Chapter 9 Cultural diversity and fluency disorders
The relevance of cultural and international factors in the assessment and treatment of communication disorders has been discussed in the literature (Battle, 1997; Guitar, 2006; Taylor, 1986; Terrell & Hale, 1992; Proctor et al., 2008). Essentially, the relevance is, in order for assessment to be accurate and meaningful and for treatment to be maximally effective, both should be conducted with regard to the client’s cultural identity, cultural assimilation, cultural environment, and cultural system (Crowe et al., 2000; Robinson & Crowe, 1998). Clinicians and researchers have attempted to address this issue by providing models for service delivery in various clinical settings and with various cultures (Robinson & Crowe, 1994; Robinson & Crowe, 1998; Seymour, 1986; Seymour & Seymour, 1977; Taylor, 1986; Taylor & Payne, 1983; Taylor & Samara, 1985; Van Kleeck, 1994; Vaughn-Cooke, 1983, 1986). These models, for the most part, have been discussed relative to nonbiased assessment of speech articulation disorders, with little reference to the treatment process.
Attention has been given to the influence of cultural factors on the evaluation and treatment of stuttering (Bullen, 1945; Cooper & Cooper, 1993; Crowe et al., 2000; Robinson & Crowe, 2000, Watson & Kayser, 1994). Consideration of cultural variables should begin when clients or their families first contact clinical centers to schedule evaluations or merely to obtain information. Clinical intervention for treatment of stuttering should be structured within the context of each client’s cultural system and cultural environment. After determining the client’s cultural identity and degree of assimilation into the culture, in order for therapy to be maximally effective and also for therapy to be efficient in regard to time spent setting and achieving goals. Clinicians’ attention to these cultural dimensions of the therapy relationship also will increase the probability that counseling for the prevention of stuttering will be effective (Crowe, 1995).
Cultural environment is also important to take into consideration when structuring a plan for counseling in fluency intervention. This includes all aspects of the client’s environment: his or her phenomenal field; access to experience; semantic environment; relationships with significant others; and language environment. In the case of child clients, it is important for clinicians to remember that parents are the chief architects of their child’s environment and should be counseled to be active in designing an environmental gestalt for their child that is conducive to speech fluency and to normal personality development (Crowe, 1994). The environment of the child with disfluencies should be conducive to him or her developing the use of ego functions that might in turn help prevent the development of defensive reactions to speech disfluency and to speech therapy.
Universality of fluency disorders
Like most disorders that affect the human condition, fluency disorders, in specific stuttering, are not restrained by geographic demarcations. Stuttering appears on every continent, in every country, in every corner of the globe. The evidence for the universality of stuttering is summarized effectively by Van Riper (1982), Bloodstein (1995), and Bloodstein and Bernstein Ratner (2008).
The universality of stuttering pertains to cultures as well as continents and countries. There is strong evidence that stuttering appears in all cultures, or to put it more conservatively, there is no compelling evidence for any culture that indicates stuttering does exist within it.
Cultural groups that have been studied include Native Americans (Clifford et al., 1965; Johnson, 1944a, 1944b; Lemert, 1953; Snidecor, 1947; Stewart, 1960; Zimmerman et al., 1983), African Americans (Anderson, 1981; Brutten & Miller, 1988; Conrad, 1985; Ford, 1986; Goldman, 1967; Leith & Mims, 1975; Nathanson, 1969; Proctor et al., 2008; Robinson, 1992; Robinson & Crowe, 1987, 1998; Robinson et al., 2000), Asians (Lemert, 1962; Toyoda, 1959; Wakaba, 1983), Hispanics (Bernstein-Ratner & Benitez, 1985; Dale, 1977; Jayaram, 1983; Nwokah, 1988; Travis et al., 1981), West Indies (Ralston, 1981); and African (Aron, 1962; Goodall & Brobby, 1982; Kirk, 1977; Morgenstern, 1953, 1956; Nwokah, 1988). Results of these studies generally suggest that cultural differences influence speech fluency and that there are differences in perceptions, beliefs, values, and norms about speech fluency and fluency disorders among various cultural groups. One possible significance of these suggestions is that cultural factors might appreciably affect the outcomes of clinical intervention with fluency disorders.
