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 9781799871347, 9781799871361

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Critical Perspectives on Social Justice in SpeechLanguage Pathology

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RaMonda Horton Midwestern University, USA

A volume in the Advances in Linguistics and Communication Studies (ALCS) Book Series

Published in the United States of America by IGI Global Information Science Reference (an imprint of IGI Global) 701 E. Chocolate Avenue Hershey PA, USA 17033 Tel: 717-533-8845 Fax: 717-533-8661 E-mail: [email protected] Web site: http://www.igi-global.com Copyright © 2021 by IGI Global. All rights reserved. No part of this publication may be reproduced, stored or distributed in any form or by any means, electronic or mechanical, including photocopying, without written permission from the publisher. Product or company names used in this set are for identification purposes only. Inclusion of the names of the products or companies does not indicate a claim of ownership by IGI Global of the trademark or registered trademark. Library of Congress Cataloging-in-Publication Data Names: Horton, RaMonda, 1973- editor. Title: Critical perspectives on social justice in speech-language pathology / RaMonda Horton, editor. Description: Hershey, PA : Information Science Reference, [2021] | Includes bibliographical references and index. | Summary: “This book addresses a current gap in our understanding of multicultural issues, communication disorders, and literacy discussing critical perspectives on issues of race, class, language, disability status, gender, and sexuality that are important and necessary for shaping novel research, teaching, practice, and policy that is oriented towards social justice for the individuals served by our profession”-- Provided by publisher. Identifiers: LCCN 2021008510 (print) | LCCN 2021008511 (ebook) | ISBN 9781799871347 (hardcover) | ISBN 9781799871354 (paperback) | ISBN 9781799871361 (ebook) Subjects: LCSH: Communicative disorders--Cross-cultural studies. | Communicative disorders--Social aspects. | Speech disorders. | Language disorders. | Language and culture. Classification: LCC RC429 .C75 2021 (print) | LCC RC429 (ebook) | DDC 616.85/5--dc23 LC record available at https://lccn.loc.gov/2021008510 LC ebook record available at https://lccn.loc.gov/2021008511 This book is published in the IGI Global book series Advances in Linguistics and Communication Studies (ALCS) (ISSN: 2372-109X; eISSN: 2372-1111)

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British Cataloguing in Publication Data A Cataloguing in Publication record for this book is available from the British Library. All work contributed to this book is new, previously-unpublished material. The views expressed in this book are those of the authors, but not necessarily of the publisher. For electronic access to this publication, please contact: [email protected]

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Rationalist Bias in CommunicationTheory Leonard Shedletsky (University of Southern Maine, USA) Information Science Reference • © 2021 • 320pp • H/C (ISBN: 9781799874393) • US $215.00 Innovative Perspectives on Corporate Communication in the Global World María Dolores Olvera-Lobo (University of Granada, Spain) Juncal Gutiérrez-Artacho (University of Granada, Spain) Irene Rivera-Trigueros (University of Granada, Spain) and Mar Díaz-Millón (University of Granada, Spain) Business Science Reference • © 2021 • 319pp • H/C (ISBN: 9781799867999) • US $215.00 Rhetoric and Sociolinguistics in Times of Global Crisis Eda Başak Hancı-Azizoglu (Mediterranean (Akdeniz) University, Turkey) and Maha Alawdat (Kaye Academic College of Education, Israel) Information Science Reference • © 2021 • 419pp • H/C (ISBN: 9781799867326) • US $195.00 Handbook of Research on Representing Health and Medicine in Modern Media Gülşah Sarı (Bolu Abant İzzet Baysal University, Turkey) Information Science Reference • © 2021 • 618pp • H/C (ISBN: 9781799868255) • US $265.00 Strategies and Tactics for Multidisciplinary Writing Kemi Elufiede (Carnegie Writers, Inc., USA) and Carissa Barker Stucky (Carnegie Writers, Inc., USA) Information Science Reference • © 2021 • 222pp • H/C (ISBN: 9781799844778) • US $195.00 Redefining the Role of Language in a Globalized World Ai-Ling Wang (Tamkang University, Taiwan) Information Science Reference • © 2021 • 354pp • H/C (ISBN: 9781799828310) • US $195.00 Handbook of Research on Contemporary Storytelling Methods Across New Media and Disciplines Lorena Clara Mihăeş (University of Bucharest, Romania) Raluca Andreescu (University of Bucharest, Romania) and Anda Dimitriu (University of Bucharest, Romania) Information Science Reference • © 2021 • 467pp • H/C (ISBN: 9781799866053) • US $245.00

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Handbook of Research on Discrimination, Gender Disparity, and Safety Risks in Journalism Sadia Jamil (Khalifa University, UAE) Barış Çoban (Doğuş University, Turkey) Bora Ataman (Doğuş University, Turkey) and Gifty Appiah-Adjei (University of Education, Winneba, Ghana)

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For Mattie, Aaron, and Julia; Angela and Precious; James and Jamie

Editorial Advisory Board

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Johanna Boult, Louisiana State University Health Shreveport, USA Jose G. Centeno, Rutgers University, USA Valarie B. Fleming, Texas State University, USA Melissa P. Garcia, Texas A&M International University, USA Yvette Hyter, Western Michigan University, USA LaMonda Horton Stallings, Georgetown University, USA Valerie E. Johnson, Emerson College, USA Yolanda Keller-Bell, North Carolina Central University, USA Nicole Koonce, Governors State University, USA Maria L. Muñoz, University of Redlands, USA Benjamin Munson, University of Minnesota, USA Elia Olivares, DePaul University, USA Robert J. Patterson, Georgetown University, USA Crystal Randolph, Valdosta State University, USA Brandi Newkirk Turner, Jackson State University, USA Stacey Wallen, Georgia State University, USA

 

Table of Contents

Preface.................................................................................................................................................. xvi Acknowledgment................................................................................................................................. xxi Introduction: Social Justice in Speech Language Pathology......................................................... xxii Section 1 The Need for a Social Justice Orientation in Speech-Language Pathology Chapter 1 Disproportionate Representation in Special Education and the Intersectionality of Race, Ethnicity, and Socioeconomic Status....................................................................................................................... 1 Yolanda D. Keller-Bell, North Carolina Central University, USA Chapter 2 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community............... 18 Gregory C. Robinson, University of Arkansas for Medical Sciences, USA Andrea L. Toliver-Smith, University of Arkansas for Medical Sciences, USA

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Chapter 3 The Determinants of Health: Social, Structural, and Political Contributions to Health-Related Outcomes............................................................................................................................................... 39 Molly Jacobs, East Carolina University, USA Fatima Jebahi, East Carolina University, USA Charles Ellis, East Carolina University, USA Section 2 Concepts and Theories Oriented Towards Justice Chapter 4 The Power of Words: A Preliminary Critical Analysis of Concepts Used in Speech, Language, and Hearing Sciences............................................................................................................................. 60 Yvette D. Hyter, Western Michigan University, USA



Chapter 5 Critical Race Theory for Speech-Language Pathology: How Race-Conscious Practice Mitigates Disparities.............................................................................................................................................. 84 Chelsea Privette, University of Arizona, USA Chapter 6 A DisCrit-Informed Critique of the Diference vs. Disorder Approach in Speech-Language Pathology............................................................................................................................................. 105 Betty Yu, San Francisco State University, USA Laura Epstein, San Francisco State University, USA Vivian Tisi, San Francisco State University, USA Section 3 Developing Research and Evidence Oriented Towards Justice Chapter 7 Deconstructing the Three Pillars of Evidence-Based Practice to Facilitate Social Justice Work in Speech Language and Hearing Sciences.............................................................................................. 130 Reem Khamis-Dakwar, Adelphi University, USA Melissa Randazzo, Adelphi University, USA Chapter 8 Research Methodology to Examine Disparities in Communication Disorders in Underrepresented and Vulnerable Populations................................................................................................................. 151 Molly Jacobs, East Carolina University, USA Charles Ellis, East Carolina University, USA Chapter 9 An Unequal Partnership: Communication Sciences and Disorders, Black Children, and the Black Speech Community.............................................................................................................................. 180 Brandi L. Newkirk-Turner, Jackson State University, USA Lekeitha R. Morris, Lamar University, USA

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Section 4 Curriculum, Training, and Practice Oriented Towards Justice Chapter 10 An Ethics-of-Care Approach to Developing Students’ Antiracist Practice in SLP Curricula: The Cross-Cultural-Communication Project............................................................................................... 198 Johanna Boult, Louisiana State University Health, Shreveport, USA Jennifer E. Whited, University of Louisiana, Monroe, USA Tamara M. Easley, DC Therapy Solutions; Travel and Give, USA



Chapter 11 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers: Simulated Interpreter Encounter........................................................................................... 224 RaMonda Horton, Midwestern University, USA Elia Olivares, DePaul University, USA Chapter 12 The Promise, Pitfalls, and Context of Restorative Justice: Through a Lens of Communication Disorders.............................................................................................................................................. 245 Heather Dalmage, Roosevelt University, USA Chapter 13 Grassroots Organization and Justice Through Social Media............................................................... 262 Christina Navas, Independent Researcher, USA Vivian Tisi, Independent Researcher, USA Tamala Close, Independent Researcher, USA Compilation of References................................................................................................................ 285 About the Contributors..................................................................................................................... 347

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Index.................................................................................................................................................... 352

Detailed Table of Contents

Preface.................................................................................................................................................. xvi Acknowledgment................................................................................................................................. xxi Introduction: Social Justice in Speech Language Pathology......................................................... xxii Section 1 The Need for a Social Justice Orientation in Speech-Language Pathology Chapter 1 Disproportionate Representation in Special Education and the Intersectionality of Race, Ethnicity, and Socioeconomic Status....................................................................................................................... 1 Yolanda D. Keller-Bell, North Carolina Central University, USA Over 50 years ago, Dunn expressed concern that many children placed in special education classes were more likely children with mild learning problems from socially culturally diverse backgrounds rather than intellectually disabled. Further, Dunn described the then practices and policies as “morally and educationally wrong.” From this viewpoint, the chapter will use a multifactorial perspective to examine issues regarding disproportionate representation in special education, including communication sciences. Further, the chapter will discuss how these factors intersect with demographic variables such as the race, ethnicity, class, and home language of children with disabilities.

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Chapter 2 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community............... 18 Gregory C. Robinson, University of Arkansas for Medical Sciences, USA Andrea L. Toliver-Smith, University of Arkansas for Medical Sciences, USA The purpose of this chapter is to discuss the sociopolitical landscape of gender and sexuality in order to assist speech-language pathologists (SLPs) in dismantling systems of oppression for LGBTQIA+ people. An overview of principles and best practices in working with LGBTQIA+ people is provided. The chapter defnes terms related to LGBTQIA+ culture and practical recommendations for how to practice in ways that challenge culturally-constructed, oppressive gender and sexuality stereotypes and communicate afrmation and support to individuals of all genders and sexualities.



Chapter 3 The Determinants of Health: Social, Structural, and Political Contributions to Health-Related Outcomes............................................................................................................................................... 39 Molly Jacobs, East Carolina University, USA Fatima Jebahi, East Carolina University, USA Charles Ellis, East Carolina University, USA The determinants of health have received substantial attention in the medical literature as recent evidence has shown that they play in vital role in general health and health-related outcomes. Despite the advancing literature, the feld of communication sciences and disorders (CSD) has been slow in the both the consideration of the determinants of health as well as the measurement of commonly known determinants believed to infuence clinical outcomes. The goal of this chapter is to explore the determinants of health and potential relationship to the study of communication disorders and the outcomes being measured. Section 2 Concepts and Theories Oriented Towards Justice Chapter 4 The Power of Words: A Preliminary Critical Analysis of Concepts Used in Speech, Language, and Hearing Sciences............................................................................................................................. 60 Yvette D. Hyter, Western Michigan University, USA Recently, speech, language, and hearing sciences (SLHS) programs became increasingly aware of structural racism, inequity, and injustice in the professions and world. Although a consistent experience for many people of color, this current reality requires scholars and educators to interrogate concepts and employ more transformative concepts ftting for this new era. Concepts are the basis of thought, essential for communication, necessary for building knowledge, and the building blocks of theory. Critical theory was used to conduct a preliminary analysis of fve concepts used in SLHS. The concepts were analyzed keeping in mind the historical, political, and cultural infuences on how the concepts are used and understood in SLHS. The analysis revealed that these concepts were typically not defned in SLHS literature, and without collective critical refection, the continued use of those concepts could lead to inequities and/or exclusion. Suggestions for more equitable concepts are provided.

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Chapter 5 Critical Race Theory for Speech-Language Pathology: How Race-Conscious Practice Mitigates Disparities.............................................................................................................................................. 84 Chelsea Privette, University of Arizona, USA Race has yet to be discussed as a signifcant factor in the feld of speech-language pathology. Race is often confated with nonmainstream dialects and discussed in purely linguistic terms. However, the terms we use to describe dialects are highly racialized, centering white mainstream norms and treating nonmainstream varieties of English as “diferent” and, therefore, inferior. Hierarchical thinking about language contributes to the misdiagnosis in Black and other communities of color because racialized language ideologies have been left unstated. This chapter demonstrates through a critical race theory approach how structural racism shapes the feld’s conceptualization of language and competence. Using an intersectional lens in particular, this chapter discusses race, disability, and language ideology as systems of domination that compound the efects of racism for communities of color. CRT is then used



to reveal, critique, and intervene on the historically embedded racist structures that continue to manifest in speech-language pathology research, teaching, and practice today. Chapter 6 A DisCrit-Informed Critique of the Diference vs. Disorder Approach in Speech-Language Pathology............................................................................................................................................. 105 Betty Yu, San Francisco State University, USA Laura Epstein, San Francisco State University, USA Vivian Tisi, San Francisco State University, USA The disproportionate representation of students of color in special education is among the most longstanding and intractable problems in education. In this chapter, the authors examine the phenomenon of racial disproportionality through the theoretical framework of disability studies and critical race theory (DisCrit). They argue that a DisCrit-informed lens challenges the current framing of racial disproportionality in speech-language pathology as merely resulting from a failure to distinguish between diferences and disorders. Rather, racial disproportionality is a predictable outcome of the institutionalized segregation of students based on perceived deviations from normative standards, a process grounded in the mutually reinforcing mechanisms of systemic ableism and systemic racism. Section 3 Developing Research and Evidence Oriented Towards Justice Chapter 7 Deconstructing the Three Pillars of Evidence-Based Practice to Facilitate Social Justice Work in Speech Language and Hearing Sciences.............................................................................................. 130 Reem Khamis-Dakwar, Adelphi University, USA Melissa Randazzo, Adelphi University, USA

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This chapter reviews the limitations of the evidence-based practice (EBP) framework adopted by American Speech Language Hearing Association for the feld of speech, language, and hearing sciences (SLHS) in addressing systemic racism. The authors argue that a shift from a medically-based EBP model to a pluralistic EBP model would better serve the needs of black, indigenous, people of color (BIPOC) with communication impairments in the current sociopolitical landscape. The authors examine the three pillars of EBP through the lens of social justice work. They describe how the current EBP model limits the development of social justice work in SLHS. They describe the need to refne the EBP model by validating the contribution of qualitative research as scientifc evidence, reevaluating the basis of clinical expertise in client-clinician cultural mismatch, and address the importance of integrating policy and culture in consideration of client and family preferences. These transformations are critical in light of the under-representation of BIPOC clinicians in the feld of SLHS profession. Chapter 8 Research Methodology to Examine Disparities in Communication Disorders in Underrepresented and Vulnerable Populations................................................................................................................. 151 Molly Jacobs, East Carolina University, USA Charles Ellis, East Carolina University, USA The existence of disparities in health has gained national attention. While disparities in communication



disorders undoubtedly exist, little research has documented these disparities. Disparities may occur across categories such as race/ethnicity, age, sex/gender, geographic, and socioeconomic status. In order to heighten awareness of existing disparities in the feld of communication sciences and disorders (CSD), this chapter focuses on designing and conducting research to identify and explain disparities among population subgroups. The chapter consists of seven sections: 1) Challenges in Defning Variables for Measuring Health Disparities, 2) Other Data Considerations, 3) Thinking Beyond the Traditionally Measured Sociodemographic Variables, 4) Causal Pathways Between Social Determinants and Health Outcomes, 5) Research Designs, 6) Research Frameworks, and 7) Theories of Contextual Factors. The goal of this chapter is to ofer information that assist CSD researchers in systematically identifying, analyzing, and addressing health disparities in CSD. Chapter 9 An Unequal Partnership: Communication Sciences and Disorders, Black Children, and the Black Speech Community.............................................................................................................................. 180 Brandi L. Newkirk-Turner, Jackson State University, USA Lekeitha R. Morris, Lamar University, USA This chapter addresses what Rickford referred to as an unequal partnership between researchers and the researched. In this chapter, Rickford’s assertion of an unequal partnership within the feld of sociolinguistics is extended to the feld of communication sciences and disorders (CSD). A summary of the CSD literature on the Black speech community identifes shortcomings, leading the authors to argue that more can be done to equalize the partnership between CSD researchers and the Black speech community. The authors make the case for the establishment of service-in-return as a general principle of CSD research – especially when the researched community is a minority, marginalized, or underserved community. Ideas of ways that researchers can give back to the researched communities are provided. The authors also suggest ways that researchers can foster a sense of civic responsibility in student researchers in order to usher in a new generation of researchers who are more committed than past generations to equalizing the partnership between researchers and researched communities. Section 4 Curriculum, Training, and Practice Oriented Towards Justice

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Chapter 10 An Ethics-of-Care Approach to Developing Students’ Antiracist Practice in SLP Curricula: The Cross-Cultural-Communication Project............................................................................................... 198 Johanna Boult, Louisiana State University Health, Shreveport, USA Jennifer E. Whited, University of Louisiana, Monroe, USA Tamara M. Easley, DC Therapy Solutions; Travel and Give, USA There is a necessity for students to learn about multicultural multilingual (MM) content in speechlanguage-pathology curricula. One reason for doing so is personal motivation: an awareness of and commitment to developing competence in working with diverse clients. Awareness can grow given specifc instructional experiences in the form of special projects that aim to build cross-cultural relationships with the goal of fostering empathy and compassion. This chapter provides a tutorial explaining one such instructional experience: the cross-cultural communication (CCC) project. Central to the project are faceto-face meetings and refective journaling on topics including counteracting stereotypes and planning for culturally responsive service provision. Activities have antiracist intentions guided by the moral



obligation to care for fellow human beings (as per ethics of care [EoC] theory). This chapter provides (1) theoretical underpinnings of the project, (2) procedures for its completion, and (3) description of a modifcation of the project for a language disorders course. Chapter 11 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers: Simulated Interpreter Encounter........................................................................................... 224 RaMonda Horton, Midwestern University, USA Elia Olivares, DePaul University, USA Cross cultural competence and responsiveness (CCCR) is an important aspect of clinical service delivery in speech-language pathology (SLP). Beyond the issue of CCCR, there is also a need to address how professional practices can facilitate justice in traditionally marginalized populations. Limited language access can facilitate inequities and disparities within institutions and systems when it is not considered in clinical service delivery. However, within the feld of SLP there is a limited amount of information available on the efectiveness of pedagogical strategies needed to facilitate student CCCR and train SLPs in how to minimize barriers posed by language access. Simulation, using standardized patients, is a strategy from the medical feld that has been used for such purposes. There are few published reports on the use of simulation for fostering various aspects of CCCR development among SLP students. Therefore, the purpose of this chapter is to provide an overview of a research project examining the efectiveness of a simulated interpreter encounter for multicultural training. Chapter 12 The Promise, Pitfalls, and Context of Restorative Justice: Through a Lens of Communication Disorders.............................................................................................................................................. 245 Heather Dalmage, Roosevelt University, USA

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This chapter addresses the promises and pitfalls of restorative justice (RJ) practices for youth with communication disorders. This chapter begins with the historical context, the current zero-tolerance policies and other harsh, exclusionary discipline measures used in schools and (in)justice system, harming Black disabled students disproportionately. This chapter then addresses the promise of RJ as a way to challenge zero-tolerance while building inclusive communities that focus on the growth of young people in community. This chapter provides a step-by-step discussion of a restorative circle, a practice based on talking, listening, and processing emotions. Speech-language pathologists are called upon to learn about the promise of RJ, engage in restorative practices, and then utilize their specifc knowledge of communication disorders to develop universal design circles so that youth with communication disorders and other invisible disabilities can be included and the promise of restorative justice fully realized. Chapter 13 Grassroots Organization and Justice Through Social Media............................................................... 262 Christina Navas, Independent Researcher, USA Vivian Tisi, Independent Researcher, USA Tamala Close, Independent Researcher, USA This chapter will provide the reader with information on the importance of grassroots organization in addressing social justice issues for speech-language pathologists (SLP). The authors provide background information on the use of social media to promote social justice eforts. The chapter also identifes



and discusses the development and implementation of two online platforms that have been efective in raising awareness about the importance of diversity, advocacy, and social justice issues in the feld of speech-language pathology. It provides the reader with important information on the issues and problems in the feld of SLP that led to the development of the two online platforms and the processes involved with developing them. Finally, the chapter concludes with a description of previous and current goals and outcomes, along with future endeavors of both platforms and recommendations for others who are interested in using social media as a tool to transform professional environments to facilitate justice within the discipline and society. Compilation of References................................................................................................................ 285 About the Contributors..................................................................................................................... 347

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Index.................................................................................................................................................... 352

xvi

Preface

Over the past two decades, the field of communication sciences and disorders (CSD) has promoted cultural competence as a helpful framework to improve the quality and effectiveness of service delivery to individuals from diverse backgrounds. Cultural competence has been described as acquisition of three core components: awareness, knowledge, and skills (Horton et al., 2010; ASHA, 2017). As such, CSD has focused training efforts on a few of the following areas:

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1. Teaching students and practitioners how to be aware of clinician-client mismatches, and identify their personal biases. 2. Establishing a knowledge base on the impact of sociocultural factors on language and communication in various populations; 3. Developing a service delivery skill set for implementing least biased assessment procedures and culturally sensitive interventions. Unfortunately, the development of cultural competence does and has not necessarily provided practitioners with an opportunity to foster changes beyond the individual level. In large part, cultural competence for individual SLP practitioners has become the goal rather than a pathway to a more significant outcome, social justice for the populations served by our discipline in educational and healthcare settings. Social justice as a paradigmatic or philosophical orientation focuses on examining and transforming the systems and settings that guide and impact the lives of those who experience systemic forms of oppression (Prilleltensky & Nelson, 1997). As such, social justice research, pedagogy, and practice is concerned with protecting the rights of traditionally marginalized groups, improving access and opportunity of these groups, and working toward equitable outcomes in how these groups benefit and participate in society (Payne, 2011; Level and Sidel, 2013). Historically, there has been very little discussion of socially just approaches to speech-language pathology (SLP). However, discussions about social justice are important given the current sociopolitical climate and landscape that our clients carry out their day-to-day functioning. A climate that is characterized by increasing globalization, unresolved racial/ethnic discord, health and educational disparities, a rise in white nationalism, and a global pandemic (Bieber, 2018; Bordo et al., 2007; Daniel, 2020; Hammonds & Reverby, 2019; Weitzer, 2017). As such, it is imperative that SLP, as a discipline, dedicate attention and efforts towards understanding and changing institutionalized forms of oppression that result in poorer and more negative, if not life-threatening, outcomes for individuals and communities who have been marginalized. It is my hope that through discussion of the content and topics in this book that we can begin to articulate a framework for speech-language pathology that is oriented towards social justice.  

