Section Five
Module 18: Multi-Cultural Clinical Service Delivery
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How can we be successful for everyone in multi-cultural clinical service delivery?
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After working with the material in this module, readers will be able to
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Multi-cultural clinical service delivery refers to situations that include many people from many backgrounds and with many identities. Group screenings provide the best example, and some assessment or group-treatment situations can also be multi-cultural. As Module 18 describes, our methods and our goals in multi-cultural clinical situations build on our knowledge of dimensions, continua, and human universals, rather than being intended to match the specific preferences of any individual.
Be sure you understand the distinctions between “multi-” situations and “cross-” situations, from Module 16, before you try to read this module.
Community screenings, facility-wide screenings, or other group screenings provide excellent examples of truly multi-cultural situations, as we are defining “multi-cultural.”
In these kinds of situations, we interact with many people, usually with minimal foreknowledge of, and minimal detailed information about, their specific cultures, identities, or backgrounds. Each person we see for screening will bring something different and will need something different, and we must be prepared to pivot to each of those needs. At the same time, however, our goal is not to develop a careful, specific, permanent therapeutic bridge to each of the many different people we encounter during group screenings. Our goals, instead, are framed more at the level of a multi-purpose room, or defined by our awareness of universal human needs.
In screening situations, in other words, we think universally. The goal of screening is to identify people who deserve further assessment, either because they have questions about their own communication or swallowing abilities in the context of their own lives; because relevant others from their own environment have concerns; or because their abilities or trajectories meet our thoughtful, professional definitions of potentially signaling a condition for which the person might benefit from professional assistance, when those definitions have been developed broadly to address genuine human universals and in the context of those other people’s own lives.
For all group screenings, therefore, we can draw on our basic awareness of dimensions, continua, and variability, and on our awareness of higher-level universal and shared aspects of human communication. Let’s think about the social and interpersonal structure of the situation first, and then we can address the content of the work we will do within that structure.
Cultural Dimensions Create the Interpersonal Structure of Multi-Cultural Clinical Interactions
As we plan and conduct multi-cultural screenings, it helps to remind ourselves of the many dimensions, continua, identities, options, and interactions that define equally acceptable and typical social routines for human groups and individuals (as most of the previous modules in this website have been addressing; explore Sections One through Four, if you started here in the clinical applications section). Before we can focus on any individual’s speech, language, swallowing, or other specific abilities, therefore, we need to be ready to interact with a wide range of different people who will bring a wide range of different interpersonal and behavioral assumptions to the screening situation.
Explore the wide range of possibilities described in Box 18.1, which focuses on the culturally influenced behaviors you might encounter during pediatric screening situations.
Can you identify the human universal associated with each continuum? For the first entry, for example, the universal is that children cannot bring themselves to screening appointments. Beyond that, however, whether the mother “should” or the grandparents “could” or both caregivers “must” are simply some of the many culturally influenced specifics, dimensions, or continua.
Notice, also, that these descriptions are not phrased as “People from Culture X will do Y.” We are not memorizing stereotypes; we are preparing for the full length of a continuum. Our goal is to be aware of the universals or the continua and prepared to work respectfully with the full range of how those universals are expressed along the continua.
Box 18.1. Culturally Influenced Dimensions, Assumptions, and Behaviors that Shape the Interpersonal and Social Structure of Screening Situations*
One or more adults may attend with the child, representing one or more genders and/or one or more generations.
Children will refer to the adults in their lives using names or titles you cannot predict and reflecting a range of relationships or family shapes.
Children and adults will come to screening situations with assumptions about who can appropriately be in a smaller room with whom or which adult will be more directly involved in conversations about children or about potential disorders in children. Common assumptions include that women will focus on the child’s needs, that men will not discuss with strangers anything they might perceive as “babying” their sons’ “weaknesses,” or that children of any gender should or should not interact with adults of any gender.
In situations where more than one adult is with the child, those adults will expect you to interact, or not to interact, with one or more of them to varying degrees. Common assumptions include a man speaking for the family, a woman speaking about topics related to childcare, deference to the oldest adult present, deference to the adult who knows the child best, deference to the adult who is most comfortable speaking English, or an assumption that both/all adults should be equally part of the conversation.
Adults will or will not expect the professional to engage in brief to more extended social conversation with them or with their child, to varying degrees, before beginning the formal aspects of the screening.
Adults will or will not expect children of younger or older ages to speak for themselves in a screening situation or to allow the adult(s) to speak to the professional for them, to varying degrees. During conversations between the adult(s) and the professional, adults will or will not expect children of different ages to wait quietly, to explore their surroundings on their own, and/or to be part of the adults’ conversation.
Siblings may or may not be in attendance. If siblings are in attendance, the family will have assumptions that you will or will not interact with the siblings to varying degrees, and the family will also have assumptions about how the siblings are expected to occupy themselves to varying degrees during the target child’s appointment.
Adults will or will not hold their infants or children, to varying degrees or for varying reasons. Adults will or will not use slings, wraps, other baby carriers, or strollers for infants or children of a narrower or wider range of ages than you might use. Adults with baby carriers or strollers will or will not assume to varying degrees that it is acceptable to bring such pieces with them into a clinical area or to leave them unattended in a waiting room.
Adults will or will not assume that it is appropriate for infants, children, and/or adults to sit on the floor, to sit in a chair, to sit on another person’s lap, or to sit on a table, to varying degrees. These expectations may or may not vary for people of different genders or vary depending on who else is in the room, as well as varying by age.
Adults will or will not assume that infants and children of different ages should feed themselves or should be fed, to varying degrees.
Adults will or will not assume that you are seeking either brief or extended answers from them or from their child, to varying degrees. Children will or will not assume that you are seeking brief answers, expansive answers, answers to all questions, and/or answers only where your question could be genuine (i.e., children may have been taught to display their knowledge by reciting the obvious in front of adults or they may have been taught to respect adults’ time by not reciting the obvious in front of adults, and depending on their experiences to date they may fall anywhere along such a continuum).
