Elsevier

Journal of Communication Disorders

Volume 58, November–December 2015, Pages 74-90
Journal of Communication Disorders

Supporting culturally and linguistically diverse children with speech, language and communication needs: Overarching principles, individual approaches

https://doi.org/10.1016/j.jcomdis.2015.10.002Get rights and content

Highlights

  • Six overarching Principles of Culturally Competent Practice (PCCP) were identified.

  • Examples from 14 international sites are provided to illustrate the 6 PCCP.

  • Tensions for implementing the principles in real world settings are discussed.

  • SLPs are called to advocate for reform of existing practice using the 6 PCCP.

Abstract

Speech-language pathologists (SLPs) are working with an increasing number of families from culturally and linguistically diverse backgrounds as the world's population continues to become more internationally mobile. The heterogeneity of these diverse populations makes it impossible to identify and document a one size fits all strategy for working with culturally and linguistically diverse families. This paper explores approaches to practice by SLPs identified as specialising in multilingual and multicultural practice in culturally and linguistically diverse contexts from around the world. Data were obtained from ethnographic observation of 14 sites in 5 countries on 4 continents. The sites included hospital settings, university clinics, school-based settings, private practices and Indigenous community-based services. There were 652 individual artefacts collected from the sites which included interview transcripts, photographs, videos, narrative reflections, informal and formal field notes. The data were analysed using Cultural-Historical Activity Theory (Engeström, 1987). From the analysis six overarching Principles of Culturally Competent Practice (PCCP) were identified. These were: (1) identification of culturally appropriate and mutually motivating therapy goals, (2) knowledge of languages and culture, (3) use of culturally appropriate resources, (4) consideration of the cultural, social and political context, (5) consultation with families and communities, and (6) collaboration between professionals. These overarching principles align with the six position statements developed by the International Expert Panel on Multilingual Children's Speech (2012) which aim to enhance the cultural competence of speech pathologists and their practice. The international examples provided in the current study demonstrate the individualised ways that these overarching principles are enacted in a range of different organisational, social, cultural and political contexts. Tensions experienced in enacting the principles are also discussed. This paper emphasises the potential for individual SLPs to enhance their practice by adopting these overarching principles to support the individual children and families in diverse contexts around the world.

Introduction

In the field of speech-language pathology the need to engage in culturally competent practice with children and families from culturally and linguistically diverse backgrounds is identified in a number of key professional documents (e.g., American Speech-Language-Hearing Association, 2004a, Canadian Association of Speech-Language Pathologists and Audiologists, 1997, International Association of Logopedics and Phoniatrics, 2011, International Expert Panel on Multilingual Children's Speech, 2012, Speech Pathology Australia, 2009). Culturally competent practice “acknowledges and incorporates—at all levels—the importance of culture, assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs” (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003, p. 294).

In this paper the term “culturally and linguistically diverse” is used to refer to children and families who are not of the dominant language and cultural background of the broader social context in which they reside, as well as children and families with multiple linguistic and cultural influences. The many challenges that speech-language pathologists (SLPs) face in the provision of services to culturally and linguistically diverse populations have been documented extensively. These include lack of: culturally appropriate tools for assessment; developmental norms for linguistically diverse populations; service provision in children's primary languages; professional support and training for working with families from different cultural backgrounds, and sufficient time to undertake additional elements of practice recommended for working with diverse families (Caesar and Kohler, 2007, Guiberson and Atkins, 2012, Jordaan, 2008, Kritikos, 2003, McLeod and Baker, 2014, Pascoe and Norman, 2011, Peña and Iglesias, 1992, Stow and Dodd, 2003, Williams and McLeod, 2012). However, limited data have been published regarding practical approaches for overcoming these challenges.