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Preface

Professionals working in communication sciences and disorders, multicultural education, special education, and healthcare will find this book useful when working to develop practices and scholarship that are culturally responsive. This book is for practitioners, teachers, students, and researchers who are interested in understanding how social position factors and social stratification mechanisms such as racism, classism, linguicism, ableism, homophobia, and transphobia create unique ecological contexts that reproduce inequities for those from traditionally marginalized groups in our society. Moreover, this book is a collective effort of the contributors to highlight and promote the value of literature and approaches that identify and dismantle institutionalized and systemic forms of oppression that result in negative and disparate outcomes for those from marginalized communities. The Introduction and Section 1 of the book (Chapters 1-3) discuss the importance of social justice and identifies the types of sociopolitical and structural factors that influence and contribute to educational and healthcare disparities. In the Introduction, RaMonda Horton introduces the reader to the concept of social justice, and identifies important issues of concern for various marginalized groups. She provides a preview of concepts, terminology, and theories that will be discussed in greater detail throughout the book. Finally, she shares with the readers a framework for helping researchers, teachers, and practitioners develop agendas, strategies, curriculum, and practices that are oriented towards social justice. In Chapter 1, Yolanda Keller-Bell provides the reader with an historical and current perspective of disproportionality in special education, with discussion of relevant policy and legislation on educational programming for students with disabilities. She also provides an overview of the literature documenting and explaining disproportionality for students from marginalized communities. Keller-Bell also describes particular areas of concern for school-based SLP practitioners hoping to engage in service delivery that is oriented towards justice. In Chapter 2, Molly Jacobs, Fatima Jebahi, and Charles Ellis introduce the reader to the evidence base regarding the social and structural determinants of health. In doing so, they provide an overview of how race, socioeconomic status, residential location, gender, and sexual orientation shape the health outcomes of individuals and specific communities. The authors introduce the reader to key terminology and concepts in the literature regarding health disparities. They also provide a critical perspective on how systems, privilege, and political power influence outcomes related to health and well-being. Strategies to reduce implicit bias among healthcare professionals are discussed, along with, suggestions for how professionals in communication sciences and disorders can begin to address determinants of health. In Chapter 3, Gregory Robinson & Andrea Toliver-Smith discuss the importance of considering sexual orientation and gender identity and expression in speech-language pathology service delivery. They provide the reader with an overview of specific sociopolitical contexts impacting the lives of LGBTQIA communities. They direct careful attention to discussing gender and sexual diversity in the Black Diaspora and the deconstruction of heteronormativity and binary gender roles. The authors then explain how speech-language pathology can use this information to provide gender affirming care to individuals that they serve, along with solutions and recommendations for addressing broader issues related to health disparities, discrimination, and research paradigms focused on the needs of LGBTQIA populations. The second section of the book (Chapters 4-6) introduces readers to scholarship and frameworks used across multiple disciplines to interrogate institutionalized and systemic oppression. In Chapter 4, Yvette Hyter describes the importance of understanding the relationship between words, language, power, and the discipline’s framing of discussions on equity and justice. Guided by critical social theory, the author completed a concept analysis to explain how five words/concepts can be used as xvii

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Preface

tools for exclusion and marginalization in the context of oppressive systems and structures. Based on the results of the concept analysis, Hyter recommends that an alternative set of words/concepts be used by speech-language-hearing professionals when engaging in scholarship and rhetoric on equity and justice. In Chapter 5, Chelsea Privette introduces the reader to critical race theory (CRT) by providing a summary of its history and use in legal studies. She then discusses how systemic racism has shaped healthcare and education contexts. A summary of scientific racism in medicine and anti-literacy laws are discussed as significant factors that have contributed to BIPOC communities mistrust of healthcare providers, under-resourced schools, and health and educational disparities faced by BIPOC members of U.S. culture. The author details how other researchers have applied critical race theory in healthcare and educational scholarship, practices, and settings. Finally, she uses this analysis to identify why and how CRT should be applied in speech-language pathology, using language diversity as an example. In Chapter 6, Betty Yu, Laura Epstein, and Vivian Tisi provides readers with an overview of the history of disability studies and race scholarship. They introduce readers to the framework of DisCrit, which incorporates tenets and principles from disability studies and critical race theory. DisCrit, as explained by the authors, is a useful framework for investigating the ways that ableism and racism operate in school-based contexts to create disparate outcomes and experiences for students. The authors use a DisCrit lens to examine special education disproportionality and its relationship to systemic and structural factors that facilitate injustice based on racial identity and disability status. Section 3 of the book (Chapters 7-9) contextualizes the importance of acquiring, using, constructing, and developing evidence and research that examines inequity and promotes justice. In Chapter 7, Reem Khamis and Melissa Randazzo describe the limitations of medically based, evidence based practice (EBP) frameworks used in speech, language, and hearing sciences. The authors specifically focus on the ways that the current framework fails at addressing and incorporating culturally responsive practice. The incongruity between cultural responsiveness and the three pillars of EBP (scientific evidence, clinical expertise, and client preferences) are then critically evaluated to demonstrate how they can facilitate injustice and impede culturally appropriate service delivery. The authors then provide a model of EBP that integrates cultural responsiveness. In Chapter 8, Molly Jacobs and Charles Ellis describe research methodology for studying marginalized populations, with a specific focus on health disparities. A comprehensive description on the challenges associated with operationalizing variables that will be measured in research on health disparities is provided for the reader. The authors summarize important theories used to investigate the complex relationship of causal pathways between health outcomes and those social determinants described in chapter three of this text. Readers are provided with an overview of study designs used in health services research, along with, interdisciplinary frameworks and analytical tools that demonstrate great potential for being utilized for health disparities work in communication sciences and disorders. In Chapter 9, Brandi Newkirk-Turner and Lakeitha Morris place a critical lens on the relationships that exist between the Black speech community and researchers. They offer a historical overview of language research on Black children in communications sciences and disorders. The authors then identify three primary discipline specific factors that can lead to unequal partnerships between researchers and Black speech communities. Finally, they make several suggestions for carrying out research on AfricanAmerican children that are rooted in cultural responsiveness. Section 4 of the book (Chapters 10-13) focuses on describing curriculum and training strategies and professional practices that promote equity and justice.

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In Chapter 10, Johanna Boult, Jennifer E. Whited, and Tamara Easley, explore the effectiveness of an instructional approach, the Cross Cultural Communication Project, in facilitating the development of cultural awareness and anti-racist practices in pre-professional students, enrolled in a multicultural CSD course. The authors describe the rationale and history of multicultural curriculum and training in CSD and how Ethics of Care (EoC) theory guided the development of their Cross Cultural Communication Project. They provide the reader with information on the procedures used to implement the project and how it can be adapted by instructors who do not teach a specific course on multicultural issues but who also want to practice integral infusion of multicultural information. In Chapter 11, RaMonda Horton and Elia Olivares provide background information on issues related to language access and its impact on facilitating inequitable educational and health outcomes. The authors describe how the use of frameworks for interpreted encounters can help SLPs minimize barriers related to language access. They then provide an overview of a research project, which incorporated the use of simulated learning and standardized patients to train pre-professional SLP students on best practices for interpreted encounters. In Chapter 12, Heather Dalmage summarizes the historical context of restorative justice practices used in school-based settings and its potential for helping to address the school to prison pipeline for students with special education needs. She then describes the purpose, advantages, and challenges of implementing restorative justice practices in school-based settings. Lastly, the author describes the types of issues that will need to be considered by SLPs who are interested in the use of restorative justice practices for students with communication disorders. In Chapter 13, Christina Navas, Vivian Tisi, and Tamala Close discuss how grass roots organizing and social media can be used to create community and networks for individuals of color in SLP. The authors provide reflections of their own experiences in developing digital platforms designed to connect students and practitioners of color; increase awareness about the types of inequities that exist in CSD; and support the economic empowerment of practitioners of color. They incorporate literature from communication studies, cultural and ethnic studies, and instructional technology to provide readers with a framework that can be used by others who are interested in advocating for social justice. The chapters in this book, taken together, seek to address current limitations in the discipline’s approach and treatment of multicultural issues and communication disorders. Critical perspectives on issues of race, class, language, disability status, gender, and sexuality are important and necessary for shaping novel research, teaching, practice, and policy that is oriented towards social justice for the individuals and communities served by our profession. This shift to a more critical paradigm of social justice in professional practice will require innovative, long-term, collective efforts that critique, resist, and transform systems, institutions, and practices that oppress and marginalize not just individuals, but entire communities.

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REFERENCES American Speech-Language-Hearing Association. (2017). Issues in Ethics: Cultural and linguistic competence. Available from https://www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/ Bieber, F. (2018). Is Nationalism on the Rise? Assessing Global Trends. Ethnopolitics, 17(5), 519–540. doi:10.1080/17449057.2018.1532633 Bordo, M., Taylor, A., & Williamson, J. (2007). Globalization in Historical Perspective. University of Chicago Press., doi:10.7208/9780226065991 Daniel, S. J. (2020, October). Education and the COVID-19 pandemic. Prospects, 49(1-2), 91–96. doi:10.100711125-020-09464-3 PMID:32313309 Hammonds, E.M., & Reverby, S. (2019). Toward a Historically Informed Analysis of Racial Health Disparities Since 1619. American Journal of Public Health, 109, 1348-1349. doi:10.2105/AJPH.2019.305262 Horton, R. (2020). Let’s not fall short: COVID-19, social justice, and speech-language pathology. Journal of the National Black Speech, Language, and Hearing Association, 15(2), 49–51. Levy, B., & Sidel, V. (2013). Social Injustice and Public Health (2nd ed.). Oxford University Press. Payne, K. (2011). Ethics of disability: Foundation of the profession of speech-language pathology. Seminars in Speech and Language, 32(04), 279–288. doi:10.1055-0031-1292753 PMID:22144078 Sleeter, C. (2017). Critical race theory and the whiteness of teacher education. Urban Education, 52(2), 1–15. doi:10.1177/0042085916668957

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Weitzer, R. (2017). Theorizing Racial Discord over Policing Before and After Ferguson. Justice Quarterly, 34(7), 1129–1153. doi:10.1080/07418825.2017.1362461

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Acknowledgment

Special thanks to my children Octavia and Elijah, my mother Vanessa, LaMonda, Latasha, William, and the entire Walker clan for love, patience, and support while attempting to pursue justice and peace of mind. To Drs. Munoz, Thomas-Tate, and Keller-Bell, I appreciate the twenty years of support and ongoing dialogue about many of the topics in this book. To the EA Collective, thank you for the encouragement and space to be, feel, and think about equity and justice. I would also like to acknowledge Dr. Ida J. Stockman for her preternatural wisdom in speaking and writing about multicultural education, science, and sociopolitical context. My educational experiences have been especially important in shaping my interests and scholarship on diversity, equity, and justice. As such, I am thankful for the opportunities of growth and learning provided to me during my time in DPS, and at NC State, Appalachian State, and UW-Madison. Special thanks to the students and colleagues who inspire me to keep talking about equity and justice; and reflecting on the best ways to teach and share this information. Finally, I don’t think that there are enough words, paper, or time available to express the enormous amount of gratitude that I feel for the contributors and editorial advisory board members who were so committed to making sure that this scholarship was disseminated in a book format. So, I will just employ one of my favorite expressions for recognizing greatness and simply say, “Thats whats up!”

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RaMonda



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Introduction

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INTRODUCTION: PERSPECTIVES OF EQUITY AND JUSTICE As a behavioral science discipline, speech-language pathology (SLP) focuses on the development and implementation of techniques to change communication behavior. Our profession is also rooted in human services. This orientation to service means that our practices also focus on ways to enhance or remediate one’s ability to communicate for a better quality of life within the context and environments of one’s home and communities. However, there does seem to be a barrier to using discipline knowledge about communication to foster change beyond the individual level. This barrier is due to a persistent failure to directly discuss or address harmful and unfair institutional and systemic contexts in shaping the outcomes of those we serve. More specifically, the discipline has rarely considered the ways in which various ideological orientations, practices, policies, curriculum, and training models widely incorporated within the discipline reinforce marginalization. This lack of consideration can increase the likelihood that scholars and practitioners will unintentionally contribute to or reproduce larger societal injustices against professionals, students, and stakeholders who have been minoritized in our society. Levy and Sidel (2013) characterize social injustices as denying fundamental human rights: economic, social, cultural, or political. As such, social justice agendas should be intentionally focused on the protection and restoration of opportunity and access to those rights for communities who, historically, have been marginalized and/or experienced inequitable outcomes. Development of SLP practices and scholarship that can have a broader impact on how society views communication and human behaviors linked to learning and socialization, will require an ethical, moral, and ideological orientation rooted in social justice and frameworks that prioritize equity. Therefore, the purpose of this chapter is to provide an overview of many of the issues that will be discussed in detail throughout this book. This chapter introduces an historical perspective of how social justice has been conceptualized, delineates the sociocultural factors and sociopolitical contexts that influence equity and justice; and describes a framework that can be used to guide the discipline’s efforts to facilitate justice. Lastly, the reader is provided with a summary of approaches that practitioners, organizations, and training programs can use within the context of speech-language pathology and audiology to promote social justice.

 

Introduction: Social Justice in Speech Language Pathology

BACKGROUND Social Justice Early models of social justice from the fields of economics, sociology, and philosophy can be, in many ways, linked to movements concerned with universal human and civil rights. Karl Marx, expostulated that equality could be achieved when societies work to secure the economic well-being of all individuals, and ensure that rights and privileges are equally distributed without regard to one’s socioeconomic standing (Bannerji, 2005; Husami, 2014). Meanwhile, Rousseau argued that government and policies are responsible for protecting individuals’ rights in their society (Jost & Kay, 2010; Munger et al., 2016). Hence, human and civil rights movements across the world have focused on justice and served as mechanisms for pursuing equity and protecting the rights of those who experience oppression (Moody et al, 2009). There is a myriad of sources operationalizing the term social justice (Adams et al., 2016; Ratts et al., 2010; Vera & Speight, 2003). Bell’s (1997) conceptualization argues that social justice is both a goal and a process. As a goal, social justice focuses on the: full and equal participation of all groups in a society that is mutually shaped to meet their needs. Social justice includes a vision of society in which the distribution of resources is equitable and all members are physically and psychologically safe and secure (Bell, 1997, p. 3). The process of social justice is then concerned with the structure and actions of making sure that the concepts of fairness and equity are situated in real-life contexts. The method of social justice, according to Bell (1997), is open, participatory, emancipatory, collaborative, and focused on change at the level of institutions and systems. Thus, promoting and facilitating justice within SLP practice and settings will require a greater and more nuanced understanding of the relationships between identity, power, and systems.

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Power, Marginalization, Systems, and Justice In societies across the world, marginalization and inequities are facilitated through social stratification. SLP practitioners and institutions interested in facilitating social justice will need to acknowledge that sociocultural factors are used in societies to stratify and privilege its members (Beeghley, 2008; Horton, 2020). The consequences of one’s social position contributes to the level and degree of educational, social, or economic mobility and health quality that an individual may achieve over a lifetime (Grusky & Weisshaar, 2018). As such, there is a need for more CRITICAL discussions of how one’s racial/ethnic identity, class background, language(s) spoken, disability status, gender identity, or sexual orientation might influence the level of privilege or oppression that clients, students, and practitioners face. These particular sociocultural and identity factors do mediate and moderate a person’s access, opportunities, protections, outcomes, and participation in professional settings, their communities, and the larger society (Beeghley, 2008).

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Race

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Race is a primary factor that needs to be addressed in our discussion of social justice. Racial and ethnic minorities in the U.S. continue to face a variety of complex, systemic, and historical health and educational disparities. Over half of the U.S. population of Blacks live in urban areas, with 55% living in the South (Allen & Easley, 2013). These tend to be areas that are disproportionately impacted by disinvestment, overcrowding, inadequate housing, poor public education and high crime (National Academies of Science, Engineering, and Medicine, 2017). All of these contextual factors impact the availability, accessibility, and acceptability of health services and educational opportunities. Race is consistently linked to K-12 schooling and academic outcomes. The National Center for Educational Statistics (2011; Bohrnstedt, et al.,2015) and the Nation’s Report Card (NAEP, 2020) data indicate significant disparities in academic achievement between many children of color and their white peers for multiple outcomes (i.e., standardized reading test scores, grade point averages, graduation rates, and college admissions rates). In spite of recent reports that the opportunity gap is about school poverty (Reardon et. al, 2019), the literature also indicates that Black and Latino children are more likely to attend schools in under-resourced neighborhoods and communities (Morgan & Amerikaner, 2018). They are also more likely to be situated in classrooms where the effects of institutionalized and racialized educational practices negatively affect their opportunities for learning and development (Milner, 2012; Milner & Howard, 2015; White et al., 2019). People of color in the U.S. suffer from more chronic conditions, receive less preventative and quality health care, and adhere to their own beliefs about non-medically necessary services (Levy & Sidel, 2013; Chin, 2009). Additionally, evidence indicates that aversive racism/implicit bias influences physician decision-making process about patient referrals, differential diagnosis, and even ethical responsibilities related to mandatory reporting (Dovidio et al, 2013; Harris, 2021). Within early childhood settings, even preschool teachers demonstrate implicit biases in how they report and discipline the behaviors of Black children, practices that result in disproportionate representation of children in the school to prison pipeline (Gillam et al., 2016; Neittzel, 2018). The racial status of Black, Indigenous, or Other people of color (BIPOC) also increases the likelihood that limited access to educational and health resources, protection from discrimination, and participation in local community environments may be areas of concern (Johnson, 2020). Finally, the majority of research regarding the communication, language, and socialization behaviors of speakers from communities of color have simplified or ignored the moderating influence of race on outcomes in these areas (Horton et al., 2018). This is a particularly concerning issue, since it has been established that the social construction of race and racism has led to oppressive contexts that mediate various outcomes for those who are not white (Markus, 2008; Moya & Markus, 2010).

Class Class status can also influence the degree of marginalization experienced by those served by our profession. Those individuals, families, or communities who are identified as belonging to poor, working class, or lower socioeconomic status (SES) groups are faced with limited access or fewer opportunities for improved life outcomes than their peers from middle to upper SES groups (Fiske & Markus, 2012). Low SES status has been linked to poorer educational and health outcomes for a variety of racial groups, but BIPOC are at greater risk for experiencing long term and adverse outcomes related to poverty (Mixxiv

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chener & Brower, 2020; Williams et al., 2016). Thus far in SLP, SES has been examined, primarily, as a demographic variable. Used in this fashion, it simply provides information about an individual or family’s potential access to material resources that can shape communication and literacy behaviors and environments. This type of individual model of behavior that is used to explain disparities, posits that a person’s behavior is the result of individual/family characteristics (attitudes, beliefs, skills) and that educational and health disparities can be resolved through changes to the individual/family through prevention and training programs (Stephens et al 2012). SLP research examining the impact of SES on communication and literacy has seldom adopted a structural model of explanation to examine disparities. Structural models recognize that systems and institutions (i.e. school and healthcare funding) create context for attitudes, behaviors, and practices. Interdisciplinary scholarship in sociology, psychology, and economics recognizes that the structural model offers a more effective approach for examining the complex relationship between outcomes and structural contexts (Stephens et al, 2012). This is especially important given the amount of research documenting that individuals/families who occupy lower SES groups are not afforded the same access to power, status, or opportunities for participation in institutions and experiences that allow for economic mobility and stability, as their middle SES peers (Stephens et al, 2014). Research concerning SES related disparities also indicates that geography and race can amplify negative structural conditions that make it difficult for those from lower SES groups to experience the same or better outcomes than their middle SES peers. The Center for Public Education reports that poverty, and the effects of poverty are deeper and long lasting in rural areas of the US, as opposed to urban locations (Lavalley, 2018). The majority of states affected by the type of deep poverty, in which a family’s income is “below half of the poverty line”, are located in the South (p.4). Reduced educational and healthcare funding and initiatives, distance, and poverty interact to produce detrimental consequences for children and adults living in rural areas (Tikamayer et al., 2017). Lower SES status also increases one’s likelihood of experiencing classism or discrimination and prejudice based on economic standing (Fuller-Rowell, et al, 2012). It has been reported that health service providers and educators exhibit class bias and make moral judgments about the health behaviors and decision-making of those who are poor (Haider et al., 2011; Zoric, 2015). Fuller-Rowell and colleagues.,(2018) also reported that negative stereotypes and discrimination based upon class, in workplace and community settings, was linked to declining health outcomes in US adults over a 17-19 year period. For BIPOC families and communities, there is likely to be a compounded effect of racism and classism that influences interactions with educational and health care systems (Harvey, 2017; William et al., 2016; White et al., 2019).