Adults will or will not assume that they should help their child with any tasks or questions you ask the child to complete, to varying degrees. Children will or will not assume that they should guess if they are not sure, ask a familiar adult for help if they are not sure, and/or not answer if they are not sure.
Adults will or will not assume that they should speak to you, and/or speak to each other in your presence, using any particular one of their dialects or languages or using any particular mixture of their dialects or languages.
Adults will or will not come into the screening situation with varying degrees of awareness of any inequities that have been addressed toward their culture(s) or toward yours throughout world history. If they are aware of such historical inequities in a direction that has traditionally marked either their culture(s) or yours as less socially or politically powerful than others, they may or may not begin with related assumptions about the judgments that this screening might make about their child or about them, to varying degrees.
Adults will or will not assume that your role is primarily supportive (to help them with their child) versus primarily judgmental (to judge their child or to judge their parenting), or any combination of these purposes. Younger children will tend to understand their caregiver’s emotions about the screening; older children will have developed their own assumptions about whether unfamilar adults are supportive or judgmental.
*These entries are phrased for pediatric screening, but the issues are equally applicable for group screening situations with adults and older adults; see the main text.
Interesting list, isn’t it? Did you immediately recognize your default assumption about these issues, or even feel that you know the “correct answer” for some of these issues? Try to describe several other positions that exist to either side of your position on that continuum. How will you, as the individual you are, need to prepare to respond to the many other, equally acceptable, points along that dimension or continuum, given your unique starting point?
Were you also thinking about adult screenings? Most of the elements in Box 18.1 apply equally well and are equally important with adults. Take the time to re-read Box 18.1 several times, substituting the words “adult,” “older person,” or “loved one” for “child.” The issues are the same, including for these examples and for most of the other entries in Box 18.1:
One or more other people may attend with the older person, representing one or more genders and/or one or more generations.
Adults will refer to the people in their lives using names or titles you cannot predict and reflecting a range of relationships or family shapes.
Accompanying adults will or will not expect the professional to engage in brief to more extended social conversation with them or with their older loved one before beginning the formal aspects of the screening.
Accompanying adults will or will not assume that they should speak for their older loved one, allow that person to speak for themselves, and/or help their older loved one with any tasks or questions you ask the older person to complete. Adults of any age will or will not assume that they should guess if they are not sure, ask for help if they are not sure, or not answer if they are not sure.
The need in multi-cultural situations, again, is not to have memorized details about all cultures’ tendencies, to have prepared for any specific culture or identity, or to have prepared a specific way that you will act with a certain “kind” of person. The need is to be ready to encounter, recognize, respect, and respond appropriately to all points anywhere along the many continua that define both groups and individuals.
How exactly can we or should we respond to such a wide range of possibilities? The question includes its own answer: In multi-cultural situations, we are responding to a range, not building a specific bridge. We do so by applying all of the background information from the first four Sections of this website and by using all of this website’s themes: kindness, respect, continua, interacting dimensions, our ability to recognize and respond, and the distinction between universals and specifics. Box 18.2 contains a few key ideas and general strategies for the interpersonal elements of any multi-cultural screening or other clinical situation.
Box 18.2 Universal Strategies to Create Welcoming and Responsive Interactions in Multi-Cultural Screening Situations
Follow the family’s lead.
Offer choices for infrastructural details.
Use “Yes and” or “Yes, thanks, and, because.”
Accept the answers being communicated to you behaviorally.
Remember why you are there.
As Box 18.2. begins with, for many of these variables and in many situations, the simplest answer will be to follow the adult’s or the family’s lead — that is, in many cases, we can recognize, respect, and respond to a family’s needs by simply accepting the family’s assumptions. The family’s or the adult’s assumption will make them most comfortable; will make a child most comfortable; and usually will not interfere with your attempts to screen the child’s or the adult’s speech, hearing, language, or communication abilities.
Regardless of your initial assumptions about who would or should speak for a child or serve as a family’s spokesperson, for example, you can easily pivot to speaking with the person who seems to be answering you.
If your assumption is that meaningless chitchat is a waste of time and should be kept to a minimum, you can go ahead and answer the parent’s slightly longer conversational openers about the weather and the paintings in your waiting room anyway. If your assumption is that longer initial conversations lead to better therapeutic relationships, even for or especially for brief encounters such as screenings, you can notice that the parents are looking at the clock and looking at your clipboard and transition into your planned formal activities sooner than you might have preferred.
And even if you expect children over a certain age (1 year? 2? 4?) to sit on their own chairs, you can certainly conduct a screening of an older child’s speech and language as they sit on their parent’s lap.
A related strategy can be to offer choices for as many of your encounter’s infrastructural details as possible. Consider such comments as “Who’s coming along?”, as you leave a waiting area to move to a clinical space, or “Chairs? Or the floor?”, as you get settled with a family with an infant or toddler. This type of comment allows you to establish your professional control over the general shape and timing of the session (i.e., we are leaving this area now and moving to this other area, or we are all going to sit down now) while also conveying your openness to the details that the family needs.
Do be aware of your pragmatics and intonation as you offer choices. If your intonation is open ended, then offering two suggestions allows the family to suggest their third preferred solution, which is the overall intent here. It’s not a forced-choice situation, it’s an invitation for the client and family to act in ways that make them the most comfortable. If their need turns out to be for you to tell them what to do, they will ask you where they “should” sit, and you will then go ahead and tell them.
If for any reason you would like to request a different option than the one the family first presents, use our universal “Yes and” strategy to convey your recognition and respect for their initial approach and to ask for a next step that you need to require for professional reasons that the family might not have yet understood. The appropriate variation here is often “Yes, thanks, and, because” (notice that this is a literal rephrasing of “recognize, respect, and respond”!).
“Yes, thanks for such a succinct answer! And can you give me some examples, so I can get a better sense of what you are seeing in Rory’s language at home?”
“Yes, nice, well done, I see how good you two are when you work together! Now how about if we let Rudy try it all by herself, so I can see how far she can get on her own?”