Often in the field of speech-language pathology professionals are directed towards a gold standard method of enacting practice for certain groups of patients or disorders (Dollaghan, 2004). The trouble with identifying and implementing one gold standard approach to practice with culturally and linguistically diverse populations is that it tends to lead to homogenising practices based on the dominant culture and fails to acknowledge the complexity, variation and strengths that exist among the individuals and families that SLPs serve (Verdon, McLeod, & Wong, 2015). Therefore, rather than advocating for a standard one size fits all model of best practice, this paper proposes a set of six key overarching Principles of Culturally Competent Practice (PCCP) that provide guidance to SLPs in their practice with families from culturally and linguistically diverse backgrounds. A principles-based approach is used to guide practice in a number of fields including speech-language pathology, education, and nursing (e.g., Hatfield, 1995, Royal College of Nursing, 2014, Speech Pathology Australia, 2014). The current paper identifies principles for embracing and supporting culturally and linguistically diverse families that can be applied to all, given that every family has their own unique cultural influences. This paper draws upon international examples to illustrate individual approaches to applying these overarching PCCP as undertaken by SLPs in multilingual and multicultural practice in diverse contexts around the globe.

The development of functional speech, language and communication skills is an essential component of childhood and lays the foundation for lifelong autonomy and participation in society (McCormack et al., 2009, Stothard et al., 1998). Therefore, it is important that children receive rich exposure and support to develop competency in the language(s) they speak.

With increased mobility of people between countries over the last few decades, cultural and linguistic diversity has become a common feature of many societies around the world (Hugo, 2004, Ottaviano and Peri, 2006). The United Nations’ Global Commission on International Migration found that in 2005 there were almost 200 million international migrants around the world, as compared with 82 million in 1970 (Global Commission on International Migration, 2005). Many children considered to be culturally and linguistically diverse come from migrant families. This includes both new migrants as well as families and communities who may have migrated to a country a number of generations ago. Migration may result from forced relocation, due to war or natural disaster, or the voluntary relocation of families seeking better social or economic opportunities in a new country. In the process of migrating to a new country, families are faced with complex issues such as loss of identity, loss of status and loss of connection to family and community (Wong Fillmore, 1991). One key way that migrant families maintain a connection to their home country and identity is through the preservation of language and culture. Similarly, the preservation and continuation of identity among Indigenous people whose lands have been colonised is supported by the maintenance of culture and language (Williams, 2013). Therefore, supporting children's cultural and linguistic diversity during the development of their speech, language and communication is integral to developing their sense of self and cultural identity (Park and Sarkar, 2007, Puig, 2010).

Parents and professionals alike often find it difficult to create balance between what is perceived as necessary acculturation to the dominant context (including understanding of the dominant culture and mastery of the dominant language) and the preservation of families’ own language and culture. It has long been recognised that when two or more cultures interact on a regular basis, attributes from each culture will be adopted and in turn the original cultures themselves will be impacted by such interactions (Redfield, Linton, & Herskovits, 1936). It is essential that the process of acculturation, that is, the process of acquiring a second culture, is not confused with assimilation, that is, the process of replacing one's first culture with a second culture (Berry, 2005). Therefore, dialogue, understanding, and collaboration between all parties involved in children's development (including teachers, parents, SLPs, and the children themselves) are necessary to identify goals that will allow children to maximise their participation in multiple cultural spaces, in both the academic and social domains.

Supporting children to become competent communicators can be complicated when children have speech, language and communication needs. Aside from the many challenges documented from SLPs’ perspectives as previously mentioned, there are also issues that arise as a result of different cultural views, explanatory models and interpretations of disability (Nuckolls, 1991, Vukic et al., 2011). For example, the use of diagnostic labels (such as speech sound disorder and specific language impairment) is common in western cultures (American Psychiatric Association, 2013) but may be inappropriate in some cultures and have a negative impact on SLPs’ ability to build rapport with families and develop mutually motivating goals for assisting children's speech, language and communication development (Zeidler, 2011). Therefore, it is necessary for SLPs to engage in culturally competent practice (Westby, 2009).