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Language Language, like race and class, is an important factor to consider in discussions of equity and social justice (Baker-Bell, 2020; Alim et al., 2016; Alim & Smitherman, 2012). In particular, the functions and purposes of language in larger society are its utility as a tool for socialization, expression, and persuasion (Cummins, 2000; Theoharis and O’Toole, 2011). Many linguists and language policy scholars argue that language in a society helps maintain power and reinforce expectations of the mainstream group (Cummins, 2000; Fairclough, 1989). Complex power dynamics shape the perceptions and use of language and communication (Mayr, 2000). In a social sense, all languages and linguistic systems are not deemed

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to be equal. This linguistic discrimination or linguicism acts as a social stratification mechanism that upholds existing power structures and inequity that normalize the linguistic systems of white speakers. Language is heavily linked to how social status is assigned in many countries, including the U.S (Simpson et al., 2018). It also provides its listener with clues to their speaker’s cultural identity. Postcolonial racism has made this an increasingly more complicated matter for BIPOC clients and families who do not use white, mainstream American English. And even in an era of changing racial dynamics, the accepted or mainstream variety of any language is still based upon its use by the majority culture, those with the greatest sociopolitical power, or those who are at the upper echelons of social hierarchies based on class (MacNeil & Cran, 2005: Lippi-Green, 2012). Language also serves as a proxy for race in employment, housing, and legal proceedings that can promote discrimination in subtle and nefarious ways (Baugh, 2006; 2017). Furthermore, there continues to be a rise in white nationalism (Bieber, 2018). The definition of who is American is being ascribed more and more to the language spoken by a person (Shu & Shen, 2021). In the absence of an official U.S. language policy that recognizes and appreciates linguistic pluralism, those who do not speak English are at greater risk for experiencing inadequate and inappropriate health care, limited educational opportunities, and lower health literacy (Rodas & Osborn, 2016). The relationships between one’s language, their academic achievement, economic and career outcomes, or ability to participate in healthcare decisionmaking are especially salient (Leech et al., 2019).

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Disability In addition to race and language, ability status is another important factor to consider when working towards justice. The American Community Survey reports that the prevalence of disability in the U.S. for people of all ages has varied and is currently at 12.7% (Erickson et al, 2021). Historically, individuals with disabilities were denied fundamental rights related to education, vocation, marriage, and reproduction (Patterson, 2018). And even though key pieces of legislation such as PL-94-142, Americans with Disabilities Act, and the Rehabilitation Act of 1973 resulted in policies and protections to ensure disability rights, individuals with various conditions still report less access, opportunity, and participation in education and healthcare settings (Meade et al., 2016; Stransky et al., 2018; Terzi, 2005). Several disability advocates note that attitudinal, environmental, and contextual barriers posed by the medical model of disability reinforce ableism and/or ideology and practices which reinforce prejudice or discrimination against those with disabilities (Terzi, 2005; Oliver, 2013). The Model of Healthcare Disparities and Disabilities recognizes that incongruities between personal and environmental factors is an issue that can result in limited access to healthcare and poorer health outcomes for those with disabling conditions (Meade et al., 2015). Poorer educational and health outcomes are not the only areas of concern for those with disabilities. It is also the case that the percentage of working-age adults with a disability is 37.8 compared to those working who do not have a disability (Erickson et al,. 2021). Those who do have some level of employment still experience a number of difficulties in their employment settings (Dutta et al.,2008; Ma, 2020). Additionally, youth and adolescents with disabilities continue to face victimization or bullying in their school and social environments (Twyman et al., 2010; Zeedyk, et al., 2014) even into adulthood (Fisher et al., 2016). The high levels of social exclusion and limited educational achievement and opportunities for those with disabilities persist in current times (Erickson et al, 2019; Yoder & Cantrell, 2019). Furthermore, lower socio-economic status exacerbates the stigma, isolation, and limited access to various xxvi

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opportunities that can affect quality of life across the life span (Malecki et al, 2020). These disparities are increasingly magnified in the context of the global pandemic (Annaswamy et al., 2020).

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Gender/Sexuality A person’s sexual orientation and/or gender identity and expression also needs to be considered in discussions regarding social justice and equity. Those who identify as lesbian, gay, bisexual, transgender, queer, intersex, or asexual (LGBTQIA) have been minoritized and marginalized in ways that contribute to negative experiences and poorer economic, educational, and health outcomes (Kelly & Robinson, 2011; Mahendra, 2019). Results of a 2019 survey by the Gay and Lesbian Alliance Against Defamation (GLAAD) reports that 12% of the population identifies as LGBTQIA. Gallup polls also indicate that between 2017 and 2020, 4.5-5.6 respondents identified as LGBTQIA (Jones, 2021). Researchers across multiple disciplines have noted that there is a need for specialized training with service providers in both health care and educational settings (Kattari et al., 2017; Lienthal et al., 2018; Meyer et al., 2015; Rider et al., 2018). Kimmel (2014) identified several aging concerns faced by adults and seniors who identify as LGBTQ in long-term health settings. These concerns included recognizing factors affecting disclosure of sexual identity; acknowledgment of non-heteronormative perspective, and realizing how caregiving responsibility and roles can differ from hetero and gender normed family structures. Sexual and gender identity also need to be considered in school-based contexts. Youth and adolescents who identify as LGBTQIA are at higher risk of displacement and homelessness (Page, 2017), poorer educational and mental health outcomes due to the amount of discrimination, stigma, and isolation they may face in educational settings (Lienthal et al., 2018). For those LGBTQ youth receiving special education services, the co-occurring issues of isolation/ exclusion and discrimination can be compounded in the absence of teachers and service providers who have been trained in understanding the needs and concerns of these students (Arrieta & Palladino, 2015; Meyers et al, 2015). Adults with a disability who identify as LGBTQIA are faced with similar issues when accessing health and social services (McCamp et al., 2016). SLPs working in healthcare, K-12 settings, and higher education will likely provide services or instruction to children, adolescents, and adults who identify as LGBTQIA. Several sources indicate that SLPs can benefit from additional training in creating LGBTQIA friendly environments, developing attitudes, knowledge, and skills that consider the needs of these individuals, along with acquiring specific knowledge related to voice and communication therapy (Hancock & Haskins, 2015; Mahendra, 2019). SLPs also serve as a valuable resource and team member in providing genderaffirming care to transgender individuals, particularly within the context of voice and communication therapy (Devore et al, 2020). Finally, it has been reported that the prevalence rates of disability within the transgender community ranges from 28 to 39%, nearly or more than double of what has been reported for the mainstream population (Disability Rights Education and Defense Fund (2018). SLP practice and research that is oriented towards social justice will need to consider the impact of heteronormative systems and contexts, and their relationship to ableism to avoid facilitating injustice through underlying homophobia and cis-gendered norms.

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Intersectionality Intersectionality is a term used to discuss the idea that individuals can experience multiple and compounded forms of oppression, prejudice, and discrimination when their identity is linked to various social position factors (Crenshaw et. al., 1995). Discourse and examination of intersectionality is vital to social justice agendas and practices given that identifying with more than one marginalized group can exacerbate difficulties with access, opportunity, participation, and equitable outcomes. Scholars in medicine have begun to address intersectionality, particularly as it relates to gender and race. For example, it has been noted that racialized, gender microaggressions predict mental and physical health outcomes for Black women (Lewis et al, 2020). Intersecting forms of oppression also impacts educational outcomes related to special education (Losen et al., 2014). Many of the chapters in this text highlight how important it is for the profession to acknowledge and study intersectionality and its role in mediating how individuals from marginalized communities are included or excluded from participation and activities in their daily environments.

SOLUTIONS AND RECOMMENDATIONS: PROMOTING SOCIAL JUSTICE IN SLP Agendas for practice and research developed to focus on social justice will need to utilize ideological orientations that can help clarify what action or steps are needed to transform institutions and contexts. Hailes et al. (2021) have refined the conceptualization of social justice along three domains discussed in social and organizational psychology:

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1) Interactional justice is concerned with equity in interpersonal relationships. As such, acknowledging and considering the positionality of all participants in the relationship and how power dynamics mediates their interaction is essential for fair and reciprocal relationships. 2) Distributive justice focuses on prioritizing the needs and concerns of marginalized communities and allocating resources and support based upon where they are needed most. 3) Procedural justice is concerned with macro-level structures and the acquisition of knowledge about broad-based systems and ideologies that reinforce institutional and structural injustices. This knowledge is necessary for becoming effective agents of change and advocates for those who have been marginalized. This conceptualization of social justice can and should be considered in attempting to clarify the roles and responsibilities of SLPs and the discipline at large. An understanding of interactional, distributive, and procedural justice can help practitioners and organizations shift paradigms in developing professional practices, research, curriculum, training models, and procedures that are oriented towards, not just cultural competence, but equity and social justice.

Interactional Justice- Clients and Professional Team SLPs who are oriented toward social justice should be mindful of how their own understandings and perspectives on racism, ableism, classicism, linguicism, and heteronormativity can hinder or strengthen relationships with those that they interact with in professional settings. Knowledge of these five mechaxxviii

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nisms of injustice can facilitate use of specific strategies to eliminate the attitudinal and social barriers posed by systems or contexts shaping proximal and distal environments. SLPs in educational settings will need to examine their assumptions about schooling and disability, advocate for those with disabilities, and educate their peers about how special education services can contribute to change beyond the individual level in school-based settings. In healthcare settings, SLPs will need to consciously deliver services using systems-based practice (SBP). SBP refers to the provider’s awareness of and cultural responsiveness to the larger context and system of health care and the ability to effectively utilize other resources to provide optimal healthcare (Johnson et al., 2008). When interacting with student and adult clients, SLPs should be mindful of some additional purposes of language and not underestimate its importance in the provision of services for individuals. For those from marginalized communities, language is a tool for maintaining identity, acculturation, and resistance (Fairclough, 1989; Ng & Deng 2017). SLPs concerned with interpersonal justice will make every effort to insure that procedures, materials, and activities honor the language practices of those they serve across contexts. They will also need to be mindful of how language can serve as a tool for marginalization, particularly as it relates to accessing and understanding health information. Low levels of English proficiency and a monolingual context is linked to reduced health literacy that results in higher health care costs, and problems with self-management of health care (Sentell & Braun, 2012). SLPs in health and education settings need to develop and maintain relationships with bilingual SLPs and interpreters in order to adequately eliminate barriers posed by language access. Practitioners also need an understanding of intersectionality and how different forms of oppression and privilege can result in individual variation for clients from similar marginalized groups. Those who lack this understanding, may over or under estimate the significance of communicative behaviors and environments examined and observed during clinical interactions. They also may fail at demonstrating cultural responsiveness. A failure to acknowledge the impact of intersectionality is a lost opportunity to engage in transformative and meaningful relationships with clients and families.

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Distributive Justice: Research and Evidence The goal of social justice work is to disrupt systems of privilege and oppression. From the perspective of distributive justice, this purpose is extended to the process of science and the use of evidence to inform policy (Griffiths, 2009). Recall that distributive justice focuses on prioritizing the needs and concerns of those who have been marginalized and allocating resources and support accordingly. SLP researchers and scholars will need to do more than research and study the communication and learning behaviors of those from minoritized communities. They will need to place a higher priority on: supporting the work of marginalized scholarship and scholars; incorporating community knowledge, learning more about what different communities need from their perspectives, and develop agendas which support local and specific communities’ participation in various aspects of the research process designed for them. When experiential knowledge about race, language, disability, gender, sexuality, and intersecting identities is gathered by and from those who have been marginalized it can be used to emancipate, liberate, and transform their communities (Aaydarova, 2019; Kimball et al., 2016).

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Construction of Evidence Base on Educational Disparities and Health Inequity Distributive justice within a social justice framework, will also offer a focused inquiry and critique of knowledge construction. This inquiry will examine the relationship between power and sociocultural differences as a mechanism for addressing a particular phenomenon (Hailes et al., 2021). Ideology and identity do affect personal interactions as noted in the preceding section, but they also affect broader systems. In the case of research in SLP, scholars must be willing to deconstruct institutional contexts and relationships, rather than the individual and their families, as a way to clarify the power dynamic that exists between behavioral outcomes under investigation and the ideology of the institutions in which they are observed and measured. Power and prestige also are at the center of how SLP scientists view the process of development and maturation, disability, language proficiency, literacy, child rearing, family structure, treatment models, and health outcomes. Development of research agendas, which address ideology and power, fosters cultural responsiveness in science. This leads to greater understanding about how the trajectory of outcomes for those from marginalized communities are mediated by power dynamics, systems, and context (APA, 2017). This type of critical approach challenges scholars to move beyond paradigms focused on the individual beliefs or behaviors of those from minoritized communities (McKinney, 2017; Ruppar et al., 2017).

Beyond Deficit and Difference Distributive justice will also require that SLP researchers explicitly and intentionally work to reject deficit frameworks that normalize the behaviors of white, mainstream culture; pathologize behaviors of minoritized groups; and sustain social hierarchies and marginalization (Gorski, 2008; Ladson-Billings & Tate, 1995; Sólorzano & Yosso, 2002). These frameworks have essentially shaped how practitioners and academics, alike, view individual potential and the pedagogical and therapeutic strategies used to educate or address a variety of behaviors. Several scholars have noted that deficit oriented scholarship and frameworks, across multiple disciplines, continue to perpetuate harmful ideas (Johnson, 2020; Penner et al., 2010; Valencia, 2002) that those from communities of color or poor communities:

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1) Do not possess the foundational skills, knowledge, and support systems to foster academic achievement 2) Do not value education 3) Lack the appropriate judgment or ability to make healthcare decisions. As a result of deficit frameworks, research across education and healthcare settings have focused on developing programs or interventions to change the behaviors of individuals, families, and entire communities with very little change or elimination of harmful institutionalized systems and ideologies that mediate and moderate the contexts of human behaviors and outcomes (Marks et al., 2020; Sólorzano & Yosso, 2002; Cabrera, 2019). In addition to rejecting deficit framed research it will be important to move beyond difference models as well (Gorksi, 2011). Difference models have created a useful platform for establishing the importance of considering how unfair it is to generalize and apply mainstream findings to those from minoritized communities (Horton et al., 2018). However, they still haven’t allowed us to come up with workable solutions to completely address education and health equity, or pipeline issues (Gorski, 2010). Both xxx

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deficit and difference oriented frameworks are inadequate paradigms for research that seeks to be transformative and address issues of justice for communities of color as they are centered in whiteness and western culture (Zuberi & Bonilla-Silva, 2008), nor do they allow for the perspectives and experiences of minoritized communities to shape the evidence base (Kafe, 2013; Rosqvist, et al., 2020). Research paradigms oriented towards social justice will emphasize, prioritize, and promote the voices, perspectives, and experiential knowledge of those from marginalized communities during the development, implementation, analysis, and dissemination of a research study’s findings. (Aydarova, 2019; Hudson et al., 2017). Constructivism, Indigenous approaches to scientific inquiry, and critical paradigms that prioritize participatory action research can inform research, curriculum, training and policy aligned with social justice (Whyte et al., 2016; Fleury & Garrison, 2014). These approaches utilize methods and techniques that are collaborative, interpretive, integrative, and useful in describing complex systems, power, and people (Mertens, 2007; Onwuegbuzie & Frels, 2013).

Procedural Justice- Socio Political Context, Curriculum/Training Models Procedural justice is focused on equity in decision-making and allocation of resources at the macro-level of systems and organizations (Hailes et al., 2021). As such, the evaluation of fairness and equity encompass more than just examining individual outcomes. Fairness of policy and procedures in determining those outcomes are also important (Skarlicki & Folger, 1997). Researchers in organizational management also note that procedural justice significantly influences engagement, motivation, belonging, inclusion, and value (Bal et al., 2011; Tyler & Blader, 2003). Consideration of macro-level factors will need to include an understanding of the socio-political context in which SLP practitioners and researchers carry out their professional duties.

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Broader Socio-Political Context in U.S. Schooling and Healthcare SLP practices in professional settings of schools and healthcare organizations have been guided by sociopolitical contexts, policies, and broader issues related to resolving inequities in educational achievement for school based settings and healthcare access and outcomes in medical settings. Sociopolitical context refers to the pre-imposed social, cultural, and historical conditions that may influence a particular phenomenon or event (Stockman, 1995; 2010). A number of sociopolitical factors have played a significant role in why we should view not only language, but also race, disability, gender, sexuality, and class as essential factors to consider in our research and practice related SLP in educational and healthcare settings. Current SLP professional practices and service delivery have been, and continue to be, impacted by several sociopolitical events or contexts. These events and contexts include: Brown vs. the Board of Education; the Civil Rights Act of 1964; Medicaid and Medicare Act; Education for All Handicapped Children Act/Individuals with Disabilities Education Act; the American with Disabilities Act; Title 1 and Section 504 of the Rehabilitation Act of 1973; Deferred Action of Childhood Arrivals (DACA) Act; the Affordable Healthcare Act; Bostock vs. Clayton; and both the COVID -19 CARES Act and American Rescue Plan Act (Benuto et al., 2018; Jones, 2013; Michener & Brower, 2020; Patterson, 2018; Wey,2020; Rosenbaum et al 1997; Kim, 2020). They were supposed to: 1) Set precedence for equal opportunity and participation and legal protection of those from minoritized groups; xxxi

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2) 3) 4) 5) 6) 7) 8) 9)

Eliminate discriminatory practices in education, medical, and government organizations; Operationalize disability in educational settings Provide resources and funding for disability services; Provide resources and funding for vocational training, Offer temporary protection for immigrant children without formal citizenship Fund healthcare for those with limited financial means. Provide universal access to healthcare Offer resources and support to vulnerable populations during global crisis

Unfortunately, attempts to protect rights, address integration, and eliminate discrimination across settings has resulted in marginal success in fostering inclusivity and equitable outcomes for those from minoritized communities (Benuto et al., 2018;Hoffman, 2012; Losen, 2018; Vitulli, 2010). Special education disproportionality, academic opportunity gaps, and health care disparities remain persisting problems. The COVID 19 pandemic has exacerbated these disparities for individuals from communities of color (Lopez et al., 2021; Yip, 2020). Questions regarding legislation and policy for education and healthcare can no longer simply be about equality but must address those related to equity. This includes inquiry into who benefits from these actions, has access to resources, opportunity to utilize resources, is protected and or supported by programs aligned with these policies (Chandra et al., 2017; Hoffman, 2012; Reardon et al., 2019). SLP as a discipline can advocate for centering and prioritizing equity in policies and programs that impact stakeholders who are BIPOC, poor, disabled, LGBTQIA, or use a language other than English.

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SLP Curriculum/Training Models Professional disciplines typify, encapsulate, integrate, and reproduce macro-level systems, structures, and broader ideologies of society (Ray, 2019). In the U.S. the 1980s and 90s were a time of additional change for post-secondary education. Trends in multiculturalism highlighted the importance of recognizing differences and embracing the diversity of children and their families in curriculum and training models (Mahendra, 2019). However, the embracing of diversity with SLP training programs has largely been superficial, without a significant change or impact on inequitable outcomes or pipeline issues for those from marginalized communities (Deal Williams, 2020). The discipline has not intentionally, nor explicitly addressed social justice in any of its procedures, policies, or guidelines concerned with training (Speech, Language, Hearing Scientists Equity Action Collective, 2021). In SLP, Hyter & Salas-Provance (2019) have discussed the importance of curriculum and training models which focus explicitly on the examination of power and the relationship between power and practices of the discipline through the use of critical theory. Critical theory, its underlying assumptions, and goals can be useful not just for the purposes of research, but also for praxis of reforming or abolishing practices that uphold the status quo of inequity, and developing those that are transformative and purposeful in sustaining equity. Critical pedagogy, then also becomes necessary for helping students to develop a consciousness that observes more than individual differences (Cowden & Singh, 2015; Freire, 1997). It teaches students and practitioners the “how and why” of viewing our professional practices through an equity lens to address systemic and institutionalized forms of injustice (McLaren, 2015; Freire, 1996). In education, critical constructivism, culturally sustaining pedagogy, and equity/racial literacy frameworks have xxxii

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been promoted for their impact or effectiveness in making curriculum more inclusive; shifting teacher classroom behaviors that center Whiteness; improving cultural competence; and remediating climates that reinforce marginalization (Croom et al., 2020; Duncan-Andrade, 2008; Goodman, 2008; Gorski & Swalwell, 2015; Paris & Alim, 2018; Stevenson, 2014). Critical social theory in law, education, and environmentalism has also provided leaders with effective frameworks and strategies that can facilitate justice in the development, implementation, and evaluation of policy (Aledo-Tar & Dominguez-Gomez, 2017; Fairclough, 2013). Critical discourse analysis offers an effective approach for examining policy and procedures that may reproduce injustice (Chase et al., 2014; Fairclough, 2013; Taylor, 2004). Ecological frameworks of policy analysis also assist in uncovering inequitable power structures and relationships (Weaver-Hightower, 2008). Finally, social and equity impact assessments utilize constructive and critical orientations to consider the knowledge, perspectives, and experiences of marginalized communities when evaluating the process and implementation of decision-making and policy (Esteves et al., 2014; Povall et al., 2014)

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FUTURE RESEARCH DIRECTIONS: SHIFTING PARDIGMS In the discipline, the evidence base regarding the relationships between power, broader social systems, identity, and communication remains rather limited (Hyter & Salas-Provance, 2019). There are three primary reflection points to keep in mind as the profession moves forward with shifting paradigms. First, sociopolitical context and issues of power are interconnected during the process of scientific inquiry and discovery. Scientific inquiry, funding decisions, and pathways for dissemination of findings are influenced by social political context, even when it is not recognized or explicitly acknowledged (Stockman, 2007). As such, even research produced under the aegis of non-deficit models retains some underlying assumptions or residual limitations of deficit-oriented research (Gorski, 2011; 2016). Future research should incorporate the use of theoretical and conceptual approaches that critique how knowledge about language and communication is constructed or that examine the relationship between communication and structures, institutions, and systems. Secondly, findings associated with social justice research in SLP should not merely be disseminated among academics and policy makers. They need to be shared with the communities they are most likely to affect in the short and long term (Duong, 2020). Collaborative and intentional action plans can then be developed and implemented based on those findings as a way to facilitate structural and systemic changes that are sustainable (Garnett et al, 2019). Third, literature regarding pedagogy and instructional strategies for best practices in addressing topics of justice for marginalized communities is still an area of SLP research ripe for growth. In order to address this limitation, different paradigms of science, pedagogy, and policy are necessary for understanding more about the marginalized communities who experience injustices within education and healthcare contexts.