Be ready for the family to agree with you politely but then not change their behavior; to seem uncomfortable with your request or unsure how to answer; or to provide an only tangentially related answer. You might then be able to ask again in a different way, rephrase your explanation, or provide an example. But it might be that their behavior or their discomfort has already provided you with very clear information, or with everything you need to know in this situation. If so, respect and accept the larger answer that their behavior is giving you.
Remember, in a multi-cultural screening situation, we are seeking quick information about how a person functions in their environment, not trying to impose our cultural assumptions about social, familial, or clinical interactions onto anyone else. Our responsibility is to recognize, respect, and respond appropriately to all points anywhere along the many continua that define both groups and individuals and that can shape the form of our interactions with other people. Our goal, the reason we are there, is to determine if this person might need or deserve further assessment about their abilities in their contexts.
So let’s think next about the actual content of our screening. We are doing our best to create a welcoming form or structure for our multi-cultural clinical situation. What are we then attempting and accomplishing within that structure, and why?
Your Turn
Try being aware of your facial expression, tone of voice, and physical mannerisms, as well as the content of your first few sentences, as you greet everyone you greet today or this week. How exactly do you, in your unique way, convey “welcome, come in, I am glad you are here” when that is what you are feeling? What might you therefore choose to do, purposefully and overtly, as you greet each new client in a screening situation?
Don’t let tidbits of knowledge paralyze you! Have you read somewhere that the appropriate way to greet people from certain cultures is to shake hands, even though you yourself would never extend your hand to a stranger? Have you been told that you should shake hands with people who appear to be from certain backgrounds but not with people who appear to be from other backgrounds, but then also been told that we should never make assumptions about people based only on their initial appearances? Have you been told that you should greet the man first and also been told to greet the older woman first? How can we possibly simultaneously shake hands, not shake hands, greet both of two people first, and also decide instantly and correctly who feels old enough that they want to be treated as an elder? No wonder you feel paralyzed! Try using the knowledge and skills you have developed throughout this website, including that Module 1 started with thinking about ourselves for a reason; if you would never offer your hand to a stranger, or have never bowed to anyone in your life, then you are not required to figure out how to do so correctly every 5 minutes as you meet a range of people in a multi-cultural clinical situation. Find the universal: Everyone wants to be greeted in a way that makes them feel welcomed and comfortable. How can you achieve that, given who you are and given that you will be meeting many people from many different backgrounds? Our basic answers from Box 18.2 will get you a long way: Watch the clients and follow their lead (if you can), have a basic plan for what you need to accomplish but offer infrastructural options, and use “yes and.” Infection control concerns can be your friend, here, too: Try holding a clipboard to keep your hands busy, smiling at everyone with a brief nod of your head, and saying “Hi, I’m Anne, I’m glad to meet you, how are you today?” — and then respond to the person who answers you.
This segment focused on families’ and clients’ behaviors, but think about the range of people’s physical appearances, too. What are some of the continua along which people’s appearances vary, both in terms of their immutable traits and in terms of their choices? (My grown children have multiple facial piercings and occasionally sport purple hair and death-metal rock-band T-shirts. What might you assume if they came to your screening?) Are you aware that your immediate reactions to some of those appearances might be more positive or more welcoming than your immediate reactions to other appearances might be? Remember that human beings are comfortable with the familiar, and positive feelings increase as familiarity increases. How can you help yourself become more familiar with the possible appearances that clients might represent?
Which parts of which options from Box 18.1 and Box 18.2 are you resisting, for which kinds of example situations? Try using the 16 Questions matrix to analyze your reactions: Fill in as many of the 16 cells as you can from your point of view, then fill in as many of the 16 cells as you can while attempting to represent the point of view of the other person or family you are imagining. Reflect on any piece of this exercise, if you’d like to, or discuss it with a trusted friend.
Screening for Universal Abilities and Trajectories with Children
Screening serves to identify people who need further assessment, not to describe any person’s abilities in detail. And, again, a group screening situation provides an excellent example of a genuinely multi-cultural situation. We use our knowledge of continua, dimensions, and human universals to do the best we can for as many people as we can, thinking differently than we might think if we knew which specific person we would be working with. In multi-cultural screening situations, in other words, we focus on the features of human speech, language, cognition, communication, swallowing, and development that are known to be true for all people.
In pediatric multi-cultural screening situations, to begin with, we do not start from the specific phonemes, morphemes, or semantic items that would be our focus if we were building a specific bridge to a specific child. Instead, we use our knowledge of linguistic and communicative universals, and we focus on the known trajectories in typical development for all infants and children.
Spend some time with Box 18.3, which lists many universal, or almost universal, abilities and trajectories in children’s communicative and swallowing development that can serve as the basis for your multi-cultural screening procedures.
Box 18.3. Universal Abilities and Trajectories in the Typical Communicative and Swallowing Development of Children from Many Cultures Who are Developing Spoken Language, to Use as the Basis for Multi-Cultural Screening Procedures*
Infants babble using at least one speech-like consonant by age 3 months and with increasing complexity thereafter.
Infants engage in communicative joint attention by age 9 months and use an increasing number of communicative intents or functions thereafter (see Liszkowski et al., 2012; Moreno et al., 2021).
Infants understand social and caregiving words that are frequent in their lives by age 12 months (e.g., in English, “byebye” or “bedtime”; see Braginsky et al., 2016; Łuniewska et al., 2019).
Toddlers produce at least one recognizable word by age 12 months.
Toddlers combine at least two words by age 2 years.
Children have extended conversations that stay on topic, respond to the partner’s speech, and include primarily spontaneous self-generated content by age 3 years.
Children are largely intelligible to most listeners in their daily lives by age 4 years.
Children produce and combine most of the phonemes of their language(s) the way the adults in their lives produce and combine those phonemes by age 5 (see McLeod & Crowe, 2018).
Toddlers and children understand and use a continually increasing number of words, of multiple types (including nouns, verbs, grammatical function words, and adjectives).
Toddlers and children understand and use continually more complex sentence structures.
Infants spit up without apparent distress.