Intervention in itself has no inherent value if it is not relevant to the person receiving the intervention and their functional participation in their own lives. In order for practice to be relevant and culturally competent it is essential that individual children are viewed in a holistic manner. This is done by considering their broader social and cultural context as well as environmental and personal factors that influence their functioning and participation in society. Verdon et al. (2015) drew upon the knowledge and experience of international experts to describe aspirations and recommendations for reconceptualising culturally competent practice in speech-language pathology. These recommendations called for the expansion of current practice to include: (1) SLPs being aware of cultural and linguistic influences in children's lives in order to undertake appropriate and accurate assessments of children's strengths and needs; (2) using multiple data sources to draw appropriate conclusions about whether a speech, language or communication issue is present; (3) identifying the impact of such an issue on children's daily lives; and (4) consulting appropriate collaborators (such as parents and teachers) to identify and implement appropriate strategies to support children's development and increase their capacity in their daily functioning. Supporting holistic practice through the application of these recommendations can help to ensure that services are intervention is relevant to the individual and facilitate their optimal participation in daily life.

A number of initiatives towards promoting culturally competent practice are being undertaken worldwide in the field of speech-language pathology. Some of these initiatives include: (1) the development of assessment tools in multiple languages so that children can be assessed in their own primary language and not just the language(s) in which the SLP is fluent (see Bernhardt and Stemberger, 2015, McLeod and Verdon, 2014); (2) alternative approaches to assessment including dynamic assessment (Lidz & Peña, 1996) and parental or adult target contrastive analysis (McGregor, Williams, Hearst, & Johnson, 1997), and (3) specialist speech-language pathology university programmes dedicated to multilingual and multicultural practice.

A number of online resources have also been developed to support SLPs in their practice with multilingual children. These include: screening tools in multiple languages to identify whether a comprehensive assessment of a child's communication may be needed (McLeod, 2012, Paradis et al., 2010) and downloadable information about the components and structure of languages to aid in SLPs’ differential diagnosis between a genuine speech, language or communication difficulty and a language difference resulting from multiple linguistic influences upon a child's communication (McLeod, 2012).

In 2012 the International Expert Panel on Multilingual Children's Speech developed a position paper to guide practice for SLPs working with culturally and linguistically diverse children (McLeod, Verdon, Bowen, the International Expert Panel on Multilingual Children's Speech, 2013) and six key position statements regarding practice were made (see Box 1).

The position statements used the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY, World Health Organization, 2007) to ensure consideration of the breadth of knowledge, skills, and responsibilities required for engaging in culturally competent practice which holistically considers children's functioning and participation in context.

The current paper aims to move beyond the identification of aspirations and recommendations for practice, by describing the state of the art in terms of practices that are currently being undertaken by SLPs in a diverse range of real world contexts to support the speech, language and communication needs of culturally and linguistically diverse children. A focus on documenting professional knowledge is consistent with the American Speech-Language-Hearing Association (2004b) definition of evidence-based practice, of which clinical expertise comprises one of three components, with the other two being external scientific evidence and client perspectives.

Professional knowledge is useful in areas of practice with limited scientific evidence to guide practice (for example, limited developmental norms for multilingual children upon which to base a differential diagnosis). This is not to say that professional knowledge is a substitute for scientific evidence, but rather that these two aspects of evidence-based practice in conjunction with client perspectives, can support professionals’ decision making and engagement with families. Therefore, in lieu of the existence of a substantial body of scientific evidence currently available to direct practice in this field, this paper outlines professional knowledge and contemporary practices in a range of cultural contexts against which SLPs and other professionals in the field can consider their own practice.

The aim of this paper is to use a holistic system-based approach to the analysis of SLPs’ practice in culturally and linguistically diverse contexts to answer the following research questions:

  • (1)

    How do SLPs in multicultural and multilingual practice support culturally and linguistically diverse children with communication needs?

  • (2)

    How do SLPs in multicultural and multilingual practice develop, maintain and demonstrate cultural competence in their practice with culturally and linguistically diverse children and their families?

This paper draws upon data obtained through ethnographic observation of 14 international sites identified as engaging in multilingual and multicultural practice with children with speech, language and communication needs and their families, to identify and describe approaches to culturally competent practice.