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CONCLUSION Transformative SLP practice, research, curriculum, training, and policy will require some new attention to interactional, distributive, and procedural aspects of social justice given that the disciplines’ approach to understanding culture has been rooted in a superficial perspective of multiculturalism and differences. The historical lack of attention to the role of institutionalized mechanisms of oppression and privilege means that the discipline must work intentionally and persistently to prioritize efforts for equity and justice in the short and long term. Solutions to injustice are possible when we acknowledge, consider, learn more about, and undertake work to address racism, linguicism, ableism, classism, and heteronormativity in professional and academic settings. The content covered in this book provides the reader with great points of reflection and suggestions for how the discipline and professional practices can be more oriented towards justice.

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Section 1

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The Need for a Social Justice Orientation in SpeechLanguage Pathology

1

Chapter 1

Disproportionate Representation in Special Education and the Intersectionality of Race, Ethnicity, and Socioeconomic Status Yolanda D. Keller-Bell North Carolina Central University, USA

ABSTRACT Over 50 years ago, Dunn expressed concern that many children placed in special education classes were more likely children with mild learning problems from socially culturally diverse backgrounds rather than intellectually disabled. Further, Dunn described the then practices and policies as “morally and educationally wrong.” From this viewpoint, the chapter will use a multifactorial perspective to examine issues regarding disproportionate representation in special education, including communication sciences. Further, the chapter will discuss how these factors intersect with demographic variables such as the race, ethnicity, class, and home language of children with disabilities.

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INTRODUCTION The passage of the Education for All Handicapped Children Act of 1975 (Education for All Handicapped Children Act, 1975) was meant to assure that children with disabilities have access to a “free and appropriate public education,” to provide due process for children and families, and to evaluate the effectiveness of the special education and related services for these children. Similarly, the Education for All Handicapped Children Act (“Education for All Handicapped Children Act,” 1975), in conjunction with the Rehabilitation Act of 1973 was designed to provide individuals with disabilities access to an DOI: 10.4018/978-1-7998-7134-7.ch001

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 Disproportionate Representation in Special Education and the Intersectionality

appropriate education. Together, this legislation should provide all children with access to equitable and effective special education services. However, since its earliest inception, special education has been the subject of legal challenges regarding racial, ethnic, and language minority disproportionality (Council for Children with Behavioral Disorders, 2013). This chapter will review the literature on disproportionality and special education from federal legislation, particularly IDEA. The chapter will then examine the research that has explored relationships between race, socioeconomic status, ethnicity, home language, and special education identification, and access to services. While studies have consistently found that disproportionate representation in special education for children with disabilities, there is conflicting research on what type of disparity exists for children with disabilities from racial or ethnic minorities. Finally, the chapter will examine the literature regarding the disparities that have been reported in the identification of communication disorders and access to services in speech-language pathology

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BACKGROUND Disproportionality can be defined as the underrepresentation or overrepresentation of a specific group within a setting relative to that group’s proportion in the total population (Dever et al., 2016). Questions regarding the disproportionate representation of students from diverse backgrounds in special education classrooms were raised over fifty years ago. In 1968, Dunn expressed concern regarding the number of children in special education classrooms from racial, ethnic, language minority, or low-resourced homes. Dunn posed that it was more likely that these children had mild learning problems instead of having an intellectual disability. Further, Dunn (1968) described special education practices and policies as “morally and educationally wrong” (pg.5). This seminal article recognized and highlighted disparities amongst racial and ethnic minorities in the special education system and facilitated an ongoing evaluation and discussion on inequities in special education and related services. The Individuals with Disabilities Education Act (Individuals with Disabilities Education Act, 20 U.S.C. § 1400, 2004) has been amended to address concerns regarding the disproportionate representation of children with disabilities based on race, home language, and ethnicity. The Individuals with Disabilities Education Act (2004) theoretically ensures the right of all children with disabilities to have access to special education and related services, which includes services for speech, language, and hearing impairments. Thus, speech-language pathologists play an essential role not only as direct service providers but also have the opportunity to develop practices that address social justice for children with disabilities. Accurate and early identification of disabilities plays a critical role in successful academic and communication outcomes. Alternatively, delays in identification or misidentification, whether overor under-identification, can have a negative impact on academic and communication outcomes.

MAIN FOCUS OF THE CHAPTER Issues, Controversies, Problems Amendments to the IDEA Act (2004) require states to determine if there is significant disproportionality, that is, an overrepresentation based on race or ethnicity, in the identification of children with disabilities,

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 Disproportionate Representation in Special Education and the Intersectionality

placement in more restrictive educational settings, or higher rates of disciplinary actions (U.S. Department of Education, 2016). In contrast, the Council for Children with Behavioral Disorders (2013) uses disproportionate representation to refer to both the underrepresentation and overrepresentation of children with disabilities in identification or disability categories. The intent of these measures was to monitor disproportionality using quantitative and qualitative measures; however, the outcome of these monitoring efforts may vary depending upon how states interpret and apply these principles. For example, states that interpret disproportionality primarily as the use of inappropriate special education identification policies or procedures have reported little to no finding of local school systems with disproportionality in special education services (Council for Children with Behavioral Disorders, 2013). To answer these questions, researchers have explored relationships between race, ethnicity, socioeconomic status, language status, disability, and academic performance. Educators and researchers have posed various theories and explanations as to why disproportionally exists in special education, including systemic bias (Oswald et al., 2001; Artiles, 2014). The cost of disproportionate placements of students can include students being placed in restrictive environments, limited academic achievement, and higher dropout rates (Artiles et al., 2010).

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More Issues, Controversies, Problems Socioeconomic Status (SES). The question of how race and socioeconomic status contribute to the probability of a diagnosis in special education and to what extent these measures account for ethnic disproportionality in special education were examined by Skiba et al. (2005). Using school-district level state data, Skiba and colleagues evaluated the interaction of poverty, race, school resources, and academic-behavioral outcome. The authors found an inconsistent and weak relationship between poverty, measured as the percentage of children receiving free lunch, and disproportionality measures. Poverty was not a significant predictor of the level of disproportionality or diagnosis with emotional disturbance (ED), moderate intellectual disability (ID), or overall enrollment in special education. Disproportionality for speech-language impairments and learning disabilities decreased as the proportion of children receiving free- or reduced lunch increased (Skiba et al., 2005). Overall, Skiba et al. (2005) reported that when poverty levels were controlled in a logistic regression analysis, race significantly influenced the identification of a disability. For example, African American children were 1.5 times more likely to be identified than otherwise similar children as having ED, moderate ID, and 2.5 times more likely to be identified as mildly ID. An ideal type analysis of race, poverty, and the probability of disability identification showed that, at all poverty levels, African Americans were disproportionately represented. However, the disproportionality varied depending upon the disability category. Poverty level appeared to heighten existing racial discrepancies in special education identification (Skiba et al., 2005). Sumski & Karwowski (2012) reported that children from lower socioeconomic (SES) backgrounds were less likely to receive less restrictive placements, and some have argued that this is because families need resources to advocate for less restrictive placements (Kurth et al., 2016). Lauderdale-Litten et al. (2013) used logistic regression analysis to examine the relationship between educational placement, child age, income, level of social skills, and behavior. The results indicated that social skills, child age, and income were significant predictors for 87.5% of educational placements. Cosier and Causton-Theoharis (2010) examined the relationship between demographic factors, economic factors, and the percentage of children with disabilities who were highly included in general education

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 Disproportionate Representation in Special Education and the Intersectionality

classrooms in 129 school districts. The results of hierarchical multiple regression analyses indicated that the percentage of students receiving free- or reduced-price lunch alone did not significantly predict inclusion levels. However, when the percentage of free- or reduced-price lunch recipients was combined with other economic factors such as median family income, spending per pupil in general education, and spending per pupil in special education, the combination of these factors did significantly predict the percentage of highly included students (Cosier & Causton-Theoharis, 2010). The authors report a positive correlation between the levels of inclusion for children with disabilities in per-pupil spending in general education and a negative correlation between special education spending per pupil and the levels of inclusion (Cosier & Causton-Theoharis, 2010). The relationship between socioeconomic status and racial-ethnic disproportionality in special education was examined by Kincaid and Sullivan (2017). They reported that parental income and occupational prestige were not associated with the identification of special education services. Maternal level of education and parental knowledge about autism spectrum disorders were reported to account for differences in the number of state services received between Latino and non-Latino White children by Magaña et al. (Magaña et al., 2013) Kurth et al. (2016) utilized hierarchical cluster analysis to examine state special education placement patterns in the United States for students with autism spectrum disorders (ASD), ages 6 to 22 years of age. The authors reported that students with ASD living in states with a higher number of students receiving free or reduced lunch, higher population density, more Black residents, higher per-pupil spending, and higher median income were more likely to be placed in the most restrictive educational settings. Conversely, students with ASD living in states with higher graduation rates, more rural areas, more adults with high school diplomas, and more White residents were more likely to be placed in inclusive education settings (Kurth et al., 2016). In sum, there is evidence that students with parents with higher levels of education have access to more state services and are more likely to be placed in inclusive settings. This is in direct contrast to one of the basic tenants of IDEA in that students with disabilities will be placed in the least restrictive setting. Race and Ethnicity. While studies have consistently found that disproportionate representation in special education for children with disabilities, there is conflicting research on what type of disparity exists for children with disabilities from racial or ethnic minorities. One body of research suggests that children from racial or ethnic minorities are overrepresented in special education, especially for certain types of disorders such as emotional and behavioral disorders (Hosp & Reschly, 2004; Losen & Orfield, 2002; Skiba et al., 2005; Sullivan & Bal, 2013). Other investigations have found the underrepresentation of children with disabilities by gender, race, and ethnicity (Morgan et al., 2018; Morgan et al., 2015). Administrative identification of individuals with autism spectrum disorders at the state-level was investigated in the years 2000 and 2007 (Travers et al., 2014). While there was a positive trend in identification for all racial groups, Travers et al. (2014) found that Blacks and Hispanic students were underidentified in 2007 when compared to similar White students with similar backgrounds. Morgan, Farkas et al. (2015) posed that differences in research methodologies are why studies of minority disproportional representation may differ in the direction of the representation. Specifically, it is argued that since school- family-, and child-level factors may confound results, statistical covariate adjustments should be used to control for these factors (Morgan et al., 2015) The aim of a study by Morgan et al. (2015) was to examine whether racial, ethnic, or language minority children were under- or over-identified as having a disability and the direction of any disproportional representation in special education. The authors analyzed data from a national longitudinal sample of 4

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 Disproportionate Representation in Special Education and the Intersectionality

children in kindergarten through middle school using hazard modeling estimates and statistically corrected for confounding variables at the child-, family, and school levels. The results showed that after accounting for child-level factors such as academic achievement and behavior, and family level variables such as SES, racial and ethnic minorities were less likely than similar White children to be categorized as having a disability (Morgan et al., 2015). In comparison to similar White children, Blacks were less likely to be identified as having a health impairment (77% less), emotional disturbance (64% less), speech or language impairment (63% less), a learning disability (58% less), or intellectual disability (57% less). Morgan et al. (2015) reported a similar pattern when comparing Hispanic children with otherwise similar White children who were 73% less likely to be diagnosed with health impairment, 33% less likely for speech or language impairment, or 29%, less likely to be diagnosed with a learning disability. Language minority children were 40% less likely than similar White children to be diagnosed with a speech or language impairment and 28% less likely to be diagnosed with a learning disability. Across multiple studies, these results suggest that when racial, ethnic, or language minority children display similar characteristics as white children, they are less likely to be identified as having a disability. A missing or incorrect diagnosis can lead to a delay in appropriate services which can negatively impact outcomes for children. Language Status. Using an integrative synthesis design, Morgan et al. (2018) found that when studies with the strongest measures of validity were examined, there were no statistically significant results that indicated overrepresentation in special education based on race, ethnicity, and language use.Other studies have reported that home language, gender, and race are better predictors of type of special education setting than socioeconomic status and academic performance (Bruce & Venkatesh, 2014; Hosp & Reschly, 2004; St Amant et al., 2018). The intersection of ethnicity, parent language, and acculturation on access to services and type of services was studied by St. Amant et al. (2018). When ethnicity, gender, and the child’s age were controlled, parent language was significantly associated with the number of hours of services received and whether the child’s Individualized Education Plan (IEP)addressed social or communication skills. Children whose parents primarily spoke a language other than English received significantly fewer hours of services which is consistent with other studies (Liptak et al., 2008; Mandell, Stahmer, et al., 2008; St Amant et al., 2018) Shifrer et al. (2011) utilized data from the Education Longitudinal Study of 2002 to examine potential patterns of disproportional identification of learning disabilities of high school children. The study reported that gender, academic history, and SES were associated with the identification of a learning disability and that children who participated in English as Second Language programs were 1.55 times higher than similar students. Hispanic and African American children were found to be disproportionately identified as having a learning disability, and that low SES was a significant predictor of this disproportionality.

Even More Issues, Controversies, Problems Speech-language pathology. ASHA requires SLPs to provide preventative, diagnostic, and treatment services for children and adults. Culturally responsive frameworks and practices should be used to provide effective services for diverse populations. The intersection of race/ethnicity, socioeconomic status, and language status may lead to disparities in the profession itself, assessment and eligibility procedures, and disciplinary actions.

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 Disproportionate Representation in Special Education and the Intersectionality

Demographic Inequities. In 2013, speech-language pathology was identified as the fourth “Whitest” profession using data from the U. S. Bureau of Labor Statistics (Thompson, 2013). According to ASHA (2021), 7.3% of certified speech-language pathologists identified as a racial minority, 5.6% identified as Hispanic or Latino, and 8% identified as bilingual service providers. However, these demographics contrast to the increasing diversity of the U.S., where 16.3% of the population identify as Hispanic or Latino and 27.6% identify as a racial minority (U.S. Census Bureau, 2010). The contrast between the demographics of the profession and the country emphasize the need for speech-language pathology training programs – for all students – to employ a framework of cultural responsiveness, cultural competence, and cultural humility to work with a population that is increasingly diverse (Lynch & Hanson, 2011; Tervalon & Murray-Garcia, 1998). Cultural competence is a developmental process, rather than an endpoint, that evolves and addresses: a) cultural awareness and attitudes, b) knowledge of other cultures, and c) application of skills (Franca & Harten, 2016; Lynch & Hanson, 2011). Cultural humility requires an individual to engage in lifelong self-reflection, self-awareness, and openness (Tervalon & Murray-Garcia, 1998). SLPs are expected to engage in the practice of cultural humility and required to demonstrate cultural competence. Further, academic training programs are expected to facilitate the development of cultural competence in future professionals (American Speech-Language-Hearing Association, 2004, 2010, 2016).While accredited graduate programs in SLP are required to provide training in cultural competence, programs vary widely in how they approach educating and training students in issues related to diversity, equity, and inclusion (Franca & Harten, 2016; Keller-Bell et al., 2017; Stockman et al., 2008). Cultural and linguistic differences between the SLPs and clients may impact multiple aspects of services such as assessment procedures, interpretation of communication styles, and interactions with family members and stakeholders (ASHA, n.d.). Further, given the limited number of bilingual speech-language pathologists and the research indicating that language status may be a factor in the disproportionality surrounding access to services, SLPs have an essential role in shaping and implementing culturally relevant and appropriate eligibility and assessment procedures. SES Inequities. Researchers have reported that SES, often measured by the level of maternal education, has a predictive relationship with aspects of language acquisition (Rice & Hoffman; Hammer et al., 2010); however, this information should be interpreted cautiously as that variation in maternal education may lead to the overidentification of language impairment in children of color (Restrepo et al., 2006). The SES of children has been found to play a role in the receipt of services for communication disorders where there is evidence that the receipt of services is not related to the severity of the language impairment or the child’s cognitive ability but to the mother’s level of education (Bishop and McDonald, 2009; Wittke and Spaulding, 2018; McGregor, 2020). Additionally, families with high levels of resources have access to private services to supplement school-based services. This option may not be available to families with lesser resources (McGregor, 2020), creating further inequities. SLPs should be aware that the intersection of SES, disability category, and language status may result in differing identification patterns. Smith et al. (2019) found that SES did not negatively impact access to hearing aid evaluations or participation in speech-language therapy for children diagnosed with a hearing loss. However, bilingual students may be overrepresented or underrepresented in disability categories depending upon the level of language ability. For example, bilingual students across income levels have been found to be disproportionally under-identified with a specific learning disability and ASD (Yamasaki and Luk, 2018). However, low-income, proficient bilingual speakers were underrepre6

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 Disproportionate Representation in Special Education and the Intersectionality

sented among those identified with a speech-language impairment. Conversely, less-proficient bilingual speakers across income levels were found to be overrepresented (Yamasaki and Luk, 2018). Assessment and Eligibility Inequities. Similarly, the patterns of disproportionality of representation in identifying the categories of emotional disturbances and learning disabilities are exhibited in the category of speech/language impairment for African American students. Over ten years, African Americans in public schools were underrepresented in 62% of states in the speech/language impairment category and were overrepresented in 14% of the states (Robinson & Norton, 2019). There was a disproportionate relationship between population density and rate of representation in the speech/language impairment category in that the ten states with the highest African American student density were more likely to have an underrepresentation of African Americans identified as speech/language impaired while those with the least concentration of African American students had proportionate representation (Robinson & Norton, 2019). Few studies have examined the role of the process and procedures to determine eligibility for special education services. Dever et al. (2016) suggested that students are often referred for special education placement by a teacher; however, there may be a cultural mismatch between student behavior and teacher expectations (Skiba et al., 2006). The results showed that African American students were overrepresented in two groups of students: a) those who were not identified as at-risk by the screening measure yet were receiving special education services, and b) students who were identified at-risk by the screening measure, however, they were not receiving special education services (Dever et al., 2016). The results showed that students whose mothers had lower levels of education were overrepresented in special education and males were 126% more likely to be in special education than females (Dever et al., 2016) Morgan et al. (2016) examined the data from the Early Childhood Longitudinal Study–Birth Cohort (ECLS-B; Andreassen & Fletcher, 2005) to determine if sociodemographic factors such as race, ethnicity, gender, and SES status were less likely to receive speech-language services than similar White children by five years of age. The authors reported that Black children and Hispanic children whose home language was not English were less likely to receive speech-language services in comparison to otherwise similar White children when socioeconomic status was controlled (Morgan et al., 2016). Similar results were found when data from the ECLS-B Kindergarten classes of 1998-1999 and 2010-2011 were examined (Morgan et al., 2017). Cultural competence involves several aspects of practice, including the selection of culturally and linguistically appropriate evaluation methods (American Speech-Language-Hearing Association, 2004; Morgan et al., 2015) and incorporation of data-driven approaches to address implicit biases (Dever et al., 2016). The finding that Black children are less likely to receive speech-language services (Morgan et al., 2017; Morgan et al., 2016) than otherwise similar White children highlights the importance of working with families to promote awareness and to not only evaluate the effectiveness of the measures and policies to identify children with disabilities, but to also, address areas of inequity and disproportionality. The intersection between assessment, cultural differences, and language status has consistently been recognized. However, the need continues for reliable assessment measures to evaluate language and literacy usage and for these measures to differentially diagnose academic difficulties due to limited language ability versus an actual learning disability (Yamasaki & Luk, 2018). Multi-Tiered System of Supports frameworks such as response-to-intervention have been implemented in schools as the initial step in the eligibility process to facilitate this differentiation (Fuchs & Fuchs, 2016; Ehren & Whitmire, 2009). Students who do not respond to initial intervention supports are referred for further observation or an evaluation. Yet, interventions that are inaccessible due to cultural or linguistic differences may 7

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 Disproportionate Representation in Special Education and the Intersectionality

contribute to a student’s unresponsiveness (Harry & Klinger, 2014; Yamasaki and Luk, 2018). Artiles (2014) questioned the effectiveness of such approaches if the interventions developed for monolingual English speakers are applied to non-native English speakers without research to support their efficacy. The role of the SLP to address this concern includes engaging in interprofessional education on linguistic differences, the use of culturally appropriate materials, and cultural differences in prior knowledge of concepts and experiences. Further, the roles and responsibilities of an SLP include selecting assessment measures that are culturally and linguistically appropriate, differentially diagnosing communication differences and communication disorders, and effectively communicating with families and stakeholders from diverse backgrounds (ASHA, n.d; Gutierrez-Clellen & Peña, 2001; Gutierrez-Clellen et al., 2000). The assessment and eligibility process to determine whether a child meets the criteria for speech/language impairment should include direct and indirect assessment measures (ASHA, n.d.). Language samples, standardized tests, dynamic assessment, and criterion-referenced- measures are examples of direct assessment measures, while indirect measures include case history, teacher and family interviews, and observations (ASHA, n.d.; Dubasik & Valdivia, 2021). Discipline Inequities. There is consistent evidence of disproportionality in school disciplinary procedures and outcomes for racial and ethnic minorities (Hoffman, 2014; Skiba et al., 2002; Skiba et al., 2009; Skiba et al., 2011). This pattern has been referred to as the discipline gap. In circumstances where African American and White students engage in similar patterns of behavior, African American students, particularly African American males, are less likely to receive a form of discipline that does not exclude them from the school setting, such as receiving a warning instead of a suspension (Wallace et al., 2016; Wegmann & Smith, 2019). The intersection of race, ethnicity and communication style can lead to a negative perception of African American students who may be perceived as aggressive or non-compliant (Hamilton & DeThorne, 2021; Fordham, 1993; Morris, 2007; Stanford, 2020). For example, in an ethnographic study, Hamilton & DeThorne (2021) found that an African American male who used features of African American English, a louder volume level when speaking, and exhibited verve (e.g., expressive body language, active movement, high energy) received a higher number of corrective or behavioral warnings than peers. Notably, these disciplinary warnings were directed at features associated with communication styles exhibited by many African Americans, which include the use of verve and a louder speaking volume (Hamilton & DeThorne, 2021). The discipline gap exists for racial and ethnic minorities with and without disabilities (US. Department of Education Office of Civil Rights, 2014). The U.S. Commission on Civil Rights (2019) examined the relationship between school discipline policies and the risk of contact with the juvenile or criminal justice systems for racial/ethnic minorities with disabilities. Although Black, Latino, and Native American students did not commit more disciplinable offenses than their white peers, they were disciplined more frequently. They received longer and harsher punishments (U.S. Commission on Civil Rights, 2019). Students with disabilities were twice as likely to be suspended at each grade level than students without disabilities (U.S. Commission on Civil Rights, 2019). Further, Black students with disabilities were consistently expelled or suspended from school at disproportionally higher rates. Black and Native American students with disabilities were more likely than their White peers with disabilities to be expelled without educational services. Disproportionality in disciplinary procedures increases the risk of contact with the juvenile or criminal justice systems, particularly for children with disabilities from racial/ethnic minorities. Students with a 8

 Disproportionate Representation in Special Education and the Intersectionality

history of or who are at risk of engagement with the juvenile or criminal justice system have been found to exhibit impaired social skills, learning disabilities, reading disabilities, language disorders, and difficulty with problem-solving (Nelson, 2014; Stanford, 2020; U.S. Commission on Civil Rights, 2019). In addition, children and adolescents in the juvenile justice system have a higher rate of eligibility for special education services, three to seven times that of peers who are not in the system (U.S. Commission on Civil Rights). The school-to-prison pipeline, a term used to describe the pathway that links public schools to the juvenile justice or criminal justice systems, is marked by students who have a history of poor academic performance and disciplinary issues (Nelson, 2014). Others have used the term “school-to-confinement pipeline” to include other types of exclusionary measures or settings such as boot camps, psychiatric hospitals, and juvenile detention centers (Stanford, 2020). Due to their training in these areas, SLPs can provide preventative, diagnostic, and intervention services to directly address these children’s communication needs and indirectly address inequities in the disciplinary procedures by working with general education teachers, special education teachers, and school administrators. As a member of the IEP team, SLPs should advocate for and implement a culturally appropriate assessment process that would evaluate the student’s speech and language ability, social communication skills, executive functioning (e.g., self-regulation, impulse control, task management, organization), and theory-of-mind (Stanford, 2020). Stanford (2020) suggests that SLPs could participate in the Manifestation Determination Review (MDR), a review process required by IDEA (2004). Schools must review all relevant information such as academic performance, the child’s IEP (including communication goals), and any behavior plans to determine if the child’s disability led to the disciplinary infraction. If the SLP is not part of the official MDR process, the SLP can still serve as an advocate for the child and work with the family to ensure they understand the role poor communication and cognitive skills may have on a child’s behavior (Stanford, 2020). For children who are part of the juvenile or criminal justice system, the SLP should still address areas of need, particularly facilitating communication (e.g., sharing factual information, expressing opinions, sharing social emotional status, repairing breakdowns in communication) with professionals in the legal system. Cultural and linguistic variations in communication styles have been perceived negatively in the criminal justice system, such as the case of a witness in the State of Florida v. George Zimmerman who used African American English (Rickford & King, 2013).