Infants and toddlers manage the foods and liquids that their family believe it is appropriate to introduce to young children, on the timetable that the family believes to be appropriate for young children, without coughing, gagging, or vomiting.
Children’s voices are closer to perceptually smooth and higher pitched than adult’s voices, not hoarse or breathy. Speech volume, prosody, and resonance should be characterized by variability (not monotony, consistent hypo- or hypernasality, or problematically quiet or loud voice as judged by adults who know the child in typical circumstances).
Young children in all cultures are typically disfluent, but frustration with speech on the part of the child or the parent may signal stuttering. (Trust yourself if you hear stuttering in any child’s speech; speech-language pathologists are known to be able to identify stuttering in languages they do not know.)
Children learn to tell stories that use their culture’s narrative traditions beginning by age 3 and with continually increasing complexity thereafter (see Gutierrez-Clellen & Quinn, 1993).
Children can learn novel linguistic forms, patterns, and structures after only minimal exposure (the basis for dynamic assessment).
Parental reports of concerns about a child’s speech, language, communication, feeding, or swallowing abilities are highly correlated with the presence of a disorder.
*Most of these abilities, or an appropriate variation of that idea for signed languages, are also true for children acquiring a signed language in a language-rich environment, such as with two adults who use American Sign Language with each other and with the child.
Do you see the influence and the importance of thinking about children’s language development by seeking universals, not by starting with a specific? Children’s first words, to take an obvious example, reflect the words they have heard. As we think multi-culturally or screen 12-month-old children, therefore, we do not start with a list that includes mama, daddy, and juice. These words are very specific examples, not universal human needs, and the issues are much broader than merely translating from language to language or allowing for a family’s synonyms. In a multi-cultural or multi-lingual screening situation, you would need all the translations, a non-solution that would achieve little more than burying you under piles of word lists. Translation to another language also does not solve the larger issue that some children have not enountered mothers, fathers, or juice. The universal is that all children, by about age 12 months, should be starting to use expressively some approximations of the words that they are exposed to in their daily lives — so we start there.
Remember, also, that bi-/multilingualism is normal and that people of all ages use and combine their languages in many ways, all of which are normal (Module 6). As we screen children’s communication abilities, therefore, we screen in and using and allowing for their combined or overall abilities in their language(s) and in the ways that they use their language(s) (i.e., we assume translanguaging, García et al., 2017). Most people hear or use more than one language, dialect, or mixture of languages or dialects, some more than others; this is a human universal, not a problem that requires us to use a special strategy (Seltzer & de los Ríos, 2021). At the screening level, there is no need to ask everything twice, much less to try to nail down a specific “percentage” of the time a child “uses” any particular language. You might need an interpreter, as a cross-linguistic adaptation, if the child or the family uses only languages you do not know, but the content of your questions, and the way you think about the answers, should be designed from the universal view that bi-/multilingualism is normal. (See Module 20 for more detail about interpreting the abilities of some bi-/multi-lingual children, but the overall message is that children learn the language(s) and the combinations of languages they are exposed to. Most of the points in Box 18.3 are even true for children who use well-supported AAC systems from a young age, but such a child probably will not appear at a general pre-intervention screening.)
Finally, before we move on, let’s also take a moment to highlight the last point in Box 18.3., one of the most well-established principles from research about all children’s language and social communication: Parental reports predict and correlate highly with the identification of disorders (for a range of different examples, see Ebert, 2017; Mahendra, 2012; Restrepo, 2008). The over-identification problems we have addressed elsewhere stem from professionals’ decisions, not from parents’ concerns or descriptions. When parents are concerned, they are usually correct. When parents have complaints about the processes by which their toddlers or young children were evaluated, the complaint is usually that professionals dismissed their concerns about their children in ways that delayed accurate diagnosis or necessary assistance (e.g., Mahendra, 2012).
Building on the universals from Box 18.3, therefore, including building on our trust of parents, our actions in multi-cultural screening for expressive and receptive language development, often in the form of speech development and the development of skills with spoken and then written language, might include any of the options summarized in Box 18.4.
Box 18.4 Options for Screening Activities in Multi-Cultural Pediatric Screening Situations
Screen for a few age-appropriate universals
Screen for ongoing development and improvement
Ask caregivers to describe, so you can interpret
Ask about the caregiver’s questions or concerns
Ask universally phrased questions
Consider the Intelligibility in Context Scale
Screen through play and conversations with the child
Screen using curriculum-based knowledge
One way to approach screening for a few age-appropriate universals (from the top of Box 18.4) might be to look for such universals as those provided in Box 18.3, or in materials such as ASHA’s “How Does Your Child Hear and Talk?” (ASHA specifies that its “How Does” materials are not intended as screening instruments, and the distinction is important. We do not use them as instruments or as checklists; we use them as sources of research-supported summary information to be applied and interpreted in thoughtful ways.) The universal need is to look for the few key speech, language, hearing, swallowing, and social communication behaviors that typically developing children of this age would have developed, or to look for the appropriate equivalent of those behaviors if variations such as using ASL characterize the child’s environment.
At the same time, we screen not only for behaviors but for development itself. Typically developing children are dynamic language learners who show noticeable improvement every few months. We can therefore screen for problems by seeking information from the child’s caregivers not only about the child’s current abilities but also about the trajectory of their abilities. We can also ask caregivers to describe the child’s overall communication behaviors, using general questions that might start as broadly as “Tell me about a recent conversation you had with your child” or “Tell me about what it would be like if your child was telling you about something that happened to her earlier in the day.” We can then use “Yes and” to ask follow-up questions that acknowledge the caregiver’s statements and seek the further information we need, in a positive or neutral frame: “Thanks, and how long would her stories about what happened at school usually be?” The distinction between description and interpretation is important, here: the caregiver is the expert on what their child does, and you are the expert on what that behavior might mean.
