Cultural Considerations for Pediatric Intervention

ASHA identifies the knowledge needed by SLPs to provide culturally and linguistically appropriate services. The official statement about providing services to individuals who speak a language in which the clinician is not proficient applies to clinicians without native or near-native proficiency in the language(s)/dialect(s) spoken or signed by the client/patient. The SLP must have knowledge and skills related to:

• Obtaining information on the features and developmental characteristics of the language(s)/dialect(s) spoken or signed by the client/patient.

• Obtaining information on the sociolinguistic features of the client’s/patient’s significant cultural and linguistic influences.

• Developing appropriate collaborative relationships with translators/interpreters (professional or from the community):

  1. Maintain appropriate relationships among the clinician, the client/patient, and the interpreter/translator.

  2. Ensure that the interpreter/translator has knowledge and skills in the following areas:

  3. Native proficiency in the client’s/patient’s language(s)/dialect(s) and the ability to provide accurate interpretation/translations.

  4. Familiarity with and positive regard for the client’s/patient’s particular culture and speech community or communicative environment.

  5. Interview techniques, including ethnographic interviewing.

  6. Professional ethics and client/patient confidentiality.

  7. Professional terminology.

  8. Basic principles of assessment and intervention principles to provide context to understand objectives. (ASHA, 2004)

Cultural Bias in Parent Training

Van Kleeck (1994) published a tutorial that summarizes key studies and discusses cultural variations in parent-child interaction patterns and what this may mean regarding parent training as an intervention procedure. Some highlights from her work are summarized below; please refer to her work for more in-depth descriptions.

A common practice when focusing on intervention with children is to target the parent-child interaction. Within these intervention programs, parents are taught strategies for interacting with their child and are often encouraged to follow the child’s lead, respond quickly to the child’s attempts to communicate, provide clear and straightforward language models, and promote turn-taking. The goal is usually to get children to communicate as often as possible. These suggestions for interacting are based on linguistic research derived from the dominant American middle-class culture. So while they are research-proven methods of positively influencing language in children, the researched population is somewhat limited in scope. All cultures do not share the values and beliefs reflected in some parent training programs (Kleeck, 2013).

Cultural Considerations

The author Anne Van Kleeck stated 

• Some assumptions parent training programs make about typical parent-child interactions: 

  1. Parents are the child’s primary caregivers.

  2. The family values children talking a lot.

  3. Children should initiate conversation.

  4. Children should direct conversations rather than adults.

  5. Adults should accommodate children.

• In many cultures, siblings perform the role of the primary caregiver; typical caregiving arrangements differ across cultures.

• Many cultures value quietness in children as opposed to American culture valuing highly verbal children. How cultures view the amount of talk expected from children may vary from culture to culture.

• Other cultures may not encourage or allow children to direct conversational topics; instead, it is the adult’s responsibility to direct and the child’s role to obey.

• In American mainstream culture (and in school settings), it is common for adults to ask children questions to which the adults already know the answer; in other cultural groups, such requests for a verbal display of knowledge are not made. (Kleeck, 2013)

• Cultures vary on what is considered intentional language and when children begin using intentional language.

• The degree of “child-directed talk” or “motherese” can vary considerably across cultures. It is not universal to use this type of intonation when speaking with small children. (Kleeck, 1994)

Creating A Better Fit With Families

It must be considered that a parent-training program may not match the parent-child interaction patterns of all cultural groups. It may be beneficial for the SLP to modify parent-training programs to fit the family’s interaction patterns better and allow strategies to evolve into how they best benefit the family (Kleeck, 1994).

Strategies for learning about a family’s communication patterns

• Interview to understand the family’s social organization: Who interacts with the child? How? In what contexts?

• Ask open-ended questions that require descriptions of the child’s language or how the child interacts within the family.

• Use observation: note the value of talk, status within the family, beliefs about intentionality, and successful interactive strategies already in place.

• Be aware of cultural bias.

• Listen carefully to each family. (Kleeck, 1994)

Approach to Intervention

A successful approach to speech-language intervention should consider the cultural and linguistic diversity of the family within the treatment process. It is essential to be aware of cultural biases that may stem from a monolingual mindset. For many individuals in mainstream culture, bilingualism may seem abstract and complicated. However, to individuals who are part of bilingual/multilingual communities, the process of learning more than one language is familiar and very natural. Recognizing that there are many perspectives on language acquisition will allow professionals to be increasingly competent in dealing with a wide variety of situations.