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SOLUTIONS AND RECOMMENDATIONS Addressing disproportionality will require systematic changes in the educational system and related services such as speech-language pathology due to the confluence of variables such as language status, socioeconomic status, race, ethnicity, and disability (Sullivan & Artiles, 2011). These changes would involve: a) transparent system evaluations regarding equity and inclusion; b) input from stakeholders such as families and community leaders; c) collaboration between SLPs, general education, and special education teachers; d) a review of policies and the allocation of resources; and e) a review of the curriculum and services needed for the development of communication and academic skills (Sullivan et al., 2015). Speech-language pathologists can contribute to this process by serving as advocates for children with disabilities and those who are marginalized within educational and legal systems. As members of multidisciplinary teams who are involved in each stage of the eligibility process and the provision of

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direct and indirect services, SLPs have the opportunity to address disproportionality, improve support systems, and increase access to services for children in need.

FUTURE RESEARCH DIRECTIONS Researchers, advocates, and stakeholders should continue to examine the intersection of race, ethnicity, and disability; however, these disparities have been long recognized; therefore, researchers should develop evidence-based practices and procedures to address the systemic inequalities within the educational system (Artiles, 2014). This could include examining the effectiveness of academic training programs for teachers and related service providers such as SLPs. Are these programs using a framework that facilitates cultural competence and cultural humility? For SLPs, there is a long-standing need for assessment measures that account for variations in language status, SES, and cultural. There needs to be more research on practices such as response-to-intervention to determine their efficacy for culturally and linguistically diverse populations.

CONCLUSION The root of minority disproportionality in special education identification is multi-faceted and involves the intersectionality of race, ethnicity, socioeconomic status, gender, and academic achievement. While there may be disagreement about whether children from diverse backgrounds are underrepresented or overrepresented in special education, each direction brings challenges to effectively identifying and providing services to children with disabilities. In either scenario, minority children with disabilities may not have access to the free and appropriate educational services promised by federal legislation such as IDEA (Individuals with Disabilities Education Act, 2004). To address these factors equitably and effectively requires cultural competence, understanding the impact of social, linguistic, and cultural variables on stakeholders, and an individual’s ability to adjust their interactions and service delivery accordingly.

ACKNOWLEDGMENT

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This research was supported by the Office of Special Education Programs of the Department of Education [grant number H325K140413]; and [grant number H325K180143]. The author thanks Zachary Namey for his assistance researching this topic.

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Morris, E. W. (2007). “Ladies” or “loudies”? Perceptions and experiences of Black girls in classrooms. Youth & Society, 38(4), 490–515. doi:10.1177/0044118X06296778 Nelson, C. M. (2014). Students with learning and behavioral disabilities and the school-to-prison pipeline: How we got here, and what we might do about it. In B. G. Cook, M. Tankersley, & T. J. Landrum (Eds.), Special education past, present, and future: Perspectives from the field (Vol. 27, pp. 89–115). Emerald Group Publishing. doi:10.1108/S0735-004X20140000027007 Oswald, D. P., Coutinho, M. J., Best, A. M., & Nguyen, N. (2001). Impact of sociodemographic characteristics on the identification rates of minority students as having mental retardation. Mental Retardation, 39(5), 351–367. doi:10.1352/0047-6765(2001)0392.0.CO;2 PMID:11710847 Restrepo, M. A., Schwanenflugel, P. J., Blake, J., Neuharth-Pritchett, S., Cramer, S. E., & Ruston, H. P. (2006). Performance on the PPVT-III and the EVT: Applicability of the measures with African American and European American preschool children. Language, Speech, and Hearing Services in Schools, 37(1), 17-27. Rice, M. L., & Hoffman, L. (2015). Predicting vocabulary growth in children with and without specific language impairment: A longitudinal study From 2;6 to 21 years of age. Journal of Speech, Language, and Hearing Research: JSLHR, 58(2), 345–359. doi:10.1044/2015_JSLHR-L-14-0150 PMID:25611623 Rickford, J. R., & King, S. (2013, October). Justice for Jeantels: Fighting linguistic prejudice and racial inequity in courts and schools after Florida v. Zimmerman. Presentation at the meeting of New Ways of Analyzing Variation 42, Pittsburgh, PA. Robinson, G. C., & Norton, P. C. (2019). A decade of disproportionality: A state-level analysis of African American students enrolled in the primary disability category of speech or language impairment. Language, Speech, and Hearing Services in Schools, 50(2), 267–282. doi:10.1044/2018_LSHSS-17-0149 PMID:30973798 Shifrer, D., Muller, C., & Callahan, R. (2011). Disproportionality and learning disabilities: Parsing apart race, socioeconomic status, and language. Journal of Learning Disabilities, 44(3), 246–257. doi:10.1177/0022219410374236 PMID:20587753

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Skiba, R., Simmons, A., Ritter, S., Kohler, K., Henderson, M., & Wu, T. (2006). The context of minority disproportionality: Practitioner perspectives on special education referral. Teachers College Record, 108(7), 1424–1459. doi:10.1111/j.1467-9620.2006.00699.x Skiba, R. J., Poloni-Staudinger, L., Simmons, A. B., Feggins-Azziz, L. R., & Chung, C.-G. (2005). Unproven links - Can poverty explain ethnic disproportionality in special education. The Journal of Special Education, 39(3), 130–144. doi:10.1177/00224669050390030101 Smith, B., Zhang, J., Pham, G. N., Pakanati, K., Raol, N., Ongkasuwan, J., & Anne, S. (2019). Effects of socioeconomic status on children with hearing loss. International Journal of Pediatric Otorhinolaryngology, 116, 114–117. doi:10.1016/j.ijporl.2018.10.032 PMID:30554680 St Amant, H. G., Schrager, S. M., Pena-Ricardo, C., Williams, M. E., & Vanderbilt, D. L. (2018, February). Language Barriers Impact Access to Services for Children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 48(2), 333–340. doi:10.100710803-017-3330-y PMID:28988384

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Stanford, S. (2020). The school-based speech-language pathologist’s role in diverting the school-toconfinement pipeline for youth with communication disorders. Perspectives of the ASHA Special Interest Groups, 5(4), 1057–1066. doi:10.1044/2020_PERSP-20-0002 Stockman, I. J., Boult, J., & Robinson, G. C. (2008). Multicultural/multilingual instruction in educational programs: A Survey of perceived faculty practices and outcomes. American Journal of Speech-Language Pathology, 17(3), 241–264. doi:10.1044/1058-0360(2008/023) PMID:18663109 Sullivan, A. L., & Artiles, A. J. (2011). Theorizing racial inequity in special education: Applying structural inequity theory to disproportionality. Urban Education, 46(6), 1526–1552. doi:10.1177/0042085911416014 Sullivan, A. L., Artiles, A. J., & Hernandez-Saca, D. I. (2015). Addressing special education inequity through systemic change: Contributions of ecologically based organizational consultation. Journal of Educational & Psychological Consultation, 25(2-3), 129–147. doi:10.1080/10474412.2014.929969 Sullivan, A. L., & Bal, A. (2013). Disproportionality in special education: Effects of individual and school variables on disability risk. Exceptional Children, 79(4), 475–494. doi:10.1177/001440291307900406 Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. doi:10.1353/hpu.2010.0233 PMID:10073197 Thompson, D. (2013). The 33 Whitest Jobs in America. The Atlantic. Retrieved April 25, 2021, from https://www.theatlantic.com/business/archive/2013/11/the-33-whitest-jobs-in-america/281180/ Travers, J. C., Krezmien, M. P., Mulcahy, C., & Tincani, M. (2014). Racial disparity in administrative autism identification across the United States during 2000 and 2007. The Journal of Special Education, 48(3), 155–166. doi:10.1177/0022466912454014 U.S. Commission on Civil Rights. (2019). Beyond Suspensions: Examining School Discipline Policies and Connections to the School-to-Prison Pipeline for Student of Color with Disabilities (Briefing Report). Author. U.S. Department of Education. (2016). Fact Sheet: Equity in IDEA. https://www.ed.gov/news/pressreleases/fact-sheet-equity-idea

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Wegmann, K. M., & Smith, B. (2019). Examining racial/ethnic disparities in school discipline in the context of student-reported behavior infractions. Children and Youth Services Review, 103, 18–27. doi:10.1016/j.childyouth.2019.05.027 Wittke, K., & Spaulding, T. J. (2018). Which preschool children with specific language impairment receive language intervention? Language, Speech, and Hearing Services in Schools, 49(1), 59–71. doi:10.1044/2017_LSHSS-17-0024 PMID:29188274 Yamasaki, B. L., & Luk, G. (2018). Eligibility for special education in elementary school: The role of diverse language experiences. Language, Speech, and Hearing Services in Schools, 49(4), 889–901. doi:10.1044/2018_LSHSS-DYSLC-18-0006 PMID:30458548

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ADDITIONAL READING Beneke, M., & Cheatham, G. A. (2015). Speaking up for African American English: Equity and inclusion in early childhood settings. Early Childhood Education Journal, 43(2), 127–134. doi:10.100710643014-0641-x DeMatthews, D. (2016). Effective leadership is not enough: Critical approaches to closing the racial discipline gap. The Clearing House: A Journal of Educational Strategies, Issues and Ideas, 89(1), 7–13. doi:10.1080/00098655.2015.1121120 Foronda, C., Baptiste, D. L., Reinholdt, M. M., & Ousman, K. (2016, May). Cultural Humility: A Concept Analysis. Journal of Transcultural Nursing, 27(3), 210–217. doi:10.1177/1043659615592677 PMID:26122618 Stringer, H., & Lozano, S. (2007). Under identification of speech and language impairment in children attending a special school for children with emotional and behavioural disorders. Educational and Child Psychology, 24(4), 9–19. http://www.nclive.org/cgi-bin/nclsm?url=http://search.ebscohost.com/login. aspx?direct=true&db=psyh&AN=2008-03074-002&site=ehost-live Travers, J. C., Tincani, M., & Krezmien, M. P. (2013). A multiyear national profile of racial disparity in autism identification. The Journal of Special Education, 47(1), 41–49. doi:10.1177/0022466911416247 Vichet, C., & Amanda, S. (2013). Racialization of Abilities and Disabilities in U.S. Schools: Asian American Students in Gifted and Special Education. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations, 20(2), 49-59. %U https://pubs. asha.org/doi/abs/10.1044/cds20.2.49 Zakszeski, B., Rutherford, L., Heidelburg, K., & Thomas, L. (2021). In pursuit of equity: Discipline disproportionality and SWPBIS implementation in urban schools. The School Psychologist, 36(2), 122–130. doi:10.1037pq0000428 Zucker, S. H., Perras, C., Perner, D. E., & Murdick, N. (2013). Best Practices for Practitioners in Autism, Intellectual Disability, and Developmental Disabilities. Education and Training in Autism and Developmental Disabilities, 48(4), 439–442.

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KEY TERMS AND DEFINITIONS Cultural Competence: The understanding of the impact of social, linguistic and cultural variables on stakeholders, and an individual’s ability to adjust their interactions and service delivery accordingly. Discipline Gap: The disproportionality in school disciplinary procedures and outcomes for racial and ethnic minorities. Disproportionate Representation: The underrepresentation or overrepresentation of a race or ethnic group in the identification for special education or in the placement of restrictive educational settings Language Minority: Individuals in the United States who use a language other than English predominately in their home.

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Related Services: Transportation and developmental, supportive, and corrective services such as speech-language pathology and audiology services to assist children with disabilities to participate in the educational system. School-to-Prison Pipeline: A term that refers to the pathway from school disciplinary procedures to the juvenile justice or criminal justice system. Significant Disproportionality: The overrepresentation of a race or ethnic group in the identification for special education or in the placement of restrictive educational settings. Verve: Expressive body language in which the individual uses high energy and active movement.

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Chapter 2

Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community Gregory C. Robinson University of Arkansas for Medical Sciences, USA Andrea L. Toliver-Smith University of Arkansas for Medical Sciences, USA

ABSTRACT The purpose of this chapter is to discuss the sociopolitical landscape of gender and sexuality in order to assist speech-language pathologists (SLPs) in dismantling systems of oppression for LGBTQIA+ people. An overview of principles and best practices in working with LGBTQIA+ people is provided. The chapter defnes terms related to LGBTQIA+ culture and practical recommendations for how to practice in ways that challenge culturally-constructed, oppressive gender and sexuality stereotypes and communicate afrmation and support to individuals of all genders and sexualities.

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INTRODUCTION The global understanding of gender (identity and expression) and sexual orientation is deepening and evolving. More specifically, the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, Asexual or other sexual or gender minorities (LGBTQIA+) movement is challenging long-held gender roles and expectations accumulated across a history of European colonization and enculturation. These expectations, rules, and laws were predominantly created to limit women’s access to men’s space and further limit and oppress Black and Indigenous people of color (BIPOC; Vaid-Menon, 2020). While the understanding of these concepts may seem new to some, it is important to note that sexual orientation and gender diversity have been documented across cultures throughout history (Vincent & Manzano, 2017). European colonists imposed their socially constructed gender binary onto indigenous cultures, and attempted to erase and eradicate gender designations that were not either male or female across the DOI: 10.4018/978-1-7998-7134-7.ch002

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 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

world (Tharp, 2016; Vaid-Menon, 2020). In the United States, numerous laws were put in place to ensure that men and women dressed differently (Sears, 2015), primarily to prevent women from accessing powerful institutions and spaces that were exclusively for men (Sears, 2015; Vaid-Menon, 2020). This imposed gender binary was further used to oppress BIPOC. Transgender BIPOC are at higher risk of physical assault compared to all other race/gender groups (Coulter, et al., 2017) and are often erased from the transgender narratives led by predominantly White researchers (Singer, 2015). As Western cultures begin to shift toward greater flexibility in gender roles, many LGBTQIA+ individuals are beginning to embrace and accept themselves and live a life of greater authenticity. However, this cultural shift is also causing a backlash from others, resulting in a groundswell of anti-trans legislation currently being passed in multiple states at the time of this chapter (American Civil Liberties Union, 2021). Speech-Language Pathologists (SLPs) as communication experts are in a unique position to begin challenging and changing systems that oppress LGBTQIA+ people. This shift hopefully will lead to greater acceptance of people who are LGBTQIA+, allowing everyone to live authentically and openly without fear. However, currently, such a goal has not yet been achieved. Due to socially-constructed, binary gender expectations and assumptions that pervade the general culture in the U.S., LGBTQIA+ people experience numerous health disparities in both healthcare and education settings (Baams, 2018; Bränström, Hatzenbuehler & Pachankis, 2016). If SLPs do not become aware of the harmful paradigms that they are supporting, they will continue to contribute to these disparities hurting their clients, students, and colleagues. Such harms include poor outcomes in therapy, depression, suicidal ideation, and assault from others. The first principle of The Code of Ethics of the American Speech-Language-Hearing Association (ASHA) dictates that SLPs and Audiologists should hold the welfare of their clients paramount (ASHA, 2016). The Ethics of Care (Gilligan, 1982; Noddings, 1984; and Tronto, 2013) asserts that the core of ethical practice lies in how one expresses care and concern for others. This model stipulates that ethical practice requires practitioners to: (a) pay attention to people and the surrounding cultural context, (b) recognize power differences and act responsibly in situations where they have greater power than others, (c) always continue to acquire competence in how to care for others, and (d) be responsive to the needs of others. In other words, treat others how they wish to be treated (a.k.a., the Platinum Rule). It is important to be mindful that the concepts and terms presented in this chapter are a snapshot of rapidly evolving narratives. Those narratives are developing within and across cultural groups, where the terms, concepts, barriers, and stressors may differ. It isn’t enough for SLPs to be aware of these differences (i.e., culturally competent), but SLPs must strive for cultural humility, or the understanding that the voices of people from marginalized groups must be centered in the discussion, taken seriously, listened to, and be recognized as the foremost experts on topics which involve them. This chapter aims to increase awareness of harmful paradigms related to gender and sexuality that affect everyone, but disproportionately affect LGBTQIA+ individuals and particularly LGBTQIA+ people with additional marginalized identities. The chapter provides SLPs with key terms and best practices to affirm and support LGBTQIA+ individuals and practical ways that they can help stop oppressive ideologies of gender and sexuality.

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BACKGROUND Many categories that may be accepted as irrefutable or unquestioned by most people are actually cultural constructs that do not reflect the diversity that exists in reality. These categories serve to simplify a complex and diverse world, making it easier to understand (Berger & Luckmann, 1991). The categories framing traditional conceptualizations of gender and sex are among these culturally constructed categories. The vast gender and sexual diversity present among humanity does not fit neatly into the binary categories that people impose on them. LGBTQIA+ individuals have created and modified terms to capture these concepts more accurately. The following section will discuss key terms related to these general areas: (a) sex, (b) gender, and (c) sexual/romantic orientation.

Sex At birth, a medical professional (e.g., obstetrician, nurse, midwife) will assign the baby to one of two categories, male or female, based on the appearance of the external genitalia. In this chapter, this category will be called sex assigned at birth. Therefore, individuals, for the most part, are either assigned male at birth (AMAB) or assigned female at birth (AFAB). However, not everyone’s anatomy fits exclusively into those two categories. Some babies are born with ambiguous genitalia. Contrary to what many in the modern medical community believe, “ambiguous genitalia do not constitute a disease. They simply constitute a failure to fit a particular (and at the present, a particularly demanding) definition of normality” (Dreger, 2004, p. 30). Genital ambiguity occurs in approximately 6 out of 1000 births (Ahmed, et al., 2004), and the rate appears to be increasing (Rich, et al., 2016). When this occurs, the person will be either AMAB or AFAB, depending on the judgement of the person making that assignment. Historically, surgeries to modify intersex anatomy have been done, often without the knowledge or consent of the parents (Dreger, 2004; Dickens, 2018). Notably, people with ambiguous genitalia are only a fraction of those considered intersex. The rate of individuals with some anatomical, chromosomal, or hormonal androgyny may be as high as 1.7% of the population (Blackless, et al., 2000). For the purposes of this chapter, sex is defined as patterns of anatomical, hormonal, chromosomal and physiological variations that cluster around people assigned male and female at birth, but may not solely reside in those categories. Given this reality, a person’s sex may be male, female, or intersex, which includes numerous patterns of anatomy and genetic coding documented across humans (Hrabovszky & Hutson, 2002).