We do also ask, of course, about the questions or concerns that a caregiver might have about the child’s speech, expressive language, receptive language, and social communication abilities, using general terms such as “What would you like some help with, about your child’s talking?”, “What questions do you have about how your child understands language?”, or “What have you noticed about the way your child communicates or plays with other people?” Some families will not interpret or report many speech or language issues as “problems” or as “disorders,” so we avoid those words. (And we ask “What questions do you have” rather than “Do you have any questions” to invite questions and signal our willingness to answer them; “Do you have any questions” is often interpreted as the professional’s way of ending a conversation, with the patient expected to respond that no, they do not have any questions.)
Notice, again, that in multi-cultural screening situations we do not depend on specific words, morphemes, or syntactic structures from any particular language or dialect, and we do not depend on any forms or instruments that were developed with one set of cultural or linguistic expectations in mind, even if those forms have been translated. If you have access to a child’s caregivers, ask universally phrased questions that will allow you to gather information about the child’s overall abilities in expressive and receptive morphology, syntax, semantics, pragmatics, social communication, and pre- or early literacy regardless of, across, and combining all the languages or dialects the child uses.
Similarly, multi-cultural screening cannot attempt to screen for all children’s productions of all phonemes in all languages or dialects, but there is no need, at the screening level, to gather detailed information about specific phonemes. For children aged 2 years or older, as noted in Box 18.4, you might consider the Intelligibility in Context Scale (ICS, McLeod et al., 2012) in the caregiver’s best language (from the Intelligibility in Context Scale webpage at Charles Sturt University; http://www.csu.edu.au/research/multilingual-speech/ics ). The ICS is freely available in more than 60 languages or dialects and asks universal questions (e.g., Does the person completing the form understand the child?) using a simple 5-point scale. Substantial cross linguistic research supports general rules that children aged 2-3 years should be intelligible at least “sometimes” (rated at 3 on the ICS) for most listeners and that children aged 4 years or older should be intelligible “usually” (ratings of 4) to most listeners (McLeod & Crowe, 2018).
Are you starting to wish for a protocol or an easy list of questions to follow? And, of course, do you immediately recognize why there is no such thing, if we are genuinely seeking to be ready for any child from any background? I am not aware of any commercially available screening instrument that was truly designed to seek universally applicable information about all children’s expressive and receptive translanguaging abilities and speech-production abilities.
Despite the complexities, it is more than possible to develop a range of universally phrased questions that we can adapt and re-use in multi-cultural screening situations. Consider, among many others, some some of the examples provided in Box 18.5.
Box 18.5. Examples of Universally Phrased Questions about Children’s Abilities and Developmental Trajectories, to Use with Caregivers in Multi-Cultural Pediatric Screening Situations
How long are your child’s sentences when she talks? Is your child using longer and more complicated sentences than she did 6 months ago?
Does it seem easy for your child to talk, or does it seem difficult for her to say what she wants to say? Can you give me some examples?
If your child is talking about a specific topic, does she use specific words or does she seem to depend on a few general words like “thing” or “go”? Can you give me some examples?
What new words has your child learned in the last several months? (We are less interested in which specific words the child has learned and more attempting to establish that the child’s vocabulary is growing.)
Is your child more likely to talk about the same things repeatedly or more likely to talk about a lot of different things? Can you give me some examples?
We often change words or combine words in different ways to show that something happened in the past or is happening now [or to show that something belongs to someone, or to show when there is one or more than one of something]. Can you give me some examples of how your child uses variations of words or combinations of different words if something is happening now or in the past? [or if something belongs to someone, or if there is one or more than one of something?]
Does your child enjoy rhymes, dancing, or clapping along with songs? Can you give me some examples?
Does your child use books, either at home or at school? If so: What does your child like to do with books?
When you explain something new to your child, does she tend to understand your explanation? Can you give me some examples?
If you asked your child to do two [three, or more] things in order, would she tend to follow your directions correctly?
Does your child seem to talk and understand about the same way as other children her age? Can you give me some examples?
In addition to speaking with caregivers, we can also screen by interacting with the child or with the child and their caregiver together for a few minutes. One fairly universal approach might be to provide several toys, books, or materials; offer the child the opportunity to choose from among them; and then talk to the child about what they chose (if they chose), what they are doing, or what matters to them. Use what you see, hear, and learn from and about the child in child-directed play or conversations as the basis for marking any checklist you might be using, rather than using a pre-arranged checklist to direct your interactions with the child. Interpret the quality rather than the quantity of the child’s speech to you, and use information from the caregivers if the child’s conversations with you seem limited; you are a stranger to the child, and many children know better than to talk to strangers.
For school-aged children, our interactions can also be structured around information they have been addressing in their classrooms. Ask children what they have been doing with their teacher, what books they have been reading, or what last week’s lessons were about. Listen for words that would have been the specific vocabulary associated with that lesson; listen for the complexity of the child’s language as they explain. Curriculum-based screening is essentially a posttest-only dynamic assessment; if you have time to incorporate true dynamic assessment, building from curriculum-based knowledge again helps to provide appropriate expectations for all children (see Laurie & Pesco, 2023).
Finally, as you work with a child or with a family and begin to draw your interpretations, be sure also to listen to the child’s caregivers, and if siblings are in attendance listen to them as well. Children who sound like the other speakers in their lives are probably developing speech and language in ways that are typical for their culture or community. Notice, here, again, that children who have been exposed to more than one language or more than one dialect routinely switch between their languages/dialects and combine their languages/dialects in many ways and for many reasons. With bi-/multilingual or bi-/multi-dialectal children and families in particular, therefore, we phrase all our questions in ways that include all the child’s abilities (i.e., assuming and validating translanguaging, or seeking to understand all the child’s abilities with language and languages; García et al., 2017). Using or mixing more than one language or more than one dialect is normal, typical, and almost unremarkable for many people. Bilingualism and multilingualism are normal, as is knowing different things to different degrees. Using more than one language does not cause or contribute to speech or language disorders, and clients who use more than one language or more than one dialect are not a “problem” that requires us to learn or to use any special strategies in screening (Seltzer & de los Ríos, 2021; and see our Section Four). Ask your universal questions, and recognize and respect the answers each child and each family give you; don’t start your relationship with this family by trying to limit the child’s abilities to any one of their many dialects or languages.