Three perspectives on bilingual language acquisition

• Unitary System: children begin with a single linguistic system that separates into two separate systems over time.

• Dual System: children obtain and maintain separate language systems from the beginning of language acquisition.

• Interactional Model. (Goldstein & Fabiano, 2007)

The Interactional Dual Systems Model

This model recognizes two separate linguistic systems that influence and interact while maintaining specific language components. Bilinguals utilize the resources from both of their languages in order to efficiently organize and produce language (Goldstein & Fabiano, 2007). 

• Bilingual Approach: Treats errors that occur in both languages. Stems from the framework that intervention toward changing patterns in one language may affect linguistic/phonological patterns in the second language. Choose goals for treatment that are found in both languages. In this way, it is not one language being treated but the characteristics of both languages. This is an excellent place to begin the intervention process.

• Cross-Linguistic Approach: Treats each language separately but equally in the intervention process. Recognizes and addresses differences in the linguistic structures/patterns of the two languages. It may be most helpful in combination with the bilingual approach. After treating sounds or components found in both languages, it may be necessary to treat specific areas found in one of the languages but not the other. (Goldstein & Fabiano, 2007)

Goal of Intervention

Overall, the goal of intervention with multilingual individuals is to support the development of all languages that he/she speaks. Studies have shown that increasing abilities in the first language can also benefit second language acquisition. In addition, removing one language will not cure or improve the underlying language difficulties. Specific language instruction in the native language (L1) facilitates second language acquisition (L2). A study conducted on the Phonological Awareness and Vocabulary Enhancement (PAVE) Preliteracy program obtained results indicating that bilingual intervention of pre-literacy skills (Spanish-English) significantly increased both the Spanish and English alphabet knowledge and vocabulary and improved areas of expressive language measured by MLU (Kiernan & Swisher, 1990).

Biliteracy instruction of literacy skills and metalinguistic concepts may help make the transfer of literacy skills to English easier by supporting the first language and preventing language loss. Traditional fundamental strategies that are used for monolingual children can be applied to bilingual children as well. Treatment should be relevant to the child’s natural setting. Materials should be meaningful, and activities will be most beneficial when they are motivating for the child. However, it is also important to consider cultural differences when selecting content and materials to incorporate into treatment (Lindsey, Manis & Bailey, 2003).

In order to ensure that the treatment is meaningful and relevant to the child’s life, it is necessary to support the child’s environmental needs. Treatment should support all areas of language, including but not limited to the home, school, and community environment. Restricting support to a single language will limit the child’s opportunities to participate in all areas of his/her environment. The child’s social, emotional, and cognitive development is facilitated by communicating the home culture and linguistic context. Language is the primary tool to communicate the values of the family system. Failure to support the home language can result in a loss of cultural identity and may limit the child’s participation level in many areas. Support of the home language may also help facilitate academic achievement and cognitive development, which can influence self-esteem and social-emotional development. Facilitating, rather than simply encouraging the first language, is necessary for promoting further language development for the child (Kohnert et al., 2005).

According to Kohnert et al. (2005), families should be included in the treatment process and trained by the clinician to provide therapy services to their child throughout the language intervention process. This can be a helpful strategy, especially when the clinician is not fluent in the child’s home language. Parent and family training programs are supported by federal mandates that support partnership and cooperation between professionals and families (Public Law 99-457). Successful parent training strategies should include techniques to facilitate expressive language (expansion, modeling, and parallel talk) as well as instructional techniques from the clinician to provide feedback to the family in a systematic way (e.g., demonstration, videotaping). This dynamic method of intervention allows the family and clinician to work together and be flexible in the treatment process of implementing an individualized plan tailored to the individual needs of the client and his/her family (Kohnert et al., 2005).