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Gender For many, the word gender is misunderstood as a synonym for sex. However, there are key differences between these two terms (Schellenberg & Kaiser, 2018). As previously mentioned, sex is anatomically focused. Gender is culturally, socio-politically, and identity-focused. Gender may be an aspect of one’s identity but it is something that is performed consciously and unconsciously as a person goes about their day (Lorber & Farrell, 1991). Therefore, gender may be discussed as gender identity or gender expression. Gender identity concerns how a person feels/identifies as an individual living in a world of gender-specific expectations, stereotypes, and language. Gender expression refers to how they dress,

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 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

communicate, and otherwise move through their world, regarding and/or disregarding cultural expectations and symbols of masculinity, femininity, and androgyny. When a person identifies with the sex assigned at birth, the term cisgender is used to describe them. The term cis is a Latin preposition meaning “on the same side” (Wu, 2015). Therefore, a cis man is a person AMAB who identifies as a man; a cis woman is a person AFAB who identifies as a woman. When a person is not their sex assigned at birth, the term transgender is used. Similar to cis, trans is a Latin preposition meaning “across” (Wu, 2015). Therefore, a trans man is a man who was AFAB; a trans woman is a woman who was AMAB. When referring to gender expression, the terms trans masculine and trans feminine may be used. For many people, the binary categories of man and woman (male and female) are not sufficient to capture their gender. For these individuals, the term non-binary is used. While non-binary genders may seem new to many people in the U.S., cultures around the world have long recognized and revered gender categories beyond those of male and female (Tharp, 2016). Numerous North American indigenous tribes have had specific words for genders beyond the binary. For example, nadleeh in Navajo was a single term used to describe non-binary individuals. Other tribes, like Mohave used two terms to describe specific third and fourth genders, such as hwame and alyha (Roscoe, 1998). In India and other countries in South Asia, hijra are trans feminine individuals who have a history being respected and revered by many in those cultures (Revati, 2010). The Bugis culture of South Sulawesi, Indonesia, acknowledge five genders that include masculine men, feminine men, masculine women, feminine women, and one gender that includes all aspects of the other four (Davies, 2006; Tharp, 2016). In addition to non-binary terms with a long history of usage, modern cultures are coining new terms to refer to non-binary genders, (Ho & Mussap, 2019; Koehler, Eyssel, & Nieder, 2018). These terms include: (a) genderqueer (b) genderfluid, (c) agender, and (d) bigender. Genderqueer is an umbrella term often used to encompass an undefined gender that is neither completely man nor completely woman (Erickson-Schroth, 2014). Genderfluid refers to a gender identity that changes over time. Sometimes a genderfluid person will identify as a man, sometimes a woman, and sometimes a mixture of the two or neither man nor woman (Erickson-Schroth, 2014). Agender individuals are people who do not identify as any gender at all or a gender described as neutral (Erickson-Schroth, 2014; Richards & Barker, 2013). Bigender individuals feel that they are two genders simultaneously (Erickson-Schroth, 2014). Many non-binary people do not consider themselves transgender, and many do. Due to this diversity within the population, the term transgender/non-binary (TGNB) is used as an inclusive phrase to refer to people who are not cisgender. Also of note, when using the term transgender, it is advised not to use the suffix –ed (Steinmetz, 2014). The term transgendered is offensive to many transgender people because it signals a lack of understanding that being transgender is not a process that has been completed, but a state of being. It is also advised to only use the terms transgender and non-binary as adjectives. For example, a transgender person or people who are transgender are acceptable phrases; however, a transgender or those transgenders would be considered offensive. In the previous decade, it was acceptable to use the terms male-to-female (MTF) and female-to-male (FTM); however, those terms are now considered antiquated and inaccurate because they suggest that the transgender person was at one time a different gender than they are now. This misunderstanding does not reflect the lived experiences of many TGNB people. Regardless of gender identity, a person may choose different styles of gender expression. When a person chooses to express themselves in ways that do not align with the binary notions of masculinity 21

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

and femininity (dress, communication, interests/hobbies, societal roles, etc.), the term gender non-conforming is used. Gender non-conforming people may be cis men who wear clothes deemed by society to be feminine or cis women who express themselves in ways perceived as masculine. The separation of the concepts of gender identity and gender expression is particularly relevant when working with TGNB people. Some TGNB individuals have not yet socially transitioned. In other words, they have not yet modified their outward appearance to reflect society’s expectations of masculinity, femininity, or androgyny that align with their gender identity. In these cases, it is important to remember that they are no less the gender they say they are than others who have socially transitioned. For example, a person may have a beard and other features commonly perceived to be masculine, but if they say that they are a woman, then that is their gender.

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The Importance of Names and Pronouns A name is a noun used to reference a person during communication between people. As with any aspect of language, if that name is actually communicating something inaccurate, either the commonly agreed upon definition of that name needs to change or the name itself needs to be changed to something that more accurately communicates who that person is. There is a dialectical relationship between language and perception of reality. Perceptions often change the language we use in reference to people, but conversely, our perceptions about people may be influence by the words used to describe them (Chen, Benet‐Martínez & Ng, 2014). Generally speaking, a person is assigned a name around the same time they are assigned a sex-- at birth. In most cultures, there are names that are exclusively or predominantly associated with men and others associated with women. When the sex assigned at birth does not align with the gender of the person, then the name will communicate an incorrect gender to others. In order to correct this inaccuracy, many TGNB individuals will adopt a name that more accurately communicates their gender. In some cases, they may legally change their name, birth certificate, and identification documents. However, not everyone chooses to do this, and some TGNB may not have started or may not have completed the process of changing their legal documents. When a TGNB person changes their name (socially or legally), the old name is referred to as a deadname. Deadnaming, or calling a TGNB person by that name, can be psychologically traumatic, stressful, embarrassing, and may place the person in danger (PFLAG, 2021). In many languages a person’s gender is communicated through bound and free morphemes, such as suffixes, honorifics, titles, and pronouns. In English, the primary gender markers occur with honorifics (sir, ma’am, Mr., Ms., Miss) and the third-person, singular pronouns (he, she). However, many familial titles are also coded for gender (mom, dad, aunt, uncle, sister, brother, etc.). Understandably, a TGNB individual will often request that others use terms that more accurately reflect their gender. For those whose identity or expression align with the cultural concepts of men or women, the terms that best reflect their gender may be terms that are already commonly used in their language. In other words, a trans man might change his name to one associated with men, use the honorific “Mr.”, and request that he be called “sir”, “dad”, “uncle”, “brother”, etc. Likewise, a trans woman might change her name to one associated with women, use the honorific “Ms.”, and request that she be called “ma’am”, “mom”, “aunt”, “sister”, etc. However, TGNB people do not always make these modifications. Therefore, it is important to ask and be receptive to variations across TGNB individuals.

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Non-binary people may request gender neutral terms be used. Sometimes, these terms may be gender neutral concepts already used within the language but just expanded to include them specifically, such as the third-person singular pronoun they. Contrary to what some prescriptivist grammarians assert, singular they is an acceptable grammatical form in English (Bjorkman, 2017). Singular they has been used for centuries in English to refer to a person for which gender is unspecified (e.g., “Someone left their cellphone in here. I hope they come back for it.”). Note that when singular they is used, the verb that follows is plural. This is because the pronoun they is grammatically plural even when it is semantically singular, just like singular you (e.g., “You are the only person left.”). In this context, someone who is non-binary may request that people use they/them pronouns when referring to them (e.g., “Sam is a good friend of mine. They are always there when I need them. Their sense of loyalty is strong.”). Alternatively, someone who is TGNB might request that neo-pronouns (i.e., pronouns not commonly used in English) or genderless honorifics and titles be used in reference to them. Some examples of neopronouns are xe/xim/xis, fae/faer/faers, and e/em/es (e.g., Sam is a great artist. Xe is so creative. I love xim and xis work.). The genderless honorific “Mx.” (pronounced Mix) or Mxr. (pronounced Mixter) may be requested. Others may request that professional titles be used as honorifics, such as Dr., Rev., Teacher, Instructor, etc. Additionally, new familial terms may be requested, such as “apa” (gender-free variant of mother/ father), “nibling” (gender-free term for brother/sister or niece/nephew), or “auncle” (gender-free term for aunt/uncle). These terms are just examples; the practitioner should ask and listen to the individual to determine which terms are to be used.

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Sexual/Romantic Orientation Sexual/romantic orientation refers to what gender(s) a person is sexually/romantically attracted to in reference to their own gender (PFLAG, 2021). For many, sexual orientation is aligned with romantic orientation; however, this alignment is not the case for everyone. A person may be sexually attracted to people who are a different gender from their own (heterosexual) and romantically attracted to people who are the same gender that they are (homoromantic). Homosexual/homoromantic orientations generally include the terms: (a) gay, meaning a man who is primarily or exclusively attracted to other men, and (b) lesbian, meaning a woman who is primarily or exclusively attracted to other women. Bisexuals and pansexuals are people who experience attraction to multiple genders, including their own (PFLAG, 2021). It is a common misconception that the term bisexual refers only to individuals who are attracted according to the gender binary (i.e., men and women); however, this is not the case as many bisexuals are attracted to more than two genders and there are many non-binary people who consider themselves bisexual. Therefore, there is often a great deal of overlap between the terms bisexual and pansexual. Some use them interchangeably; others express that there is a difference between them. When that difference is expressed, bisexual may refer to people who feel a different level or type of attraction to different genders, while pansexual would refer to people who feel that gender is irrelevant in their attractions. Asexual orientations are often expressed along a continuum of orientations that describe people who have little or no sexual attraction or sexual attraction that occurs only under specific conditions (LGBTA Wiki, 2020). Similar to the other orientations, asexual orientations have a romantic cognate. Aromantics are individuals who do not feel romantic attraction to others, or feel that type of attraction conditionally or at a much lower level compared to the wider population. 23

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

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Gender and Sexual Diversity and the Black Diaspora While the above framework may be a useful way of conceptualizing different facets of gender, sex, and sexuality, different cultures navigate these facets in different ways. Many LGBTQIA+ people may not consider gender and sexual/romantic orientation to be independent of one another, and this difference is something that is more frequently seen among LGBTQIA+ BIPOC (Singer, 2015). This difference highlights that fact that each person’s journey to accept the gender and sexual diversity naturally existing across humanity, is heavily influenced by the history of the culture in which they find themselves. This fact is especially relevant for LGBTQIA+ descendants of the Black diaspora living in the context of a long history of oppression of Black people in North America. LGBTQIA+ Black Americans often experience rejection by Black friends and family for the gender and sexuality (Griffin, 2010). This ongoing homophobia and transphobia present within Black communities is influenced by the historic physical and psychological abuse of slaves by White slave owners, which often involved rape of Black slaves regardless of age or gender (Beckles, 2004; King, 2006; Ferguson, 2020). The heinous act of “buck breaking” involved White male slave owners raping Black men in public to emasculate them and break them into submission (Beckles, 2004). Due to this history, many in modern descendants of the Black diaspora view the LGBTQIA+ movement as yet another White attack on Black people (King, 2006). Black Americans have long been held to White cultural concepts of masculinity and femininity, but then denied full access to those roles due to a long history of societal oppression continuing on to today (Harris, 2009). These cultural standards paired with denial of access, have created a catch 22 situation for many. Black Americans are prevented from accessing symbols of masculinity and femininity predominantly created by White culture and are further presented with additional barriers when attempting to bypass those gendered expectations. This gendered gatekeeping has been specifically targeted at Black trans women. One example may be found in the disparate acceptance of Black versus White trans people in the U.S. In the 1950s, White trans people were beginning to receive medical interventions, such as hormone therapy, to physically affirm their gender. However, Black trans people were excluded from these interventions for decades and continued to be viewed as criminal, deviant, and/or mentally ill (Gill-Peterson, 2018). Fisher (2019) posits that due to the historical and ongoing struggle to attain basic civil rights and fair treatment in the U.S., the gender and sexual diversity of Black civil rights leaders have been obscured or erased to protect the “history of African American race work from the sullying effects of queerness and transness” (p. 189). Although the riots at Stonewall, which catalyzed what would eventually become the LGBTQIA+ civil rights movement, were led by Black trans women, such as Marsha P. Norman and Miss Major Griffin-Gracy, this historic reclamation of power was largely borne out of the reality that they had “nothing more to lose” (M. Griffin-Gracy, personal communication, March 15, 2021). In other words, it was the very fact that they were among the most socially reviled and oppressed people in the U.S. that they had to riot. There was no other choice. Fitzgerald (2013) stated, “The devastating impact of blackface minstrelsy on black manhood was countered with a hyper-masculinity” (p. 27). In other words, concepts of masculinity were fused with concepts of power, and the need to perform masculinity was central to the struggle to attain basic equality for Black people, and that fusion continues to today (Plummer, 2013). Therefore, Black LGBTQIA+ people, particularly those embracing feminine expression, are often viewed as weak (Plummer, 2013) and a distraction to the anti-racism movement (Fisher, 2019). 24

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

In short, issues related to homophobia and transphobia existing within many Black communities are the result of a long history of the heinous treatment of Black male slaves, a reluctance to embrace yet another culturally stigmatized identity in addition to race, and a distraction to the issue of racism. As a result, LGBTQIA+ Black people often face double discrimination as they are ostracized for their sexual orientation, gender identity, and expression among the Black community (Griffin, 2010) and further marginalized by the dominant White LGBTQIA+ community for being Black (Giwa & Greensmith, 2012).

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Heteronormativity and Binary Gender Roles The enculturation of gender expectations begins at birth. With the invention of ultrasound technology, medical professionals have acquired the ability to examine the general shape of a developing fetus inside the womb. This technology is primarily used by physicians to determine if the fetus is developing in a typical manner compared to other fetuses at a similar stage of gestation. However, such technology also allows people to view an image of the developing external genitalia. The appearance of external genitalia is used to assign one of the binary sex categories to infants. Many parents may embrace this prescience. They may host “gender-reveal parties” before birth, begin decorating the nursery using gender-specific themes, and buying clothing that expresses that gender. Thus, the merging of the concepts of sex and gender have been further codified in the cultural groups that have embraced ultrasound technology along with the gender binary. However, as discussed previously, there are two main problems with this merger: (a) external genitalia don’t always fit into the binary; and (b) genitals don’t always match gender. Nevertheless, humans are taught from a very early age how to perform the gender that they are assumed to be. They are taught how to dress, what kinds of behaviors are acceptable and unacceptable, and what toys they should play with. They will often be directed to observe others of the same gender as models of how one should behave as a man or a woman, thus being taught the repetitive acts necessary to perform their gender (Butler, 1988; Lorber & Farrell, 1991). The systems in place that frame the practice of speech-language pathology are largely built on the assumptions of a gender binary and a prototypic family structure that includes a man married to a woman (i.e., heteronormativity). Language assessments for children force children to assume gender based on the hair style and dress of the people pictured in the stimulus books and then use that information to either produce a corresponding third-person singular pronoun that encodes gender (i.e., he or she), or evaluate the “absurdity” of a sentence when a picture of a person wearing a dress with long hair is referred to as a boy (Chi, 2019). Normative data associated with some tests are divided according to boys and girls, leaving no perfect option for scoring a child that is TGNB (Webb et al., 2016). Therapy materials commonly depict children in stereotypic gender roles and even sequence the steps of a man and a woman dating, falling in love, getting married, and having children (Rojas, 2021). Adult cognitive assessments often ask “Are you a man?” or “Are you a woman” as a way of evaluating the patient’s ability to answer simple questions with a clear, undeniable answer (Wilson et al., 2018). The dominant paradigm is that a person’s gender is either male or female and that gender is a basic fact that is irrefutable and unable to be altered, akin to water being wet or the sky being up. The overwhelming expectation is that boys should dress, talk, walk, and behave in ways that are characteristically different from girls and that these two genders are in perfect alignment with two invariable sets of biological features that each person possesses from birth. These features include genitalia, hormones, vocal pitch, body shape, facial features and other anatomy. However, as previously discussed, a significant portion of humanity does not meet these expectations. Nevertheless, those expectations continue to be 25

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

wittingly and unwittingly promoted and maintained by SLPs through subtle actions, language, policies, and materials that often go unexamined. Culture may be described as the music that is constantly playing in the background. It continues to influence our thoughts, behaviors, and choices, even as we forget that it is playing at all. In the case of those within the LGBTQIA+ spectrum, cultural assumptions and expectations aligning with the gender binary and supporting heteronormativity often have very real and very harmful effects on their daily lives. In fact, some would argue that these assumptions and expectations actually benefit no one. TGNB author Alok Vaid-Menon asserts that no one is not harmed by the gender binary (2020).

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Gender, Sexuality, and the Field of Speech-Language Pathology The field of Speech-Language Pathology is overwhelmingly comprised of White women (ASHA, 2020). This lack of diverse perspectives biases the narrative around the topic of gender within our profession. It will come as no surprise to anyone reading this chapter that humans make assumptions about a speaker based on the speaker’s speech, language, voice, and non-verbal communication behaviors. One of those assumptions is gender. This process of assuming gender based on voice and communication, is not unlike similar assumptions made based on clothing, cosmetics, and hairstyle. Numerous factors play into what gender a person will be identified as (Hancock, Stutts & Bass, 2014). Some of those factors reside with the speaker and some with the listener. Sometimes those assumptions are accurate, and sometimes they are not. It is important to remember that this judgment is an assumption, which may or may not be accurate. When anyone is misgendered, it may cause that person to feel sad, unseen, anxious, stressed, or invalid. When that person is TGNB, these feelings may accumulate over time and become internalized (Testa, 2015). Unfortunately, for many TGNB people, a mismatch between gender and outward appearance may put them at risk for assault and physical harm. Like clothing and hairstyle, there is nothing inherently male or female about the vast majority of communication features commonly gendered as male or female by society. Although, testosterone does increase the mass of the vocal folds and the length of vocal tract, there is a great deal of overlap in vocal pitch used by men and women when they communicate. Also, similar to clothing and hairstyle, systemic misogyny plays into the social devaluing of communication features commonly viewed as feminine and the empowerment of features viewed as stereotypically masculine. Voice therapy with TGNB clients often focuses on hygiene and vocal warm-ups to ensure that the voice remains healthy as changes are being implemented. Beyond that, the best approach is one that is nuanced and avoids supporting and maintaining gender stereotypes that are often rooted in systemic misogyny. Such an approach may start out with guiding the client to discover vocal models, or speakers that they feel best represent their ideal voice. The SLP might help the client analyze what aspects of those people’s communication they like, and then lead them to begin implementing some features that they admire. While gender affirming communication services are within the scope of practice of SLPs, such services are elective and not “treatment” of a “pathology” or “disorder”. The client should always be in complete control over all aspects of such services. SLPs may serve to provide education, techniques, and feedback (if requested) and help the client navigate their efforts to modify their voice. However, every aspect of therapy should be client-led. This sentiment was captured in a comment posted by Ruchi Kapila in a professional Facebook group for LGBTQIA+ SLPs.

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 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

“If we write goals assuming the resonance qualities or configurations a client wants without their collaboration in goal formulation, the voice modification exchange, education, and service is meaningless and deleterious of the client’s agency (Kapila, 2021).” Kapila’s comment highlights the fact that each TGNB client’s journey to modify their voice should be centered on their perceptions, which are unique to each client. Client’s may be exposed to a menu of communication features they might address, allowed space to explore those possibilities, and make their own judgements about which ones they want to incorporate in their communication and which ones they want to leave out.

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Social and Health Disparities LGBTQIA+ people experience numerous disparities compared to the wider population. These health disparities are not the result of deficiencies within the LGBTQIA+ individual; they are the cumulative effects of having to deal with systemic oppression on an ongoing basis. Among these disparities, the human immunodeficiency virus (HIV) is one that many people are familiar with. While modern preventative measures and pharmaceutical interventions may have mitigated the HIV crisis, BIPOC continue to have barriers to access these (Golub, Meyers & Enemchukwu, 2020). In 2017, the Centers for Disease Control reported that transgender people were three times more likely to have received a new HIV diagnosis; half of these new cases were Black trans women (Gossett & Hayward, 2020). This issue directly affects SLPs, because many of the effects of HIV result in speech, language, and swallowing disorders (McNeilly, 2005). In addition to HIV infections, 39% of lesbian, gay, and bisexual people have been rejected by family and friends due to their sexual orientation, and 30% have been physically attacked. Twenty-nine percent feel unwelcome in their chosen place of worship, and 21% report being treated unfairly by their employer. Fifty-eight percent have been the target of homophobic jokes or slurs (Pew Research Center, 2019). Compared to heterosexuals, lesbian, gay, and bisexual people are 8 times more likely to have tried to commit suicide, 6 times more likely to report high levels of depression, and 3 times more likely to use illegal drugs. Bisexuals experience additional disparities. A total of 46% of bisexual women have been raped, compared to 17% of lesbian and heterosexual women. Forty-seven percent of bisexual men have been sexually assaulted. Bisexuals are twice as likely to attempt suicide compared to lesbians and gays. They are also more likely than lesbians and gays to have hypertension and cancer (Feinstein & Dyar, 2017). TGNB individuals are represented among those in poverty 10 to 1 compared to cisgender people. They are twice as likely to be unemployed. The rate of attempted suicide for TGNB people is 41%. Ninety-percent of TGNB people have been harassed, and they are twice as likely to be homeless compared to wider population (Grant, et al., 2011). BIPOC who are Trans women are actively profiled and targeted by law enforcement, and when they are assaulted, they often can’t depend on police to protect them (Carpenter & Marshall, 2017). TGNB people experience significant disparities in healthcare settings, as well. A total of 19% have been refused basic medical care based on the fact that they are TGNB. Twenty-eight percent have been harassed in a healthcare setting and 2% have experienced physical violence while seeking medical treatment. Half of TGNB people report that they have had to educate their healthcare provider about being TGNB, and over three-quarters of TGNB people have postponed necessary medical interventions due to fears of how they will be treated in healthcare settings. In general, due to fears of discrimination and assault in healthcare settings, TGNB are less likely to seek medical and mental healthcare. They have 27

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

more frequent visits to the emergency room and overall poorer health outcomes compared to cisgender people (Grant, et al., 2011). In addition to externally-focused stresses in society and healthcare settings, TGNB may experience gender dysphoria. Gender dysphoria is a feeling of distress that is caused by living in a society that does not recognize them for their true gender and internalizing those perceptions (Byne, et al., 2018). Gender dysphoria may be intense at times and difficult for the person to control. Sutter and Perrin (2016a) reported factors that were predictive of suicidal ideation and suicidal behavior in LGBTQIA+ students. Depression, drug use, peer victimization, and help-seeking behaviors were all factors that were predictive of suicidal ideation in these students. However, the presence of help-seeking behaviors were not predictive of actual suicidal behavior, indicating that those who seek out help may be less likely to attempt suicide. In another study by Sutter and Perrin (2016b), suicidal ideation among LGBTQIA+ BIPOC was investigated to determine how racism and homophobia/transphobia contribute to poor mental health leading to suicidal thoughts or behavior. Racism did increase suicidal ideation somewhat, but homophobia/ transphobia increased the risk of suicide to a much greater extent compared to racism alone. Racism and homophobia/transphobia did combine to increase the risk of suicide even more for LGBTQIA+ students of color compared to White LGBTQIA+ people, but homophobia/transphobia was the overwhelming contributor. Sutter and Perrin theorized that greater effect of homophobia/transphobia was the result of the students having the ability to conceal their sexuality or gender identity, but no such ability to conceal their race. Remaining closeted was theorized to have led to additional internalized stress for their study’s participants.