Overall, in multi-cultural pediatric screening situations, we presume competence, or assume that most children from all cultural backgrounds are probably developing typically for their culture. At the same time, we design our screenings such that they can identify potential concerns or problems in ways that will be as universally applicable as posible. Thus, we seek information about the child’s abilities and about their developmental trajectory; we assume that the child’s communication behaviors are appropriate for their background unless the child is not meeting applicable universal developmental markers or is not demonstrating continued growth; and we seek and believe any concerns raised by the adults who know the child.
If screening in this way does identify any cause for concern, we then move to cross-cultural assessment procedures designed specifically for that child. If screening in this way does not identify any cause for concern, we check that conclusion with the family (“From what I can tell, her speech and language seem to be developing just fine. How does that conclusion fit with what you see at home?”) and probably decide that the child is developing typically in ways that fit their community, culture, language, background, and experiences — regardless of how similar or dissimilar our own might be.
Your Turn
Imagine you have been invited to provide in-person screenings for children who are all in the same small age range (e.g., toddlers aged 18-24 months, or children in the third grade). What are a few key universal expectations as to communication abilities and trajectories for all children of that age? Develop a few questions you would ask the adults who brought the child, and develop one or two activities or questions you would use with the children.
Think further about the multi-cultural screening procedure you just created. Would your procedure work with families and children in all of the following settings, assuming the presence of appropriate interpreters to bridge any language needs?
in a coastal fishing community in Maine that includes immigrants from other fishing communities around the world
in a multi-lingual desert community in the southwest that includes people from Mexican, Anglo-American, and several Native American backgrounds
in an agricultural community in rural Indiana and with the families of African American financial and real-estate professionals in downtown Atlanta
for children who use prosthetic hands/arms or who are blind
If something about the screening procedure you designed might not be appropriate for any one or more of these communities, what would need to change to make your procedures more universally applicable? (The task here is not to develop separate screening procedures for each of the listed situations; the task is to develop one universally-oriented multi-cultural screening procedure that you could use in all of these settings and with all of these families.)
Screening for Universal Abilities and Trajectories with Adults
Multi-cultural screenings for older adolescents and adults differ from screenings for children in that the pace of developmental improvements has changed, making a trajectory of improvement less of a focus. In addition, some level of self-screening may have occurred before you meet an adult in a multi-cultural screening situation (i.e., adults may choose to attend community screenings because they have concerns or because a family member has concerns about them). Regardless of these differences, multi-cultural screenings for adolescents and adults remain similar to screenings for children in that we focus on universal abilities and expected trajectories. Multi-cultural screening with adults, as with children, again must assume that people use multiple and mixed languages and dialects (see Section Two). We do not screen by asking about abilities in any single language or dialect or based on assumptions from any single language or dialect, and we do not ask people to divide languages that they tend to mix in fluid ways.
Multi-cultural screening for adults might use similar questions to those used for children, therefore, but potentially in a different order or with different emphases, as summarized in Box 18.6.
Box 18.6 Options for Screening Activities in Multi-Cultural Screening Situations with Adolescents, Adults, and Older Adults
Ask about the adult’s concerns, and ask about other family members’ or friends’ concerns
Ask about change
Ask about expressive and receptive abilities for relevant language modalities
Ask universal versions of questions intended to address longterm memory or executive function
Watch for unnecessary repetitions, vagueness, or mismatches between answers and actions
Ask about hearing, vision, and dentition
Be aware of cultural expectations as to people’s roles and responsibilities
With an adult, we may begin with a version of “Tell me why you are here” or “What can I help you with?” or “What have you noticed about your talking, listening, and understanding?” We may also ask an accompanying person a similar question, or we ask “What have your friends or family members mentioned to you recently about your talking, your voice, or your understanding?” If difficulties are large or obvious, this question might be all you need, and the stage of multi-cultural screening will be completed quickly. Move to planning and completing an individualized cross-cultural or cross-linguistic assessment to investigate the client’s or patient’s needs, if it is obvious that they need further help.
If your screening conversation with an adult needs to continue, your next question might be to ask what has changed about their talking or their understanding. The expected speech and language trajectory for adults in all cultures is essentially flat (i.e., adults should be continuing to use their mature speech and language skills, possibly acquiring occasional new vocabulary items), but cultures interpret changes in older adults’ abilities in different ways. Questions that focus on interpretations (such as “Are you having any difficulties with your speech?” or “Are you having any problems understanding other people?”) might be answered in the negative, even when potentially relevant changes have occurred, if the family or the culture assumes that older people will show changes in their communication abilities and therefore do not interpret those changes as “problems.” More useful, more universal questions are descriptive, rather than judgmental, such as, “Has anything changed about your talking recently?”; “Has your ability to explain what you want to say changed recently?”; “Has your voice changed recently?”; “Has your ability to understand other people changed recently?” If “recently” leads to unclear responses, decide on a timeframe with the adult or with any family members who are present (“in the last year,” “since you retired,” or “as compared with when you were younger” might all be relevant). Use similar questions to ask about changes in swallowing, memory, and executive function or verbal problem-solving. As with asking about concerns, if recent or unexplained changes are obvious, then your multi-cultural screening with this person is finished; move quickly to plan and conduct a complete client-centered cross-cultural or cross-linguistic assessment.
For many adults, we seek information about their abilities or concerns with expressive speech, auditory comprehension, expressive writing, and reading comprehension, but multi-cultural screening does not assume any language modalities. Be prepared for adults who use or who do not use sign language, combinations of informal signs developed within the family, written communication, and/or AAC devices. In addition, educational and vocational history are important, especially for older adults who might not have had educational opportunities or work opportunities outside the home. Watch for signs that an adult is allowing another person to manage any paperwork before asking about reading or writing, and ask about changes in cognitive or problem-solving abilities without assuming any specific cognitive abilities. “Does your daily life involve reading or writing?” can be a universally appropriate question, and “Have you noticed any changes in your ability to read?” can be an appropriate follow-up after people have told you that reading is relevant to their lives.