Client/Family Background

Multilingual individuals come from a variety of different backgrounds and contexts. Getting to know the client and the client’s family is vital to provide and implement the most appropriate and specific intervention plan. Many of these factors will be determined during the assessment process. Cultural factors include a wide variety of components that can impact the linguistic diversity of the client. These factors should be considered when creating an individualized treatment plan. These factors may include socioeconomic level, religious beliefs, and sexual orientation (Aoyama et al., 2005; 6). However, information will constantly be obtained throughout the treatment process. Children have many different strengths, weaknesses, and abilities that will change and evolve. The treatment process should be dynamic and flexible to accommodate changes in the child and the child’s environment. According to McLeod, et al. (2017), professionals working with the individual must take into account the following factors:

Family Considerations

What is the culture of the family system, and what are the roles of family members? Who is included in the family dynamic, and how does each member interact with others? What are the family’s goals for treatment?

Language history

How long has the child been bilingual? At what age did he/she become bilingual?

Language Use/Proficiency

Professionals must know the extent to which the child uses each language and in what settings and contexts they are often used most successfully.

Environment

What language does the child speak in various contexts and environments? Who does the child communicate with regularly?

Home Language

• Phonological skills/representation

  1. Phonemes that are similar/different between the two languages

  2. Errors/error patterns

     • Found in each of the two languages

     • Frequency of occurrence

• Syntax/Morphology

  1. Meaningful vocabulary

  2. Grammatical rules 

     • Similarities/differences

(McLeod et al., 2017) 

Intervention Strategies

Phonological

There is limited information available regarding the acquisition of phonology in languages other than English and assessment and treatment techniques for children who speak more than one language. Typically, intervention techniques designed for English-speaking monolingual children with speech sound disorders are used for bilingual children with speech sound disorders. However, there is little data to support that these intervention techniques are effective for bilingual speakers.

Yavas and Goldstein (1998) compiled available research and provided an outline for valid and reliable ways to treat speech sound disorders in bilingual speakers. Their recommendations are as follows.

Intervention Approach

Choose an intervention approach.

This is determined according to each child’s unique phonological profile and will depend on several factors, including age, language status, length of exposure to L1 and L2, and dialect. The intervention approach may need to be modified according to these factors as well (Yavas & Goldstein, 1998).

Targets

Choose specific targets

The following suggested procedures should be followed in order.

1. Initially target phonological patterns that have similar error rates in L1 and L2. These are likely the patterns used to diagnose the phonological disorder. Further, these patterns probably significantly affect intelligibility in both languages. Treatment targeting these patterns should occur in both languages. In selecting targets, please consider:

   • Syllable structure and word structure patterns in the languages. For example, Hmong word patterns contain 56 initial consonants and one final consonant; therefore, treating word-initial consonants would be a better initial choice than word-final.

   • Targets not to treat. For example, Vietnamese contains few word-final consonants; therefore, choosing final consonant deletion would not likely be a pattern that affects intelligibility in both languages.

2. Target phonological patterns that present with unequal frequency in L1 and L2. These patterns may affect indelibility in one language considerably more than the other. However, if they occur in both languages, then intervention should occur in both languages.

3. Finally, target phonological patterns that are present in only one language. It is likely that patterns occur and exist in only one language. Treatment, in this case, should occur in one language. (Yavas & Goldstein, 1998)

The American Speech and Hearing Association (ASHA) provides phonemic inventory information for some languages here. Additional languages can be found on the MultiCSD language page.

Vocabulary

Perozzi and Sanchez (1992) found that Spanish-English bilingual children with language delays learned new English (L2) vocabulary more rapidly when it was initially presented in Spanish (L2). This supports the idea that new vocabulary is more easily learned when first presented in a familiar context in a more robust language system.

Thordardottir (2006) suggests that when targeting vocabulary and language skills, ask the child to translate words from L1 to L2. Encourage parents to read with their children and participate in language-facilitating activities (playing games, dramatic play) in the home language. Be aware of cultural appropriateness when suggesting activities.

In intervention, promote and accept, not limit, the natural ways bilingual speakers use language; this includes characteristics such as code-switching.

Treatment Ideas

For vocabulary

• When supporting L1, choose stimuli relevant to L1 culture (for example, meaningful pictures)

• Real objects used in a natural context

• For English sessions: 

  1. Collaborate with the classroom teacher to determine vocabulary that will be used in future lessons and focus on those items.

  2. Send the vocabulary items home for translation. Suggest that the child use any resources available for this task: parents, siblings, dictionaries, internet.