The majority of existing papers documenting practice with culturally and linguistically diverse children have described practice from the perspectives of individual SLPs, with data collected largely via questionnaires (e.g., Guiberson and Atkins, 2012, Jordaan, 2008, Williams and McLeod, 2012). The current paper takes a different approach to understanding practice and identifying opportunities to improve the cultural competence of practice. It does this by conceptualising SLPs’ practice with culturally and linguistically diverse children as a complex, multifaceted and dialectal system. By using the system of practice as the unit of analysis rather than individual SLPs, the complexity of practice and the numerous factors which impact upon SLPs’ actions within the system can be identified, described and discussed (Yamagata-Lynch, 2010).

To undertake analysis of SLPs’ practice with culturally and linguistically diverse children Cultural–Historical Activity Theory (CHAT, Engeström, 1987) was adopted as the heuristic framework for this study. A detailed explanation of CHAT and its application to the speech-language pathology profession are provided in a paper by Verdon et al. (2015). To summarise, CHAT is a practice-based approach to academic inquiry that conceptualises practice as occurring within a social, cultural and historically situated activity system and seeks to facilitate understanding of the activity system (Foot, 2001). It was developed on the basis of Vygotsky's model of mediated action, and was expanded to include all aspects of an activity system by Engeström (1987, see Fig. 1).

CHAT provides a framework for considering all the interacting elements of an activity system. These elements are identified as the: object, subject, mediating artefacts,1 rules, community and division of labour. Together these elements form the activity system that is working towards a desired outcome. Using the CHAT framework facilitates understanding of the individual elements, identification of tensions between elements, and possible means for resolving tensions to improve practice within the activity system. An explanation of each of the CHAT elements and one example of their presentation in the current study are outlined in Table 1.

Section snippets

Methods

This research project was approved by the Charles Sturt University Ethics in Human Research Committee, protocol number 2013/003. Site managers were also contacted and provided with detailed information about the study prior to data collection to ensure that the project met the ethics requirements of individual sites. Where necessary, additional ethics forms were completed in order to comply with the policy of individual sites.

Results and discussion

To allow for the interpretation of findings in light of contemporary literature the results and discussion of this paper will be presented together.

Summary and conclusions

Six principles (PCCP) for working with culturally and linguistically diverse populations were identified in this study: (1) identification of culturally appropriate and mutually motivating therapy goals, (2) knowledge of languages and culture, (3) use of culturally appropriate resources, (4) consideration of the cultural, social and political context, (5) consultation with families and communities, and (6) collaboration with other professionals. The individual approaches being undertaken in the

Acknowledgments

Sarah Verdon acknowledges support from a scholarship from the Australian Department of Education, and an Excellence in Research in Early Years Education Collaborative Research Network scholarship from Charles Sturt University. Sarah would like to thank the participants in this study for their hospitability, generosity of ideas, and for the contribution they have made to the profession by sharing their experiences of multilingual and multicultural practice. Sharynne McLeod acknowledges support

References (79)

  • L.M. Bedore et al.

    Conceptual versus monolingual scoring: When does it make a difference?

    Language, Speech, and Hearing Services in Schools

    (2005)
  • B.M. Bernhardt et al.

    Ultrasound as visual feedback in speech habilitation: Exploring consultative use in rural British Columbia, Canada

    Clinical Linguistics and Phonetics

    (2008)
  • B.M. Bernhardt et al.

    Phonological development tools and cross-linguistic phonology project

    (2015)
  • J.R. Betancourt et al.

    Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care

    Public Health Reports

    (2003)
  • L.G. Caesar et al.

    The state of school-based bilingual assessment: Actual practice versus recommended guidelines

    Language, Speech, and Hearing Services in Schools

    (2007)
  • Canadian Association of Speech-Language Pathologists and Audiologists

    Position paper on speech-language pathology and audiology in the multicultural, multilingual context

    (1997)
  • M. Cruz-Ferreira et al.