There has been disputation about the universality of stuttering with argument that it is not universal based on sparse, largely anecdotal data that for the most part were later refuted. The best known case of this was the assertion by Johnson (1944) and two of his students, Snidecor (1947) and Stewart (1960), that stuttering did not exist in the Utes, Bannock, and Shoshone American Indian tribes. This idea was on the researchers’ findings that no stuttering was reported in interviews with numbers of the tribes, social pressures on communication appeared to be minimal within the tribes, and no word in the tribal languages could be found for stuttering. Evidence was later presented (Zimmerman, 1983) that stuttering does exist in these American Indian tribes.
Prevalence of stuttering among cultures
Although the idea that in some cultures stuttering may not exist is given little credence today. The thought associated with it that social demand on communication and stuttering might be positively correlated may be one possible explanation for varying prevalence among cultures. Cooper and Cooper (1998) stated that “universally accepted definitions do not exist regarding what constitutes the fluency disorders that the English terms stuttering and stammering and their equivalents in other languages have come to encompass and symbolize” (pp. 252-253). They also pointed to a great deal of variability in the data collection process across cultures. Van Riper (1982) and Bloodstein (1995) indicated that the prevalence of stuttering in the general population is about 0.8%, whereas the incidence of stuttering in some cultural groups is between 5% and 10%. Tables 9-1 through 9-5 depict prevalence research in various cultural groups.
TABLE 9-1 African American Populations
| Study | No. of Subjects | Findings |
|---|---|---|
| Waddle (1934) | 1582 | 1.7:1 Ratio in children |
| Carson & Kanter (1945) | NA | 60% Higher than white children |
| Neely (1960) | NA | No differences |
| Pritchett (1966) | NA | 1.3:1.0 Ratio of African American to white children |
| Goldman (1967) | 694 | 2.4:1.0 Ratio of African American male to female children |
| Gillespie & Cooper (1973) | 5054 | 2.8% |
| Conrad (1980) | 1271 | 2.7% African American adults (2:1 ratio male to female) |
| Proctor et al. (2008) | 2223 | 2.60% |
| Study | No. of Subjects | Findings |
|---|---|---|
| Morgenstern (1953, 1956) | 5618 | 2.67% Ibo schoolchildren |
| Aron (1962) | 6581 | 1.26% Bantu schoolchildren |
| Kirk (1977) | NA | High incidence of disfluent speech (nonpathologic) among children from Ghana |
| Goodall & Brobby (1982) | NA | 5.5% Prevalence in Dakar schoolchildren |
| 3.5% Prevalence in Accra district | ||
| Nwokah (1988) | NA | Incidence in Nigerians and West Africans may be the highest in the world |
TABLE 9-3 Caribbean Populations
| Study | No. of Subjects | Findings |
|---|---|---|
| *McCartney (1971) | NA | 1.07-4.46% Prevalence among Bahamians |
| Ralston (1981) | 1999 | 4.7% Prevalence in Caribbean children |
| Leith & Gibson (1991) | 1217 | 3.6% Prevalence in children in Nassau |
* Cited in Leith and Gibson (1991).