  3. Create journals of targeted vocabulary written in English and with translations.

  4. Create an audio-vocabulary journal: have the child audio-record target words and their definitions in English, then have the child get parents or other bilingual speakers to record the translation and definition of the target words. (Thordardottir, 2010)

For Syntax

• Language use should be facilitated within activities that are relevant to the client’s natural context.

• Work with the child to identify grammar and morphology components that are shared between the L1 and L2.

• Address deficits that are common across the languages using the Bilingual Intervention Model.

• Using the Cross-Linguistic approach, separately but equally address components of the syntax not shared between the two languages of treatment. (Thordardottir, 2010)

Literacy

Gutierrez-Clellen (1999) suggested intervention strategies to develop the reading and spelling skills of Spanish-speaking children with language difficulties. However, the general strategies suggested could be used in intervention with children who speak other languages. Some of her suggestions are below.

As with monolingual children, bilingual children may have different experiences with literacy instruction before entering the school system. Intervention needs to focus on addressing typical differences in language experiences that may affect children’s acquisition of literacy and incorporate intervention strategies to focus on the needs of L2 learners with language disabilities. The same general intervention strategies for literacy used with monolinguals can be used with bilingual children: cooperative learning and reciprocal teaching. Additionally, these approaches group children with differing language levels so bilingual children can model English for less proficient peers.

Culturally diverse students may be unfamiliar with the standard writing formats used in American schools (poems, reports, narratives, news stories). In this case, appropriate models and instruction about the purpose of writing should be given.

Reading and spelling are interrelated processes. It is suggested that the two skills be targeted together in therapy. Further, even if a child seems to have adequate skills in retrieving phonology when speaking in English, they may not have adequate ability to retrieve phonology when reading or spelling (Gutierrez-Clellen, 1999).   

Spelling strategies

• Find a way to integrate teaching spelling with meaningful reading and literacy interventions.

• Create lists of words similar to ones children misspell in writing activities, then teach spelling regularities and rules. (Gutierrez-Clellen, 1999) 

Word decoding strategies

As with monolingual students, problems with decoding words will lead to problems with reading comprehension. Poor reading comprehension and limited access to English literature further compound low English proficiency and vocabulary knowledge. For these reasons, it is crucial not to treat word decoding in isolation but to use expressive language-rich activities.

• Explicitly teach the similarities between the phonological and orthographic systems of the two languages.

• Teach strategies that are thought to be useful for successful L2 learners: use contextual cues, use prior knowledge, identify cognates (associated or related words), and translate parts of the text into the native language to clarify meaning.

• Older children explicitly teach similarities between the morphology of the two languages. (Gutierrez-Clellen, 1999)

Cross-Language Transfer

Cross-language or linguistic transfer refers to the generalization of newly acquired skills across languages and settings.

Interventions in one language cannot be expected to result in transfer or gains in the other language(s) for all features in all areas. Transfer can be affected by several factors, including:

• The components of language targeted (phonology or grammar)

• The mode being targeted (expressive or receptive)

• The degree of similarity between targets across languages (are phonological processes similar, do similar morphological rules apply)

• The severity of the individual’s disorder

• The intervention used

A transfer will also likely be affected by the similarity between the languages. It may more easily happen between languages that are more typologically (letter symbols) and phonemically similar. For example, for individuals who speak Spanish as L1, phonemes present in L1 and English L2 may be good targets for promoting transfer. (McLeod et al., 2017) 

Intervention Delivery Models

Bilingual Support Model

The monolingual clinician provides therapy services with the help of a bilingual assistant in providing services.

Coordinated Service Model

Monolingual and bilingual clinicians work together to provide services.

(Yavas & Goldstein, 1998) 

Training Parents, Paraprofessionals, and cultural Community Partners.

Family Training Programs 

• Parents can be used to support the home language by incorporating techniques into the family's natural interactions.

  1. A program must be modified or created to fit the specific needs of the family in order to be successful, especially for linguistically/culturally diverse families.

  2. Siblings/Peers may be used to engage young children and may be used as models for interaction.

• Paraprofessionals may be used to facilitate communication between the clinician and family/caregivers.

  1. Community partners/cultural brokers

  2. Interpreters

  3. Teachers/counselors. (Kohnert et al., 2005)

Integrated Bilingual Model

The bilingual clinician provides all intervention services (Kohnert et al., 2005).

Updated May 2023