Similarly, we ask universal versions of questions intended to address longterm memory or executive function. Avoid screening instruments that depend on the names of American presidents or other specific knowledge. Try “What was popular when you were growing up?”, “How do you get help at home when you need it?”, or “Tell me anything you have learned recently from a person, from TV, or from somewhere else.” Consider two follow-up questions: one to probe for a detail, and one to determine whether the adult can connect this topic to new information (if it was a longterm memory) or relate it to a longterm memory (if the client presented it as something new).
With adults, we also need to watch for unnecessary repetitions, vagueness, and mismatches between answers and actions, any of which can be universal signs of potential cognitive decline. Think also about universal contributors to communication and swallowing abilities, including hearing, vision, and dental health; again, we ask neutral, fact-based questions or questions about abilities and changes, rather than asking if there are “problems.” If relevant, you can provide neutral information about how these issues can affect our speech and language, or you can offer pure-tone hearing screening as a routine part of your speech-language screening. For people who have glasses, hearing aids, removable dentures, or other assistive devices, ask how they manage cleaning the pieces, purchasing and replacing batteries, and other physical needs, and ask if there has been any change in these abilities. Be prepared for all possible assumptions around the necessity or use of such physical devices and all possible beliefs about who is responsible for caring for such devices.
Finally, and especially with older adults, multi-cultural screening situations require us to remain aware of the wide range of cultural expectations as to people’s roles and responsibilities. Expectations as to gender roles, individual needs versus collectivism, and the importance of individual restraint, in particular, interact with cultural assumptions about aging and communication in complex ways (see Module 2). Some older adults will assume that their role is to be “for” the larger family’s or the younger generation’s needs, rather than asserting their own individual needs; some adults will assume that their role is to assert their own needs or to actively seek assistance for another family member on that person’s behalf. Our role is to recognize and respect other people’s views of their roles in their own lives. The question in a multi-cultural screening situation is whether the adult or the family is seeking assistance with an issue they perceive as creating a need, or whether we believe the adult in question would benefit in their own environment from further individualized assessment, not whether we agree with anyone’s views of their roles and responsibilities in their own lives.
Your Turn
Think about the same communities we addressed for pediatric screening:
a coastal fishing community in Maine that includes immigrants from other fishing communities around the world
a multi-lingual desert community in the southwest that includes people from Mexican, Anglo-American, and several Native American backgrounds
an agricultural community in rural Indiana and the families of African American financial and real-estate professionals in downtown Atlanta
adults who use prosthetic hands/arms or who are blind
Develop a single, brief screening interview that you could use with all adults aged 80 years or older in all of these communities.
Multi-Cultural Assessment and Intervention
I hope the notions of “multi-cultural assessment” and “multi-cultural intervention” sound a little strange to you now, in the context of this module.
They should!
Assessment and treatment differ from screening in many ways, including fundamentally that screening requires us to be ready for anything and everything, whereas assessment and treatment are designed to meet the needs of one known individual or a small group of known individuals. Thus, assessment and treatment tend to be cross-cultural situations, not multi-cultural situations, as we have defined these terms.
Occasionally, however, we do conduct assessment or treatment sessions that combine clients or family members from a range of different backgrounds. We also occasionally find ourselves realizing, in the middle of an assessment or treatment session, that our preparation was misguided or inadequate, or that our bridge-building preparations are not a good fit for this person in this place after all.
Let’s touch briefly on three (almost!) universal approaches that, like our most basic “Yes and” strategy, can help in a wide range of multi-cultural or cross-cultural assessment and treatment situations.
Ethnographic Interviewing to Understand Individuals’ Experiences, Abilities, and Concerns
Ethnography refers, generally but certainly not simply, to a set of intertwined methods from cultural anthropology that seek to understand groups of people from and within their lived experiences and points of view (see Howell, 2018). Anthropologists engaging in ethnographic inquiry depend on multiple methods, for multiple reasons, traditionally including “participant-observation” or working as a “participant observer.” These terms refer to the ethnographer, who may be embedded within a group (as a participant) while also attempting to observe, record, and analyze that group’s behaviors and beliefs (as a researcher).
As adapted for health research and then for healthcare practice, “ethnographic interviewing” has come to refer to conversations that do not include participant-observation (see Dowdy, 2000) but that do retain the ethnographer’s desire to understand people’s experiences and interpretations of their own lives. Many discussions of ethnographic interviewing place it in larger contexts such as qualitative research methods or focus on the “dispositions” that “underpin” ethnographic interviewing for health-related topics: “humility, a readiness to revise core assumptions…, attentiveness to context, relationality, [and] openness to complexity” (Trundle et al., 2024), among others.
In early childhood education and speech-language pathology, ethnographic interviewing procedures have also been described using a streamlined set of relatively specific principles and question types that can be taught, learned (see Brown, 2017; Brown & Woods, 2011), and adapted to many clinical situations. Box 18.7 provides a few selected examples.
Box 18.7. Selected Basic Principles and Questions for Ethnographic Interviewing (see Brown, 2017; Westby, 1990; Westby et al., 2003), to Use in Multi-Cultural Screening or Assessment Focused on Communicative Universals
Start by stating your (broadly defined) interest in the family’s experiences.
“I would like to understand what it’s like when you and your child are talking.”
Ask open-ended questions, including especially “Tell me about.”
“Tell me about what it’s like at home with your child.”
“Tell me about a conversation you had with your child this morning.”
Repeat the other person’s words; repeat “tell me about”; and ask for examples.
“You said he is hard to understand. Tell me about a time when he is hard to understand.”
“You said he throws tantrums. Tell me about a tantrum he threw recently.”
Seek existing solutions.
“You said he is hard to understand. Tell me about what your family members do when he is hard to understand.”
“You said he throws tantrums. Tell me about what you and your wife do when he throws a tantrum.”
Avoid anything that might be interpreted as judgmental or that will generate your views instead of the family’s views. Avoid asking why, avoid leading questions, avoid interpreting, and avoid explaining.
