001) should be used. This framework is designed for use in classifying the functional impact of any type of disability on an individual’s ability to participate in meaningful activities and daily interactions with others in their social and family networks. Family and social networks can include immediate family, friends, personal care providers, neighbors, community members, and health care providers.
1. The types of cultural communication patterns that exist among members of the client’s social communication network, including the types of languages typically used during social interactions with the client
2. The specific attitudes and beliefs that are held by members of the support network on issues such as communication, language use, and disability
3. Social communication expectations that members have for that client and how well that individual is capable of performing in line with those expectations
The information generated from this type of assessment is particularly useful for identifying the components of disorder that go beyond culture and language to be targeted as part of an individual’s intervention plan. It also helps to pinpoint possible cultural communication differences displayed by the individual and others in their social network that can affect successful communicative interactions and the intervention process in general.
Professional association knowledge, skills expectations
In 2004, ASHA published guidelines on the knowledge, skills, and competencies for providing culturally linguistically appropriate and responsive services. The document includes important culturally and linguistically appropriate considerations for assessing different disorder areas including language, articulation, resonance, voice, fluency, swallowing, and hearing and balance. They also provide guidelines for making distinction between a disorder and a difference. A summary of sample competencies related to the issue of CLD assessments can be found in Table 12-2.
TABLE 12-2 Knowledge and Skills Needed by Speech-Language Pathologists and Audiologists to Provide Culturally and Linguistically Appropriate Services