    Assessing multilingual children in multilingual clinics: Insights from Singapore

  • Y. Engeström

    Learning by expanding: An activity-theoretical approach

    (1987)
  • K.A. Foot

    Cultural–historical activity theory as practice theory: Illuminating the development of conflict-monitoring network

    Communication Theory

    (2001)
  • G. Gillon

    The efficacy of phonological awareness intervention for children with spoken language impairment

    Language, Speech, and Hearing Services in Schools

    (2000)
  • Global Commission on International Migration

    Migration in an interconnected world

    (2005)
  • M. Guiberson et al.

    Speech-language pathologists’ preparation, practices, and perspectives on serving culturally and linguistically diverse children

    Communication Disorders Quarterly

    (2012)
  • V.F. Gutiérrez-Clellen

    Language choice in intervention with bilingual children

    American Journal of Speech-Language Pathology

    (1999)
  • G. Hugo

    Australia's most recent immigrants Australian census analytical program (Cat No. 2053.0)

    (2004)
  • International Association of Logopedics and Phoniatrics

    Recommendations for working with bilingual children

    (2011)
  • International Expert Panel on Multilingual Children's Speech

    Multilingual children with speech sound disorders: Position paper

    (2012)
  • H. Jordaan

    Clinical intervention for bilingual children: An international survey

    Folia Phoniatrica et Logopaedica

    (2008)
  • K. Kohnert et al.

    Intervention with linguistically diverse preschool children: A focus on developing home language(s)

    Language, Speech, and Hearing Services in Schools

    (2005)
  • L. Krefting

    Rigor in qualitative research: The assessment of trustworthiness

    American Journal of Occupational Therapy

    (1991)
  • E. Kritikos

    Speech-language pathologists’ beliefs about language assessment of bilingual/bicultural individuals

    American Journal of Speech-Language Pathology

    (2003)
  • S.J. Lewis et al.

    Being embedded: A way forward for ethnographic research

    Ethnography

    (2011)
  • C.S. Lidz et al.

    Dynamic assessment: The model, its relevance as a nonbiased approach, and its application to Latino American preschool children

    Language, Speech, and Hearing Services in Schools

    (1996)
  • V. Lim et al.

    English-only treatment of bilingual speakers who stutter: Generalization of treatment effects from English to Mandarin

    International Journal of Speech-Language Pathology

    (2015)
  • J. McCormack et al.

    A systematic review of the association between childhood speech impairment and participation across the lifespan

    International Journal of Speech-Language Pathology

    (2009)
  • S. McLeod

    Multilingual children's speech

    (2012)
  • S. McLeod et al.

    Speech-language pathologists’ practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders

    Clinical Linguistics and Phonetics

    (2014)
  • S. McLeod et al.

    A review of 30 speech assessments in 19 languages other than English

    American Journal of Speech-Language Pathology

    (2014)
  • K.K. McGregor et al.

    The use of contrastive analysis in distinguishing difference from disorder: A tutorial

    American Journal of Speech-Language Pathology

    (1997)
  • Cited by (30)

    • Persistence, strength, isolation, and trauma: An ethnographic exploration of raising children with cleft palate

      2021, Journal of Communication Disorders
      Citation Excerpt :

      The first author completed all of the open coding as she was present during data collection, and therefore, understood the context in which the data were situated. As described by Verdon, McLeod, and Wong (2015), this afforded her insights into the “understanding and interpretation of the data” (p. 80) through her experiencing the sites and culture. In total, 355 open codes were identified.

    • Implementing evidence based practice with limited evidence: The case of language intervention with bilingual children

      2017, Revista de Logopedia, Foniatria y Audiologia
      Citation Excerpt :

      A number of bilingual modifications have been recommended for use with bilingual children (Blumenthal et al., 2015; Fredman, 2006). Similarly, a review of clinical practices used by experienced clinicians provides useful information on what practices experienced clinicians have retained over time (see Verdon et al., 2015). Certainly, clinical expertise has an important place in EBP.

    • Development of Speech-Language Therapy Assessments for the Languages of South Africa

      2023, Handbook of Speech-Language Therapy in Sub-Saharan Africa: Integrating Research and Practice
    View all citing articles on Scopus
    View full text