Instead of “Why do you think he won’t answer you?”, try “You said he won’t answer you. Tell me more about a time when he did not answer you. What does he do?”
Instead of “It sounds as if he has a hard time expressing his basic needs,” try “You said getting out the door in the morning is almost impossible. Tell me about some examples of what makes it impossible.”
Explanations of ethnographic interviewing also depend on some specific terminology, such as refering to some questions as “grand tour” questions (e.g., “Tell me about a typical day”), “mini tour” questions (e.g., “Tell me about your job”), and “specific mini-tour” questions ( e.g., “Tell me about your talking and understanding in your committee meeting at work yesterday”), among others. Regardless of such details, the emphasis is always on the interviewer’s attempt to stand back and let the client or the family describe their experiences from their point of view. The principle is similar to the note in Box 18.4 that we ask caregivers (or clients) to describe, so we can work to understand their experiences or interpret what their experiences might mean when combined with our professional expertise (see Module 13).
Westby et al.’s (2003) summary of ethnographic interviewing is almost perfect, as an accessible description with more explanations, “how to” information, and examples. You might enjoy reading it, and we will return to it as we discuss cross-cultural assessment in Module 19.
Dynamic Assessment and Related Strategies to Understand Individuals’ Abilities and Needs as Learners
The label “dynamic assessment” refers to strategies that seek to assess not only what a person currently knows but also how that person responds to or can use feedback or new examples. It is related generally to Vygotsky’s classic models of learning, including his notion of a “zone of proximal development,” and it has been used for decades in everything from mathematics to counseling to vocational training.
If you happen to be unfamiliar with Vygotsky, imagine three points along a continuum: information or skills that you have mastered, information or skills that you can not manage on your own yet but can achieve with assistance, and information or skills that are simply beyond your current abilities. The part in the middle, the things you can’t do on your own but are ready to learn, is your ZPD.
As a general strategy, dynamic assessment combines assessment and intervention, or evaluation and teaching. It is similar to what we might call stimulability testing (such as in articulation), and it shares features with scaffolded instruction and even with errorless learning approaches. The link in all these examples is that we start where clients are, start with what they can do, give them some support, observe what happens, and then decide what they need next. The mindset is not “testing,” as in comparing a client’s knowledge and abilities to a predetermined standard or norm; the mindset requires our client-centered efforts to recognize, respect, and respond appropriately to what clients bring and to what they may or may not need in their world, precisely as most of this website has emphasized.
One typical strategy for dynamic assessment, as shown in Box 18.8, tends to be summarized as “test-teach-retest.”
Box 18.8 Dynamic Assessment Stages and Roles, with Examples from Articulation and Tennis
Test: Teacher presents an activity; learner attempts the activity
> articulation example: child names 10 picture cards
> tennis example: player serves 10 balls
Teach: Teacher provides assistance, learner attempts to change
> articulation example: child names each picture card again, several times, after the teacher’s model or given feedback about their productions
> tennis example: coach explains what player has been doing and gives a suggestion for a change; player tries 10 serves the new way, with feedback after each attempt
Re-Test: Teacher presents an activity; learner attempts the activity
> articulation example: child names 10 picture cards
> tennis example: player serves 10 balls
Notice that “test” and “retest” refer to having the client do something briefly, not to giving a long or formal test. “Observe” or “Try” would be better words, depending on whether we are assuming the professional’s perspective or the client’s.
Notice also that middle part, “Teach,” can include almost any type or style of teaching. Depending on the learners’ abilities, the teacher might explain, model, praise, correct, expand on, refelct, or make additional specific suggestions to the learner throughout the Teach phase. Many descriptions of dynamic assessment also start with a specific sequence of explanations about the new activity, drawing the learner’s attention to why the change matters and when they might use it in their real-life setting. The Teach phase typically includes only a few minutes of explanations and examples, but variations on dynamic assessment can expand the timeframe, eventually approaching what the schools call Response to Intervention programs.
The beauty of dynamic assessment, in other words, is that it can be quick, client-centered, focused on ability, and focused on potential for growth. Instead of asking closed-ended or even clinician-centered questions (“Do you know this static fact I thought of ahead of time?”; “Do you have this specific skill that a test developer decided ahead of time to ask you about?”), dynamic assessment asks “What happens when you are exposed to new information or given a bit of assistance?”
Given that intervention or specialized teaching is more likely to be necessary for people who do not learn easily from quick exposures to new things, the logic behind dynamic assessment is that clients who do learn from a few minutes of test-teach-retest probably do not need intervention, if that decision makes sense given everything else we know about them, their experiences, and their abilities.
Dynamic assessment has been recommended for assessment in speech-language pathology for well over 20 years (Gillam & Peña, 2004; Gutiérrez-Clellen & Peña, 2001; Austin, 2010; see also Peña’s four-part recorded training), often in the context of child language assessment and usually in the context of what some authors might call “culturally and linguistically diverse” clients. It is often described as a secondary or “informal” method to be used after standardized testing.
From a client-centered, culturally- and individually-focused point of view, however, I do not think it is overstating the case to suggest that variations on dynamic assessment could be our major and primary approach to assessing almost any behavior or ability that we are considering labeling “in need of change.”
We have been repeating for decades that our standardized tests were not developed for or normed on a wide enough range of test takers, making any attempt to compare most clients’ scores to those tests almost uninterpretable. The combination of ethnographic interviewing and dynamic assessment, however, can be used to help us understand the experiences, abilities, and needs of almost anyone — of “all populations,” as ASHA (2017) requires us to do.
Your Turn
Imagine using ethnographic interviewing followed by dynamic assessment as your only two evaluation procedures with clients of several ages and with several kinds of abilities. The combination would allow you to determine what the client is experiencing and then determine whether the client has the ability to benefit from brief examples or feedback. Would you miss your standardized tests? Why or why not?
Critique the underlying logic of using dynamic assessment to help make intervention decisions. If a client cannot do something on her own, but can do it with your help, is that a reason to provide her with some intervention or a reason not to provide her with some intervention? Does the selected task itself change your answer?