How Not to Be a “Karen” SLP – Part 2

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Ok ~ we’ve acknowledged we have a Karen problem in speech-language pathology.

There are efforts underway by colleges and universities to attract more people of color into the field. These efforts include, but must not be limited to, eliminating the GRE requirement for grad school admission. Eliminating the GRE is good for a couple of reasons. First, it’s really a measure of your mainstream culture life experience. Secondly, it’s incredibly expensive – around $200 to take it, plus the fees to send your scores to additional schools if your first choice schools say no thanks. Many programs also are beginning to place more emphasis on the personal statement and letters of recommendation rather than only the student’s transcript. Reducing these barriers will definitely help more people of color attend graduate programs in Communication Sciences and Disorders. But, they are long-term fixes.

We need to talk about what SLPs who are practicing now can do right now to be more inclusive of their clients from culturally and linguistically diverse (CLD backgrounds).

Let’s focus on Early Intervention (EI) in this post.

I want to begin by stating that I think EI is important to support very young children and their families. But, if you actually sit down and talk to families of color who received EI, you hear the same criticisms. “They wanted me to ‘baby talk’ my child”, “They just told me to read and talk more”, “They wanted me to let him color with markers”, “I wanted them to help her talk. They told me to work on following directions”, “They only saw her once a month. It wasn’t enough”, and “Everything was in English. We don’t speak English at home.”

First, SLPs, you must recognize that there is a huge power imbalance between the families of young children and you. You hold almost all of the power in this relationship. You may not realize it, but the families you work with do. Just opening the door to you shifts the balance of power to you, as the clinician and mandated reporter. They know you have the power to call social services if you don’t like what you see in their homes. They know you have access to a lot of information about them. That includes information about immigration status, income, adult employment, adult incarceration records, adult substance abuse, Social Security numbers, and child and adult medical histories. They know you have access to all of their contact information.

Because of this power imbalance, there are a lot of rumors swirling in CLD communities. First, in a lot of immigrant communities, there are rumor that if families don’t comply with EI or educational services, providers can call immigration services on the families. There are rumors swirling that children can be removed from families if the families don’t do what you say while you are in their homes.

Let’s get into recommendations: First, many families from CLD backgrounds do not think parents should be teachers. Many families think that the role of a parent is to parent. Teachers teach. And, you are in the role of a teacher. So teaching is your job, not theirs. It’s important to know what the family sees as their role. That means you might have to ask and have a conversation about adult roles in the family. It’s incumbent on you to make sure the adults understand that their role may need to shift somewhat to support a child who developing differently – much like the family might have to change the foods they eat if someone developed diabetes. It’s incumbent on you to provide recommendations that are as respectful of their current parenting practices and family values as possible.

Now let’s talk about child-directed speech or CDS. When I’ve worked in EI, I’ve seen very well meaning professionals recommend this parenting practice to Every. Single. Family. This includes recommending that parents talk in an “excited” voice with gestures. That’s still CDS. CDS is a parenting practice. It is not universal. It should not be universally recommended. Yes, babies and young children like CDS and respond to it. But, research shows the intervention benefits stop there. What appears to be important is the amount and frequency of language input provided to young children, not the manner in which it is provided. So, instead of recommending adults from CLD backgrounds talk in an “excited” voice (which they interpret correctly as ‘baby talk’, by the way), what if you recommended parents “think aloud” during activities of daily living with the child nearby. What if you suggested ways adults could include children in those activities rather than only suggesting they read books? Acknowledge to the adult that “thinking aloud” like this might feel strange at first, but that listening to adults and other children talk about what they are thinking is important for young children. Give examples of ways adults can include children in these interactions by giving choices at different points (e.g., “Should we wash dark or light clothes first?” [Have child point to the pile of their choice]). What if you made your recommendations like you were thinking aloud? What if you made your recommendations by saying “What if we” rather than saying, “You should…” Do you see the difference in these recommendations and how they’re made? Do you see how they might be easier for a family that values parents teaching children life skills rather than academic skills? Suggesting strategies like this also eliminates the use of display questions – another frequently recommended mainstream culture parenting practice.