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SOLUTIONS & RECOMMENDATIONS To counter these harmful paradigms, SLPs need to become aware of how they may be supporting systemic oppression specific to gender. For example, SLPs should become mindful of how they treat children of different genders in early childhood and school settings, considering the following questions: Are different books and toys presented to children of different genders? Are some colors deemed unacceptable for children of some genders compared to others? How do people respond to boys who don dresses and scarves at the dress-up station versus girls who dress up in those outfits? When greeting children of different genders, is there a difference, like always commenting on what the girl is wearing or what a boy is doing? Is rowdy or energetic behavior in boys described as “all boy”? Are girls who are direct in their communication of wants and needs called “bossy,” while boys never hear that word in reference to them? When working with adults, SLPs should also be mindful of gender differences and assumptions. If the SLP knows the gender of their client, do they treat them differently? Are assumptions about occupations different for people perceived to be men versus women? Are stressors and demands of life assumed to be different? Do SLP recommendations differ? Is the process of building rapport different? LGBTQIA+ affirmative care is a practice that doesn’t just accept or include LGBTQIA+ clients, but actively seeks to dismantle misogyny, heteronormativity, and cisnormativity. It communicates through words and other symbols that all genders and sexual orientations are valid and recognized as a key part of identity (Rafferty & Committee on Psychosocial Aspects of Child and Family Health, 2018). Affirmation is important because the identities of LGBTQIA+ people may not be recognized as valid by others in their life. In other words, they may be regularly assumed to be someone they are not, many times by 28

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

people who have power over them or are very close and important to them. In order to feel safe enough to work on communication and other goals with their SLP, they need to feel like the client-clinician space is safe and affirming. If they don’t feel affirmed, LGBTQIA+ people may assume that their SLP is just the same as the wider society, and therefore, they must be vigilant in order to protect themselves from harm. Affirmative care involves the following agreements: (a) the client is the sole expert on their own sexual orientation and identity; (b) the client is in control of who and when they disclose their sexual orientation and gender; and (c) symbols (language and materials) communicate understanding and acceptance of identity. It is important for SLPs to understand that a request for a modification of language in reference to oneself (e.g, a new name, pronouns, honorifics) is not something that is done flippantly. The person requesting such linguistic modification is taking an enormous social risk in this request. Requests like these are often dismissed or ridiculed by others. When an SLP uses the correct language in reference to a TGNB individual, it communicates to them respect and affirmation that they may not commonly receive in their daily life (ASHA Multicultural Issues Board and L’GASP: The LGBTQIA+ Caucus of ASHA, 2021). This token of respect can go a long way in establishing a bond between the SLP and the client that could greatly improve outcomes of communication intervention. Alternatively, misgendering a client may lead to additional stress for the client, gender dysphoria (i.e., the psychological and/or physical discomfort of feeling like your body or behavior doesn’t match one’s identity), and a lack of trust between the client and the clinician. In addition to adding to the client’s overall stress, anxiety, and depression, such misgendering by the SLP may also be a barrier to progress in therapy. Mistakes may happen. Such mistakes are serious and should be treated as such. However, if a person misgenders someone else, that person should apologize and move on with the conversation. Overapologizing can perpetuate the harm caused to the TGNB person.

Clinical Recommendations for Affirmative Care So much about the perspective of the clinician and the organizations through which they work is communicated through materials and procedures used across all interactions with clients, patients, and students. These materials and procedures often support and maintain ideological systems that cause harm. The following recommendations are a sampling of ways in which SLPs might begin to challenge and dismantle these oppressive ideologies.

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Creating a Safe Space Environment A Safe Space is a location in which the LGBTQIA+ person can trust that they will be listened to and affirmed for who they are. Some clinics will hang up signs displaying a rainbow flag, and some will overtly label the clinic a “safe space.” In addition to that, all single-stall restrooms should be gender neutral, rather than labeling them as specifically male or female. When greeting clients/patients, staff are encouraged to introduce themselves with their pronouns: “Hi, my name is Susan. My pronouns are she/her. What are your name and pronouns?” (ASHA Multicultural Issues Board and L’GASP: The LGBTQIA+ Caucus of ASHA, 2021).

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 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

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Demographic and Case History Forms Forms should include language that is inclusive of the diversity present within society and make it easy for staff to call people the correct name, using the correct honorifics and the correct pronouns. For example, filing forms under the legal name sets up a system in which staff are much more likely to deadname clients and patients. Therefore, one recommendation is to file forms under the name that the person wants to be called. Clinical forms should list the name that the person wishes to be called at the top in order to prevent staff from calling the person another name. For billing purposes, it may be necessary for clinical forms to document the legal name; however, in affirmative care, the deadname resides solely within the context of the office in charge of billing and is not ever stated in front of the client or reflected on clinical documentation sent to the client (Goldberg, 2019; Robinson, 2021). If the name they want to be called differs from their legal name, it is good practice to ask the person to clarify the name they wish to appear on mail arriving at their home and what name they want to be referred to when called in from the waiting room. As a general rule, when a mailing address is requested on a form, there should be a space for the client or patient to write what name should appear on the envelope. This will prevent other residents in the home from seeing a name that they don’t recognize and forcing the client/patient to out themselves before they are ready (Robinson, 2021). Forms should also include a place to denote honorifics. Honorifics are the titles that often precede names. For example, the most common honorifics in most English-speaking countries are Mr., Ms., Miss, and Mrs. It is common for people to show respect to others using an honorific plus the last name of the person. However, due to the fact that these honorifics also encode gender and/or marital status, the use of honorifics is problematic for a gender diverse society. There are a few ways in which this problem is solved. First, asking people what they want to be called is an effective way of clarifying. Second, consider including additional honorifics on intake forms, such as Rev., Dr., Mx., Mxr. Forms also might include a fill-in-the-blank option, the option to use no honorific, or the option to refer to them by their first name. Gender is another piece of information that is often included on forms. Best practice is for the question about gender to be an open-ended fill-in-the-blank, followed by a check-box “no answer.” If it needs to be a closed-ended, multiple choice response, consider using the options: male, female, non-binary, other and no answer. Avoid including the options of transgender male and transgender female, because juxtaposing those two options alongside male and female assumes that transgender people are not actually male/female, which invalidates their identity. Furthermore, transgender people should not be asked nor expected to disclose the fact that they are transgender when such information is irrelevant to the purpose of their visit. In some cases, SLPs may need to know information related to natural hormone production, especially since those hormones may affect the voice. In this case, consider a space to indicate the sex assigned at birth or a more specific question, such as “Did your vocal pitch change during puberty?” and offer a space for clarification (ASHA Multicultural Issues Board and L’GASP: The LGBTQIA+ Caucus of ASHA, 2021; Robinson, 2021). Forms should also offer a place for patients and clients to list their pronouns. When this is done, they should be called simply “pronouns”; avoid using the phrase “preferred pronouns” as the word preferred suggests that their use is optional (Goldberg, 2019). Consider offering a multiple response and a fill-inthe-blank: he/him, she/her, they/them, and others _______. In addition to requesting pronouns on forms, it is also a signal of affirming care for staff to introduce themselves with their name and pronouns: “Hi my name is Susan, my pronouns are she/her.” Another excellent signal of affirmation is to provide pronouns on name badges. 30

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

Responding to Disclosures of Sexual Orientation and Gender Identity As previously discussed, LGBTQIA+ people often go through a period of being closeted. Eventually, the psychological costs of not living authentically may outweigh the social benefits of appearing to blend into the culture. When this occurs, the person may decide to come out. This may begin with a self-acknowledgement (i.e., a coming out to oneself) and then expand to include others in their life. LGBTQIA+ people often feel that coming out is an ongoing process that must be repeated throughout their life (Coleman, 1982). It is not uncommon for clients with speech or language impairments to come out to SLPs. In a survey of 192 LGBTQIA+ people with communication disorders, Kelly and Robinson (2012) found that 35-43% of clients had disclosed their sexual orientation or gender identity to their SLP. The fact that there has to be a “coming out” for LGBTQ+ individuals is testimony to the cultural barriers that LGBTQ+ individuals endure regularly. The coming out process is one that is often filled with a mixture of emotions and reactions from others. In an online survey of 854 adults identifying as LGBTQIA+, Robinson and Crisp (2018) asked respondents to share how they felt teachers should and should not respond to a student coming out to them. The following themes for how to respond were generated from the responses: (a) gratitude (“Thank you so much for trusting me with that information.), (b) validate and reassure (“You are valid and the expert on who you are.”), (c) notice the courage (“It can be scary to share this information about yourself. You are so brave.”), (d) celebrate (“I am so excited for you and the discoveries that you are making about yourself! Congratulations!”), (e) offer a safe space (“I want you to know that you can come to me about this and you will be safe.”), and (f) offer resources (“I have some groups you might be interested in joining to find support.”). The respondents also offered examples of responses to avoid when a student comes out to a teacher. These responses fell into the following themes: (a) suggesting that they should hide or remain closeted; (b) forcing them to come out to others; (c) questioning their certainty or saying it is a “phase”; (d) prying about personal issues; (e) telling them to “fix it”; (f) bringing up religion; (g) tokenizing or forcing them to be an educational resource about LGBT for the teacher; (h) alienating or refusing to talk about it; (i) dismissing the importance or expressing apathy; and (j) stating “I knew that already”.

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FUTURE RESEARCH DIRECTIONS The field of Speech-Language Pathology is on a precipice as its researchers and practitioners become increasingly mindful and reflect on systems of oppression that need to be changed in order to create a field that is inclusive of the inherent diversity that has long been all around. Research across health professions have a long history of exploiting people from marginalized groups, interpreting findings in ways that are inaccurate and harmful, and conducting research on topics that are objectionable to many in the community. Rather than listing research topics to be studied, this section is going to make a bold, simple statement about future research directions. Namely, future research needs to center the perspectives of the people being studied. If research involves marginalized groups, such as BIPOC and LGBTQIA+ people, then people from the community need to be included as authors or paid consultants. People from those communities need to be listened to as the foremost experts on the topic. Researchers need to ask these communities what they need them to research. Finally, manuscripts and publications should be reviewed and approved by members from the communities being studied before the findings are disseminated. 31

 Sociopolitical Implications to Consider When Working With the LGBTQIA+ Community

CONCLUSION The scope of practice for speech-language pathology has begun embracing gender affirming voice services to guide TGNB people to acquire a communication style that matches their gender. Due to the embracing of these services, information about working with TGNB populations has become increasingly more available to SLPs. However, SLPs should understand that LGBTQIA+ individuals are not just seeking gender affirming voice services. LGBTQIA+ people are present across the scope of practice, and due to pervasive cultural oppression, heteronormativity, binary gender assumptions, misogyny, and racism, these clients are often dealing with more than other clients. SLPs are in a unique position to provide these individuals a safe, affirming space and work to dismantle the oppressive systems that are causing health disparities among the LGBTQIA+ population.

ACKNOWLEDGMENT Special thank you to Kristina Olson, Sarah Gillian, Ruchi Kapila, Miss Major Griffin-Gracy, and the numerous LGBTQIA+ friends, colleagues, clients, and students.

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American Speech-Language-Hearing Association. (2020). Profile of ASHA members and affiliates, year-end 2019. Retrieved from https://www.asha.org ASHA Multicultural Issues Board and L’GASP. The LGBTQIA+ Caucus of ASHA. (2021, March 25). Supporting and Working With Transgender and Gender-Diverse Individuals. Retrieved from https:// www.asha.org/practice/multicultural/supporting-and-working-with-transgender-and-gender-diverseindividuals/ Baams, L. (2018). Disparities for LGBTQ and gender nonconforming adolescents. Pediatrics, 141(5), e20173004. doi:10.1542/peds.2017-3004 PMID:29661940 Beckles, H. (2004). Black masculinity in Caribbean slavery. University of the West Indies Press. Retrieved from https://uwispace.sta.uwi.edu/dspace/bitstream/handle/2139/7626/CGDS_220.pdf

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Berger, P. L., & Luckmann, T. (1991). The social construction of reality: A treatise in the sociology of knowledge (No. 10). Penguin UK. Bjorkman, B. M. (2017). Singular they and the syntactic representation of gender in English. Glossa: A Journal of General Linguistics, 2(1), 80. Blackless, M., Charuvastra, A., Derryck, A., Fausto‐Sterling, A., Lauzanne, K., & Lee, E. (2000). How sexually dimorphic are we? Review and synthesis. American Journal of Human Biology: The Official Journal of the Human Biology Association, 12(2), 151–166. doi:10.1002/(SICI)15206300(200003/04)12:23.0.CO;2-F PMID:11534012 Bränström, R., Hatzenbuehler, M. L., & Pachankis, J. E. (2016). Sexual orientation disparities in physical health: Age and gender effects in a population-based study. Social Psychiatry and Psychiatric Epidemiology, 51(2), 289–301. doi:10.100700127-015-1116-0 PMID:26298574 Butler, J. (1988). Performative acts and gender constitution: An essay in phenomenology and feminist theory. Theatre Journal, 40(4), 519–531. doi:10.2307/3207893 Byne, W., Karasic, D. H., Coleman, E., Eyler, A. E., Kidd, J. D., Meyer-Bahlburg, H. F., Pleak, R. R., & Pula, J. (2018). Gender dysphoria in adults: An overview and primer for psychiatrists. Transgender Health, 3(1), 57–73. doi:10.1089/trgh.2017.0053 PMID:29756044 Carpenter, L. F., & Marshall, R. B. (2017). Walking while trans: Profiling of transgender women by law enforcement, and the problem of proof. William & Mary Journal for Women and the Law, 24, 5. Chen, S. X., Benet‐Martínez, V., & Ng, J. C. (2014). Does language affect personality perception? A functional approach to testing the Whorfian hypothesis. Journal of Personality, 82(2), 130–143. doi:10.1111/jopy.12040 PMID:23607801 Chi, O. (2019, November 22). Cultural competency in assessment & treatment of transgender & gender non-binary folks [Conference Presentation]. ASHA 2019 Convention, Orlando, FL, United States. Coleman, E. (1982). Developmental stages of the coming out process. Journal of Homosexuality, 7(2-3), 31–43. doi:10.1300/J082v07n02_06 PMID:7346546

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Coulter, R. W., Mair, C., Miller, E., Blosnich, J. R., Matthews, D. D., & McCauley, H. L. (2017). Prevalence of past-year sexual assault victimization among undergraduate students: Exploring differences by and intersections of gender identity, sexual identity, and race/ethnicity. Prevention Science, 18(6), 726–736. doi:10.100711121-017-0762-8 PMID:28210919 Davies, S. G. (2006). Challenging Gender Norms: Five Genders among the Bugis in Indonesia. Wadsworth Publishing. Dickens, B. M. (2018). Management of intersex newborns: Legal and ethical developments. International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics, 143(2), 255–259. doi:10.1002/ijgo.12573 PMID:29943821 Dreger, A. (2004). “Ambiguous Sex”-or Ambivalent Medicine? Health, Disease, and Illness: Concepts in Medicine.

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Erickson-Schroth, L. (2014) Trans bodies, trans selves: A resource for the transgender community. Oxford University Press. Feinstein, B. A., & Dyar, C. (2017). Bisexuality, minority stress, and health. Current Sexual Health Reports, 9(1), 42–49. doi:10.100711930-017-0096-3 PMID:28943815 Ferguson, A. L. (2020). Outsiders in the Circle: Examining the Lived Experiences of Gay Afro-Caribbean Male Immigrants Living in the United States (Doctoral Dissertation). Retrieved from https://digitalcommons.montclair.edu/cgi/viewcontent.cgi?article=1531&context=etd Fisher, S. D. (2019). Challenging Dissemblance in Pauli Murray Historiography, Sketching a History of the Trans New Negro. Journal of African American History, 104(2), 176–200. doi:10.1086/702437 Fitzgerald, T. H. (2013). Queering Black Gay Historiography: Performance,(Mis) Identifications, and Possibilities (Doctoral dissertation). UCLA. Gill-Peterson, J. (2018). Histories of the transgender child. U of Minnesota Press. doi:10.5749/j.ctv75d87g Gilligan, C. (1982). In a different voice. Harvard University Press. Giwa, S., & Greensmith, C. (2012). Race relations and racism in the LGBTQ community of Toronto: Perceptions of gay and queer social service providers of color. Journal of Homosexuality, 59(2), 149–185. doi:10.1080/00918369.2012.648877 PMID:22335416 Goldberg, A. C. (2019). Our transgender language choices make all the difference. ASHA Leader, 24(4), 6–8. doi:10.1044/leader.FMP.24042019.6 Golub, S. A., Meyers, K., & Enemchukwu, C. (2020). Perspectives and Recommendations from LGBTQ Youth of Color regarding Engagement in Biomedical HIV Prevention. The Journal of Adolescent Health, 66(3), 281. Gossett, C., & Hayward, E. (2020). Trans in a Time of HIV/AIDS. Transgender Studies Quarterly, 7(4), 527–553. doi:10.1215/23289252-8665171 Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force.

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Griffin, H. L. (2010). Their own receive them not: African American lesbians and gays in Black churches. Wipf and Stock Publishers. Hancock, A., & Azul, D. (2017, November 10). Cultural & clinical considerations for EBP with transgender & gender non-conforming [Conference Presentation]. ASHA 2019 Convention, Los Angeles, CA. Hancock, A. B., Stutts, H. W., & Bass, A. (2014). Perceptions of Gender and Femininity Based on Language: Implications for Transgender Communication Therapy. Language and Speech, 58(3), 315–333. doi:10.1177/0023830914549084 PMID:26529899 Harris, A. C. (2009). Marginalization by the marginalized: Race, homophobia, heterosexism, and “the problem of the 21st century”. Journal of Gay & Lesbian Social Services, 21(4), 430–448. doi:10.1080/10538720903163171

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Ho, F., & Mussap, A. J. (2019). The Gender Identity Scale: Adapting the Gender Unicorn to measure gender identity. Psychology of Sexual Orientation and Gender Diversity, 6(2), 217–231. doi:10.1037gd0000322 Hrabovszky, Z., & Hutson, J. M. (2002). Surgical treatment of intersex abnormalities: A review. Surgery, 131(1), 92–104. doi:10.1067/msy.2002.115840 PMID:11812969 Janssen, A., Huang, H., & Duncan, C. (2016). Gender variance among youth with autism spectrum disorders: A retrospective chart review. Transgender Health, 1(1), 63–68. doi:10.1089/trgh.2015.0007 PMID:28861527 Kapila, R. (2021, April 28). Comment on Tina Babajanians post in the LGBTQ+ SLPs Facebook Group. Retrieved from https://www.facebook.com/groups/1470673189697011 King, J. (2006). Outing the centre: Homophobia in Jamaica. Independent Study Project Collection. Koehler, A., Eyssel, J., & Nieder, T. O. (2018). Genders and individual treatment progress in (non-) binary trans individuals. Journal of Sexual Medicine, 15(1), 102–113. doi:10.1016/j.jsxm.2017.11.007 PMID:29229223 LGBTA Wiki. (2020). Asexual Spectrum. LGBTA Wiki. https://pflag.org/glossary Lorber, J., & Farrell, S. A. (Eds.). (1991). The social construction of gender. Sage. McNeilly, L. G. (2005). HIV and communication. Journal of Communication Disorders, 38(4), 303–310. doi:10.1016/j.jcomdis.2005.02.005 PMID:15862812 Meyer, I. H., & Frost, D. M. (2013). Minority stress and the health of sexual minorities. In C. J. Patterson & A. R. D’Augelli (Eds.), Handbook of psychology and sexual orientation (pp. 252–266). Oxford University Press. Noddings, N. (1984). Caring: a feminine approach to ethics and moral education. University of California Press. Pew Research Center. (2019). A Survey of LGBT Americans. https://www.pewsocialtrends.org/2013/06/13/ a-survey-of-lgbt-americans/ PFLAG. (2021). PFLAG National Glossary of Terms. PFLAG. https://pflag.org/glossary

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Plummer, D. C. (2013). Masculinity and risk: How gender constructs drive sexual risks in the Caribbean. Sexuality Research & Social Policy, 10(3), 165–174. doi:10.100713178-013-0116-7 Rafferty, J. (2018). Ensuring comprehensive care and support for transgender and Gender-Diverse children and adolescents. Pediatrics, 142(4), e20182162. doi:10.1542/peds.2018-2162 PMID:30224363 Revati, A. (2010). The Truth About Me: A Hijra Life Story. Penguin. Rich, A. L., Phipps, L. M., Tiwari, S., Rudraraju, H., & Dokpesi, P. O. (2016). The increasing prevalence in intersex variation from toxicological dysregulation in fetal reproductive tissue differentiation and development by endocrine-disrupting chemicals. Environmental Health Insights, 10. Richards, C., & Barker, M. (2013). Sexuality and Gender for Mental Health Professionals: A Practical Guide. SAGE Publications. doi:10.4135/9781473957817

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Robinson, G. C. (2021, February 26). Working with the rainbow: Clinical cultural competency with underrepresented genders and sexual orientations [Conference Presentation]. University of LouisianaMonroe 2021 Spring Conference, Monroe, LA. Robinson, G. C., & Crisp, C. (2018). What to do when your client comes out: Real advice for LGBTQ affirming care [Conference Presentation]. ASHA 2018 Convention, Boston, MA. Rojas, E. (2021). Getting married: Hear builder sequencing: Super fun deck. Super Duper Publications. Roscoe, W. (1998). Two Spirit people: Gay American Indians, Changing ones: Third and fourth genders in Native North America. Mac-Millan. Schellenberg, D., & Kaiser, A. (2018). The sex/gender distinction: Beyond f and m. In C. B. Travis, J. W. White, A. Rutherford, W. S. Williams, S. L. Cook, & K. F. Wyche (Eds.), APA handbooks in psychology®. APA handbook of the psychology of women: History, theory, and battlegrounds (pp. 165–187). American Psychological Association. doi:10.1037/0000059-009 Sears, C. (2015). Arresting dress: Cross-dressing, law, and fascination in nineteenth-century San Francisco. Duke University Press. doi:10.1215/9780822376194 Singer, T. B. (2015). The profusion of things: The “transgender matrix” and demographic imaginaries in US Public Health. Transgender Studies Quarterly, 2(1), 58–76. doi:10.1215/23289252-2848886 Steinmetz, K. (2014). Why it is best to avoid the word “transgendered”. TIME. Retrieved from https:// time.com/3630965/transgender-transgendered/ Sutter, M., & Perrin, P. B. (2016). Discrimination, mental health, and suicidal ideation among LGBTQ people of color. Journal of Counseling Psychology, 63(1), 98–105. doi:10.1037/cou0000126 PMID:26751158 Testa, R., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. doi:10.1037gd0000081 Tharp, A. N. (2016). Gender Spectrum Theory. University of New Haven. Tronto, J. (2013). Caring democracy: Markets, equality, and justice. New York University Press. Vaid-Menon, A. (2020). Beyond the binary. Penguin Workshop.