TABLE 9-4 Hispanic Populations
| Study | No. of Subjects | Findings |
|---|---|---|
| Leavitt (1974) | 10,455 | 0.84% Prevalence in New York City Puerto Ricans |
| Leavitt (1974) | 10,499 | 1.50% Prevalence in Puerto Ricans in San Juan |
| Ardila et al. (1994) | 1879 | 2% Prevalence among Spanish-speaking university students from Bogota, Colombia |
| Study | No. of Subjects | Findings |
|---|---|---|
| Toyoda (1959) | 140,000 | 0.82% Prevalence in Japanese schoolchildren |
| Ozawa (1960) | 7600 | 0.90% Prevalence in Japanese school children |
| Lemert (1962) | NA | More stuttering among Japanese than among Polynesians |
Factors that influence stuttering in cultural groups
Attitudes
An attitude is a state of mind, feeling, orientation, or disposition (American Heritage Dictionary, 1996). For years, researchers and clinicians have examined the relationship between stuttering and attitude. It has been determined that attitude plays a major role in both the diagnostic and treatment processes. The feelings that accompany stuttering are a major component of the stuttering syndrome. Starkweather (1980) indicated that treating one aspect and ignoring the other dooms any therapeutic approach to failure.
From a cultural prospective, the attitude toward communication disorders and, more specifically, stuttering changes from cultural group to cultural group. Harris (1986) indicated that attitudes evolve from individuals’ value systems and culture. She further indicated that these value systems are often so ingrained in a person’s mind that his or her values become truth, usually not only for that particular person but for all humans. Practitioners must acknowledge the potential for differences in perception of the causes and meaning of disabilities, the elements necessary for a difference in the value of rehabilitation, and the differences between their own belief systems and those of their clients (p. 229).
Myths and beliefs
It is important for clinicians to be familiar with the myths and beliefs of the culture group relative to the etiologic factors and approaches to intervention for stuttering. It is also important to note that some myths and beliefs are rooted in the fact that in some cultures, families do not see the value in speech-language services. Clinicians must take these myths very seriously because they represent the parents’ honest understanding of stuttering. Robinson and Crowe (1998) provided the following examples of African American myths about stuttering.
• The mother eating improper foods when breastfeeding the infant
• Allowing an infant to look in the mirror
• Cutting the child’s hair before he or she says his or her first words
• The mother seeing a snake during pregnancy
• The mother dropping the baby
• The child being bitten by a dog
• Stuttering can be controlled by the child.
• Stuttering can be controlled by telling the child not to move his or her feet when talking.
• Stuttering can be cured by hitting the child in the mouth with a dish towel.
• Stuttering can be cured by having the child hold nutmeg under his or her tongue.
Religion
Some cultural groups are deeply rooted in religious practice. Clinicians should be mindful that, sometimes, religious practices might greatly influence family’s acceptance of the stuttering intervention process. For example, in some cultural interactions, clinicians may find that the group views stuttering as a curse from God. Yet in another group, seeking the service in general may be against religious practices.
A culture-based model
Robinson and Crowe (1998) presented a decision model for inclusion of multicultural variables in stuttering intervention. In this model, six levels are presented: preintervention; intake; evaluation; client counseling; treatment; and carryover or generalization. Decisions are made at each intervention level as to the relevance of cultural variables in the intervention process. At each level, the decision is also made whether to revisit previous levels or to expedite progress through a given level.
Decision level I (preintervention). In this level, the client’s cultural identification, age, gender, and communication norms are determined.
Decision level II (intake). This level includes general disorder typing, specific cultural variables relative to stuttering, myths, attitudes, terminology, and beliefs.
Decision level III (evaluation). At this level, the clinician is encouraged to make cultural adjustments for nonverbal behaviors of the client as well as verbal language and interaction and visual stimuli. The clinician should also look at cognitive learning styles, parental-child interaction, and how the client interacts with the clinician.
Decision level IV (client counseling). This level allows the clinician to look at rules for interaction and how they affect the counseling process. The clinician should also examine the family unit for cultural identity, residential history, generational factors, and the language spoken in the home and its importance.
Decision level V (treatment). At this level, the clinician should build cultural-based experiences, factors, and interactions into the treatment process.
Decision level VI (carryover or generalization). This is when the clinician involves the home, peers, and client to ensure that the skills learned in therapy are taken outside of the treatment room.
Related posts:
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Middle east and arab american cultures
Hispanic and latino cultures in the united states and latin america
Communication disorders in a multicultural and global society
Multicultural aspects of hearing loss
International and intercultural aspects of voice and voice disorders
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