Display questions are those adults ask children that both the adult and child already know the answer to. Like CDS, this is not a universal parenting practice. In mainstream culture, we most often use display questions when asking young children to point to pictures in books (e.g. ,”Where’s the ball?”) or when asking them what sound a toy animal would make if it was real (e.g., “What does the cow say?”) or when asking them to label body parts on request (e.g., “Where’s your nose?”). Get out of the habit of recommending adults use display questions with children. Those families who have adopted this as a parenting practice will already use it. Those who don’t use this parenting practice aren’t going to use your recommendations anyway.

Let’s talk about children’s books for a moment. First, do you know what the #1 source of rare words is? Would it surprise you to learn it’s children’s picture books? When you recommend adults read books to children, how do you know the adults have the reading skill to read picture books? The average adult reading level in the US is 5th grade. Rhyming children’s books often are at an 8th grade or higher level because of the rhyming words. SLPs also need to realize in many low-income environments, books and toys for babies and young children are seen as unnecessary luxuries. Scarce financial resources are much better spent on food, diapers, and clothing rather than toys and books. Libraries are wonderful – I use mine all the time. I have an e-reader I use to I download e-books. When the lending period is up, I can’t access the book until I check it out again. But, e-readers are expensive and require an internet connection. If I forget to turn in a paper book on time, I can afford the late fees. I can afford to pay for a book that gets damaged or destroyed somehow. Many low-income families can’t afford to pay fines or for damaged books and they stop accessing the library when those things happen.

What are some suggestions for increasing literacy exposure that don’t necessarily require the primary adults in the home to read? First, if the family can access the library system, check what group story times are available. Not only do the children get to hear a story read by someone with mature reading skills, they get the socialization of being with other children. Another option is to let parents know about the plethora of read alouds on YouTube. Maybe the parent can’t read, but they can show videos of books being read aloud. The videos are great for literacy exposure, but you may need to model for the parent how to stop the video and ask the child, “What’s going to happen next?” or “Uh oh! What’s the problem?” Notice again, these aren’t display questions. These are open ended questions where the adult is asking the child their thoughts or opinions. The adult doesn’t automatically know how the child will respond.

Finally, but most importantly, ask the family what they see as the biggest concern and make sure you address it. I recently evaluated a medically complex, bilingual 4-year-old girl. This child had been referred to EI at birth and the family used the services for a while. But, they did not see the value in them because the family was told to work on receptive language and use CDS when the primary concern was the fact that the girl could not tell them what she wanted. When the pandemic hit, the family just let the EI services stop. The girl has recently begun attending a school-based preschool program and the parents sought out in-home therapy services again. When I directly asked the mom what she wanted for her daughter during the evaluation, she began crying. She apologized and said, “No one has ever asked me that.” She then said she wanted her daughter to be happy and to be able to tell others what she wants or needs. She said she did not want her daughter to work on following directions again because she did not feel like that was a problem to begin with. We talked through some options to immediately improve her daughter’s expressive communication skill, including light and higher tech AAC/AT options. I made sure to phrase my recommendations as questions, “What if we try X?” “What do you think about Y?” I’ve been working with this little girl for about 3 weeks now. We focus on expressive language, feeding, and AAC access. Her mom said yesterday she has already noticed a big difference in how much more her daughter is using conventional gestures, word approximations, and sign approximations and that she is able to communicate more consistently with a lot more people. That’s what she wanted for her daughter.

If you’ve read this far, thank you. If you’ve read this far, let me leave you with a couple of take home messages. When you work with clients from CLD backgrounds, a little humility goes a long way. It’s not about you. It’s about the client and their family and what they want. When you show you’re respectful of what your clients want and where they’re coming from, you’ll find your clients are more willing to do what you ask of them.

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