Early in my career I evaluated a child in Brighton Beach, a Russian neighborhood in Brooklyn, N.Y. The baby was struggling with feeding. His heart rate went up while he ate, and he often fell asleep from exhaustion before he could get adequate nutrition. It became obvious during the evaluation that the baby was not feeling the milk coming from his bottle and was getting upset and overexcited, causing the increased heart rate, subsequent exhaustion and sleep.
He was first-generation American, born to a young English-speaking mother who lived with her Russian-speaking parents. I offered the generally accepted guidance of giving the child a cold bottle so he would be more aware of the fluid in his mouth. The mother translated this advice to the grandmother. After a brief discussion in Russian, the daughter made an excuse about having to go somewhere, and told me I had to leave. Later, my agency called me to ask what had happened because the family requested a new evaluator. What had happened? I didn't know. Do you?
In that long-ago evaluation, I had offended a family because I was not aware of some tightly held beliefs and practices rooted in its culture. The grandmother firmly believed that cold milk would be detrimental to the infant and seriously questioned my competence because of my suggestion. Had I explained the reason for the cold milk and asked the family for other suggestions for solutions, I might have been able to convince the grandmother that my treatment plan would not harm the baby.
Clinicians should strive for cultural competence in delivering services to all clients, but the need for such an approach is never more essential than in early intervention services—because early intervention is a family-based model that calls for collaboration between the clinician and the child's family, with services provided generally in the family's home and other natural settings. The clinician can't help but be immersed in the family's culture.
Customs related to raising young children can be a moving target of family tradition and generational differences, and an outsider must tread cautiously in these culturally sensitive waters. Clinicians especially should be careful when doing an evaluation, because this process usually is the family's first experience with service provision and, perhaps, the first step in their journey of recognizing their child's disability. Adding an "outsider" to an already difficult situation—the evaluation of a child—can set the stage for a daunting experience.
What is cultural competence?
I have been working in early intervention assessments for more than 25 years and now consider myself quite culturally competent. In ASHA membership surveys, most respondents do not consider themselves culturally competent. However, according to ASHA's Multicultural Issues Board, clinical competence encompasses cultural competence—that is, we cannot be clinically competent without being culturally competent. But what does that mean? Does it mean we must know the language of every group we assess, or know the developmental progress and pragmatic features of each of those languages, or the child-rearing or food customs of every group? No, of course not, but you do need to know what your abilities are and how to ask the right questions.
Take, for example, a bilingual provider. If you present yourself as bilingual, you must know the language and its course of development and, therefore, you should be familiar with fundamental pragmatics. But depending on how you have learned your second language, you may not know customs or family dynamics of people who speak that language or its various dialects. Conversely, you may be asked to provide services to English-speaking families from very different cultures. For example, many second-generation families maintain the cultural practices, beliefs and pragmatics of their native country while speaking American English.
So what makes a clinician culturally competent to assess infants and toddlers under these circumstances? One factor is being aware that everyone—each individual and each family—has a culture. People have a culture that is different from yours, not different from a norm.
Cultural differences also account for child-rearing beliefs and practices, as well as variation in communication. Families have rules and structure for their intrafamily language, just as a larger culture has rules and structure for its language. In some families no one questions what the father says; in other families each family member gives input to decision making. On our journey toward cultural competence we must be willing to accept that everyone has a different way of doing things and that there is no one right way. It comes down to knowing what kinds of questions to ask when doing an assessment, knowing how to respond respectfully and knowing what the answers mean. Most important to know is that your way is not the only way—it is just your way. Recognizing your own cultural morés is the first step on your journey to cultural competence.
How do you "get" cultural competence?
How do we make progress in our journey toward cultural competence? By taking some courses that give stereotypic outlines of what cultures are like? Maybe, maybe not. Speech-language pathology students have been told that Asian children do not make eye contact when speaking to adults. Caribbean children don't answer questions posed by an adult if they know the adult knows the answer. Hispanic children use descriptives rather than nouns to name an object, using the word "thing," as in, "It's the thing you drink from."
Are these characterizations wrong? No, they are not necessarily wrong, but they are generalizations. It is not advisable to apply the generalizations to all members of a group, nor is it possible to know the language and pragmatic features of every cultural group you are asked to serve. Cultural assimilation occurs at different rates for various immigrants and even among assorted groups from the same national origin. The Manhattan Institute for Policy Research made clear in a 2008 report that a variety of factors affect the overall and individual rates of assimilation for immigrants. Looking specifically at Hispanics, the institute notes that Cuban immigrants have assimilated, economically and civically, faster than Mexican immigrants in the United States in the same amount of time—yet, in courses on cultural competence we often learn about "the Hispanic child."
The institute also notes that cultural assimilation does not necessarily follow the pattern of economic assimilation. A family may seem acculturated until it has to deal with highly charged emotional situations, and then the family will return to things that offer comfort and familiarity. So what is important? In a 2009 position statement, ASHA lists a few steps in the journey of cultural competence, not the least of which are valuing diversity, having awareness and acceptance of differences, and being conscious of the dynamics that occur when cultures interact.
Take a look at the following vignettes from several of my early intervention evaluations. Think about the issues that arose, what questions should have been asked and what steps could have been taken to ensure more successful outcomes.
- A baby from a Muslim family from Afghanistan needed an evaluation. I made the appointment for about 4 p.m., after the school day was over. I found the baby, whose family spoke English, to be seriously delayed. He presented with strong evidence of neurological impairment. I explained to the mother that her child was eligible for services and that he should be seen by a doctor for referral to a neurologist. She said she would have her husband call the agency and arrange for the individual family service plan meeting. The father never called, and the family never answered any future calls.
- I evaluated a Pakistani child who had severe reflux and, therefore, was having serious feeding issues. During the evaluation, however, the child did not seem to have any trouble drinking from and swallowing the liquid in her bottle. She did demonstrate a strong aversion when given solid food so spicy that one whiff brought tears to my eyes. The mother was not happy when I suggested different food.
- I went into a Hasidic Orthodox Jewish home with my toy farm animals and dinosaur to assess a 2½-year-old child with language impairments. The mother was appalled at the piglet and questioned my competence because I believed in dinosaurs. She requested another evaluator.
Do you see the obvious issues in these situations? I took some things for granted. In the first example, I took for granted that the family would understand my "expert" advice and that the way I did things was acceptable to them.
When working with any family, tell them about your expertise and experience. You are not bragging, you are explaining why you can do what you do.
- With the Afghan family, I made the appointment based on my schedule, and didn't ask if it was important for other family members to be present or if another time was convenient to accommodate everyone. Had the father been present, I might have been able to find a way to make him comfortable with the assessment results.
- In the case of the Pakistani child, I should have asked the mother for her suggestions for how to accommodate her child's inability to handle the spicy food, making it clear that the food was fine but that the child could not take it at this time.
- The case with the Hasidic family shows that treatment materials may raise issues with some families. No matter how innocuous you may find your materials, show them to the family and explain their purpose. Then ask if they have any objections. If they cannot be replaced with something else—as in the case of standardized tests—explain their necessity.
The bottom line is the family is the best resource and readily available to you. If you draw on family members' input and are respectful of the information you gather, you should be well along on the journey to identifying yourself as culturally competent in ASHA's next member survey.