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Vincent, B., & Manzano, A. (2017). History and cultural diversity. In Genderqueer and non-binary genders (pp. 11–30). Palgrave Macmillan. doi:10.1057/978-1-137-51053-2_2 Webb, A., Heyne, G., Holmes, H. E., & Peta, J. L. (2016). Which box to check: assessment norms for gender and the implications for transgender and nonbinary populations. Division 44 Newsletter for the American Psychological Association’s Society for the Psychology of Sexual Orientation and Gender Diversity. Retrieved from https://www.apadivisions.org/division-44/publications/newsletters/division/2016/04/nonbinary-populations Wilson, S. M., Eriksson, D. K., Schneck, S. M., & Lucanie, J. M. (2018). A quick aphasia battery for efficient, reliable, and multidimensional assessment of language function. PLoS One, 13(2), e0192773. doi:10.1371/journal.pone.0192773 PMID:29425241

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Wu, J. H. (2015). ‘On this side’: The production, progression, and potential of Cisgender (Master’s Thesis). Retrieved from https://scholarship.tricolib.brynmawr.edu/handle/10066/15359

ADDITIONAL READING Adler, R. K., Hirsch, S., & Pickering, J. (2018). Voice and communication therapy for the transgender/ gender diverse client: A comprehensive guide. Plural Publishing. Chang, S. C., Singh, A. A., Dickey, L. M., & Krishnan, M. (2018). A clinician’s guide to gender affirming care: Working with transgender and gender nonconforming clients. New Harbinger Publications. Funk, M. (2019). The book of pride: LGBTQ heroes who changed the world. Harper Audio. Griffin, H. L. (2010). Their own receive them not: African American lesbians and gays in Black churches. Wipf and Stock Publishers. Hancock, A. B., & Siegfriedt, L. L. (2019). Transforming voice and communication with transgender and gender-diverse people: An evidence-based process. Plural Publishing. Harrad, K. (2018). Claiming the B in LGBT: Illuminating the bisexual narrative. Throntree Press. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Candlewick Press. Mills, M., & Stoeneham, G. (2017). The voice book for trans and non-binary people. Jessica Kingsley Publishers.

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KEY TERMS AND DEFINITIONS Affirmative Care: A practice that doesn’t just accept or include LGBTQIA+ clients, but actively seeks to communicate through words and other symbols that their gender identity and sexual orientation are valid and recognized as a key part of who they are as a person. Cisgender: A person who identifies as the gender they were assigned at birth. A cis man is a person who was assigned male at birth and identifies as a man. A cis woman is a person who was assigned female at birth and identifies as a woman. Gender: Gender Expression refers to how a person dresses, communicates, and otherwise moves through their world, regarding and/or disregarding cultural expectations and symbols of masculinity, femininity, and androgyny. Gender Identity refers to how a person feels/identifies as an individual living in a world of gender-specific expectations, stereotypes, and language. Gender Binary: A cultural assumption that there are two distinct and unchangeable genders. Gender Dysphoria: A feeling of discomfort and anxiety that occurs when the TGNB person feels like their identity is not matching how they are perceived by themselves and/or others. Heteronormativity: The cultural assumption that everyone is heterosexual or that heterosexuality is the sexual archetype. Non-Binary: A gender that doesn’t align with either male/masculine/man or female/feminine/woman.

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Queer: An umbrella term used to reference multiple genders and sexual orientations. Queer may be considered offensive to some LGBTQ+ individuals. Sexual Orientation: The innate sexual attraction one has to others, usually in reference to gender. Transgender: A person who is not the gender they were assigned at birth. A trans man is a man who was assigned female at birth. A trans woman is a woman who was assigned male at birth.

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Chapter 3

The Determinants of Health:

Social, Structural, and Political Contributions to Health-Related Outcomes Molly Jacobs East Carolina University, USA Fatima Jebahi East Carolina University, USA Charles Ellis East Carolina University, USA

ABSTRACT The determinants of health have received substantial attention in the medical literature as recent evidence has shown that they play in vital role in general health and health-related outcomes. Despite the advancing literature, the feld of communication sciences and disorders (CSD) has been slow in the both the consideration of the determinants of health as well as the measurement of commonly known determinants believed to infuence clinical outcomes. The goal of this chapter is to explore the determinants of health and potential relationship to the study of communication disorders and the outcomes being measured.

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“Health is a state of complete mental, social and physical well-being, not merely the absence of disease or infirmity.” – World Health Organization, 1948

INTRODUCTION Good health hinges on a complex array of genetic and environmental factors some of which are beyond the control of the individual. Although beyond the individual’s total control, the presence of good DOI: 10.4018/978-1-7998-7134-7.ch003

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 The Determinants of Health

health allows one to live long and fulfilled lives. Yet many individuals do not consistently experience good health thereby resulting in disparities in health and health-related outcomes. Longstanding, health disparities remain a major health-related issue in the US. The synergistic effects of well-established social, structural and political systems (determinants) underlie many of the health disparities that exist worldwide. To date little, if any, consideration has been given to the contribution these same determinants have made to outcomes in the field of communication sciences and disorders (CSD) and the disciplines of speech-language pathology and audiology (SLP/Aud). More specifically, little is known about how the determinants of health impact disparities in rehabilitative outcomes in fields like CSD. This chapter will explore the determinants of health in general and establish a link to the field of CSD to identify strategies to close the disparity gap in health-related outcomes that currently exists in the field. The goal of this chapter is to introduce CSD researchers and clinicians to the determinants of health that drive health disparities and negatively impact clinical outcomes in the field. Traditionally research and clinical practice patterns in the field of CSD emphasize clinical measurement approaches that do not consider the impact of social and structural determinants of health on clinical outcomes. The chapter will conclude with a summary of strategies that have been utilized in other fields to reduce the impact of the determinants of health that might be considered in the field of CSD.

BACKGROUND

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Vulnerable Populations “Good health” is not a promise to everyone. In fact, some population groups experience far worse healthrelated outcomes than others. Individuals in these groups are more “vulnerable” to experiencing poor health outcomes which result from an array of factors that operate both additively and synergistically. Vulnerable populations are those individuals from disadvantaged communities that frequently experience worse health-related outcomes and require specific ancillary considerations to improve their health (Healthy People, 2020, n.d.). The populations are vulnerable to worse health-related outcomes because of decades of social, political and institutional forces that prohibit achievement of optimal population health. These focuses can include but are not limited to lack of insurance, lack of access to regular preventive specialty and care, geographic distance to services, limited health literacy, systemic racism among providers and within healthcare institutions, lack of cultural competence among providers and longstanding mistrust issues related to providers and healthcare systems. These communities may be defined by race/ethnicity, economic disadvantage, residence (rural vs urban), sex/gender identity and persons incarcerated. In addition to the financial and social disadvantaged associated with their sociodemographic characteristics, individuals from vulnerable populations are most likely to experience worse and negative health-related outcomes.

Race/Ethnicity There is substantial evidence that black, indigenous and people of color (BIPOC) experience worse health-related outcomes (Healthy People, 2020, n.d.). For example, BIPOC have higher rates of infant mortality and premature death, higher chronic disease rates and shorter lifespans than whites (Centers for Disease Control and Prevention, 2011). Chronic diseases (e.g hypertension, heart disease, cancers, etc) 40

 The Determinants of Health

are far more common among African Americans than White Americans. Similarly, American Indian/ Alaska Native men are more likely to die by accidental injury than their white counterparts (Centers for Disease Control, 2017). Even the most recent COVID-19 pandemic that was first identified in early 2020 has highlighted the impact of race-ethnicity on health as African Americans were far more likely to suffer from morbidity and mortality due to the disease (Farmer et al., 2020).

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Socioeconomic Status Socioeconomic status is also a key contributor to the vulnerability for poor health. Evidence suggests that Americans at the lowest economic and educational levels experience the worse health (Braveman, Kumanyika, et al., 2011). Low income is frequently compounded by a lack of insurance which reduces their likelihood of usual access to quality healthcare and subsequently increases their risk of morbidity and mortality (McMaughan et al., 2020). Socioeconomic status is tied directly to income earned; thus income is related to health outcomes. Specifically, people who have lower income have higher prevalence of physical and mental health problems (Howell & Howell, 2008; Kim & Von Dem Knesebeck, 2008). Concerning physical health, the results of a systematic review suggest that acute and recurrent infections, obesity, poor health status, and hospitalizations are more frequently reported in persons who have lower incomes (Spencer, Thanh & Louise, 2013). Further, these individuals have lower life expectancy. For example, the difference in life expectancy of 40-year-old men in the richest and the poorest 1% of the income distribution is 14.6 years, with the richest group living longer (Chetty, Stepner, Abraham, et al., 2016). As for mental health, burdens of depression and anxiety are more frequently experienced by persons with lower income (Bruce, Takeuchi, Leaf et al., 1991; Dohrenwend, Levav, Shrout et al., 1992; Kessler, 1982; Murphy, Olivier, Monson et al., 1991). Children born to families of low socioeconomic status are at a greater risk of having acute and chronic childhood illnesses. Similarly, their corresponding socioeconomic status is associated with higher rates of death in infancy and childhood (Spencer, 2000). Additionally, the family’s socioeconomic status has been linked to their children’s brain function, with children born to families who present socioeconomic disadvantages showing worse cognitive, linguistic, and academic outcomes (Merz, Wiltshire & Noble, 2019). Further, the effects of socioeconomic status in early childhood on health go beyond childhood years, placing a significant impact on a range of adult health outcomes (Kuh, Power, Blane, et al., 1997). In fact, there is compelling evidence that suggests that lower socioeconomic status in adults is associated with increased risk of coronary heart diseases, cardiovascular diseases, and stroke (Addo, Ayerbe, Mohan et al., 2012; Backholder, Peters, Bots, et al, 2017; Hipisley-Cox, Coupland, Vinogradova, et al, 2008; Manrique-Garcia, Sidorchuk, Hallqvist et al., 2011; Vathesatogkit, Batty & Woodward, 2014; Woodward, Brindle, Tunsfall-Pedo, 2007) all of which can cause significant irreversible disabilities that can alter one’s quality of life and mental health (Crichton, Bray, McKevitt, et al., 2016). More specifically, these disabilities affect one’s speech, language, and cognitive abilities thereby requiring speech-language therapy intervention.

Residence/Geographic Location Where one lives is frequently a function of the income they earn, which dramatically impacts their access to quality healthcare and associated health-related outcomes. For example, residents of rural communities 41

 The Determinants of Health

are more likely to earn less than urban residents (Bishaw & Posey, 2016), more likely to smoke, more likely to be obese yet less likely to exercise or eat healthy diets (Eberhardt et al., 2001). Rural residents are also less likely to have access to primary and specialty care near where they live (Health Resources and Services Administration, 2018). Place of residence is also an important determinant of many health outcomes. Residence disparities have been reported in cardiovascular health, stroke, diabetes and cancer (Cooper et al., 2000; Howard & Howard, 2020; Koya & Egede, 2007; Meilleur et al., 2013; Myers et al., 2017; Neyer et al., 2005). For example, the highest risks of mortality have been reported in the southeastern US (Rich et al., 2007) and in populations living in rural areas (Baldwin et al., 2004; Halverson, 2004). Several southeastern states have been defined as the “stroke belt” and “diabetes belt” where higher rates of stroke and diabetes are higher than the rest of the US (Barker, Kirtland, Gregg, et al. 2011; Howard & Howard, 2020). Substantially higher rates of these chronic diseases exist even after adjusting for variations in common risk factors like demographic factors (race, age), socioeconomic measures (income, education), behaviors (smoking, physical activity), and other conditions (diabetes, hypertension) (Halverson, 2004; Halverson et al., 2002; Howard et al., 2009). Interestingly, studies suggest that geographic variation could be due to more localized distributions of neighborhood risk factors. The clustering of determinants of health at the neighborhood level can greatly affect the planning, implementation, and focus of health initiatives that seek to reduce disparities. Therefore, research should focus on the various levels of spatial determinants of health can be used to better understand health needs and thus, provide needs-based health services (Cooper et al., 2000; Braveman et al., 2005). Many studies have defined neighborhoods as census tracts or smaller geographic units and investigated how neighborhood characteristics explain individual level risk of different health outcomes. However, more studies are needed to investigate the spatial patterns and clustering of high mortality risk with the neighborhood as the unit of analysis since this is important in identifying high risk communities and targeting resources to address health disparities and improve population health at the local level (Gerber et al., 2008; Lovasi et al., 2008; Petrelli et al., 2006; Tonne et al., 2005).

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Gender/Sex Identification A rapidly emerging literature suggests individuals from lesbian, gay, bisexual, and transgender and queer (LGBTQ) communities are a vulnerable population likely to experience disparate health-related outcomes. Individuals from LGBTQ communities are less likely to be insured while being disproportionately impacted by chronic and sexually transmitted diseases (Kates et al. 2018). At the same time, they are more likely to experience less access to healthcare and less healthcare utilization potentially due to prejudices, social stigma and discrimination (Baptiste-Roberts et al., 2017). Similarly, incarcerated African American men who are disproportionately impacted by HIV are vulnerable to negative healthrelated outcomes (Gaiter et al., 2006). At the same time imprisoned women are a vulnerable population due to be frequently overlooked or dismissed regarding their gynecological needs and in particular having an increased risk for ovarian and cervical cancers (Braithwaite et al., 2005).

Health Disparities Historically these same vulnerable populations are less likely to have health insurance, less likely regular access to preventative and specialty care and but more likely to experience disability and early death (Bhatt & Bthija, 2018). Consequently, individuals from vulnerable population groups are more likely 42

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to experience health disparities. According the Braveman (2006, p.180), health disparities are defined as “a particular type of potentially avoidable difference in health or in important influences on health that can be shaped by policies; it is a difference in which a disadvantaged social group or groups (such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination in the past) systematically experience worse health or greater health risks than the most advantaged social groups.” Unfortunately, the underlying cause of health disparities among vulnerable populations is not a simple one and requires the exploration of a range of determinants of health that drive the health disparities commonly reported.

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Social and Structural Determinants of Health The study of health disparities has a long history in the United States (US), yet health disparities and their underlying causes or “determinants of health”. This is of great concern because health disparities exist along several sociodemographic lines including race/ethnicity, sex/gender, socioeconomic status, residence and age among others all of which have been established as factors influencing outcomes in CSD. Traditionally, these determinants have been deemed “social and structural determinants of health” (SSDH) which are “the complex circumstances in which individuals are born and live that impact their health. They include intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.” (World Health Organization, 2021). Health is multidimensional; determined by the complex interaction of political, social, economic, and structural factors. Further, these outcomes are driven by conditions beyond one’s control. Healthy People 2030 (n.d.) framework suggests SSDH can be organized into five domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment and social and community context. The SSDH also center around an individual’s “social environment” or social and cultural institutions, norms, patterns, beliefs, and processes that influence the life of an individual or community and their “physical environment” the natural and build environment (Healthy People, 2020, n.d.). The social environment includes: a) interactions with family, friends, coworkers and others in the community, b) cultural attitudes, norms, and expectations, c) social relationships, d) policies that influence public places such as schools, neighborhoods, workplaces, businesses, places of worship, health care settings, recreation facilities, e) social aspects of health-related behaviors, f) social institutions such as how law enforcement is organized as well as g) societal level policies that drive governmental, corporate, and non-governmental sectors of society. The social environment includes both the individual and the community both of which contribute to good or poor health. In contrast, the physical environment includes a) homes, b) workplaces, c) schools, d) healthcare settings and e) recreational settings. The physical environment contributes to health-related outcomes (positive or negative) by confounding factors such as air quality, water quality, safe housing and communities, and presence or absence of transportation systems all of which impact health-related outcomes. Consequently, SSDH exist and impact at the level of the individual, group, community and society with all interacting to influence our health and well-being (Health Resources and Services Administration, 2018). The environmental contributions of the physical environment expand beyond one’s local community and includes factors that arise from the region, nationally and globally. SSDH exist also exist at the 43

 The Determinants of Health

individual and population level to impact health-related outcomes (See Table 1). Ultimately the SSDH impact individual behaviors such as whether one manages a chronic condition, smokes, drinks or uses recreational drugs, exercises or engages in preventative care and ultimately these decisions translate into the staggering healthcare costs that continue to rise (Bush, 2018). Finally, the contemporary literature suggests determinants of health extend beyond the traditional SSDH also include the synergistic impact of political influences and privilege on health. Table 1. Social and structural determinants of health

Individual

Sex/gender, race/ethnicity, socioeconomic status, social class, education, income, occupation, employment status, housing status, immigrant status, language use, disability status, and social capital (goodwill, sympathy and interactions among individuals and families)

Population

poverty, income inequality, educational opportunity, affordable housing, access to healthy foods/good nutrition, access/provision of health services, transportation infrastructure, physical and built environments and racial/ethnic population composition

Source: (Health Resources and Services Administration, 2018)

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Political Determinants of Health It is important to note that health is determined, in part, by politics. Paradoxically, the distribution of political power, resources, and money – all of which do not fall under the sector of health, shape health and health-related outcomes (Marmot, et al. 2008). Research supporting this claim notes that health is a crucial aspect of human rights, is related to citizenship and nationality, is unevenly distributed on both the local and global levels, and is dependent on political action (Bambra, 2005). These political aspects of health, along with others, give rise to inequalities, inequities, and injustices in health practices. In fact, distinct political choices across countries have resulted in significant health variations. Specifically, political decisions have increased the health disparity gap further increasing disease and death rates (Stuckler & Basu, 2013). Political decisions include laws, taxes, social security benefits, and public services, all of which will ultimately affect access to health services and consequently health outcomes (Beckfield & Krieger, 2009). Regarding differences in health outcomes, Dawes (2020a, p.1) argues that limited attention has been given to understanding the political determinants of health (PDH) or those “factors, systems or structures (laws and policies) that create, perpetuate, or exacerbate these differences, many of which unfair, avoidable, and remediable.” Consequently, the PDH which are centered around voting, government and policy “involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance equity or exacerbate health inequities” (Dawes, 2020a, p.44). Dawes (2020a) argues that it is clearly difficult at times the distinguish SSDH and PDH as one tries to determine whether health inequities are the result of social factors or masked by political factors that mask them. One must understand that PDH are the primary contributors govern a wider set of systems that contribute to poor health equity in some groups (Dawes, 2020b). The PDH are critical to health equity which represents “social justice in health (i.e., no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged), (Braveman, 2014, p.7).

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Political outputs, in form of governmental actions, are demonstrated by their declaration of what basic services, such as health care and education, are offered; by their legislative and regulatory frameworks; by their monitoring of effects and progress of movement; and their consequent actions upon it. Consequently, voting may be the most important political determinant because our voting patterns allow us to engage directly in immediate policy solutions (Dawes, 2020a). Similarly, voting patterns allow its constituency to address both the biological and social consequences of determinants of health (Dawes, 2020a). For example, the Affordable Care Act (ACA) of 2010 was designed to achieve greater health equity among Americans. However, the voting patterns of 2016 presidential election eventually resulted in a dismantling of many core components of the ACA leaving many Americans without health insurance and access to good medical care or opportunity for health equity (Gaffney & McCormick, 2017). It should also be noted that strategies of voter suppression have also historically been in play which in turn impacts health yet the specific link is less clear. It is well established that people living in democratic societies enjoy better health than those who live in repressive societies (Franco, Álvarez-Dardet & Ruiz, 2004). Specifically, it has been shown that health equity is considerably improved when national governments take responsibility for promoting human rights, thereby guaranteeing needs delivery, such as, health care (Blas, Gilson, Kelly et al., 2008). Further, governmental legislation and regulations, when established, can be effectively used to promote greater equity in health and the social determinants of health (Blas, Gilson, Kelly et al., 2008). For instance, health was overall better when the legislative choices made included decisions concerning vaccines, air quality, seatbelt safety, and smoking cessation (Mishori, 2019). Additionally, evidence suggests that an engaged civil society that enhances the acceptability of actions addressing the determinants of health equity by empowering people in terms of control over their lives can enhance health working through psychosocial pathways (Blas, Gilson, Kelly et al., 2008). Moreover, governmental power limit the range of choice and constrain action and are therefore key determinants of health inequity (Ottersen, Dasgupta, Blouin, et al., 2014). Addressing the global power asymmetries across all sectors that affect health is central to tackle the problem of health inequity (Ottersen, Dasgupta, Blouin, et al., 2014). Therefore, we must seek to understand the connections between all determinants of health and particularly the overarching impact of the PDH (Dawes, 2020b).

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Privilege as a Determinant of Health Privilege has also been suggested as a determinant of health. Johnson (2001) defines privilege as “when one group has something of value that is denied to others simply because of the groups they belong to, rather than because of anything they’ve done or failed to do”. The author further notes that “Access to privilege doesn’t determine one’s outcomes, but it is definitely an asset that makes it more likely that whatever talent, ability, and aspirations a person with privilege has will result in something positive for them.” A substantial literature has shown that lower placement in the social hierarchy has deleterious health effects. In the US, the reported health of Non-Hispanic Whites (Whites) is better on nearly all levels relative to African Americans (Subramanian et al., 2005). The health advantage experienced by Whites in the U.S. reflects their position in a racialized social system, which classifies Whites at the top of the hierarchy (Bonilla-Silva, 1996). Whiteness confers health advantages through material resources and opportunities, positive public regard, and a baseline of settled expectations that are codified in law. Thus, social status translates to better self-rated health for both whites and those who identify as white (Jones 45

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et al., 2008). According to an Institute of Medicine (2003) report, this disparity cannot be accounted for by clinical appropriateness, needs, and patient preferences, but rather exists at the level of the system of health care as well as by discrimination that occurs at personal, institutional, and societal levels. This disparity is an example of the assets of white privilege. Differences in life expectancy and health outcomes based on race likely elicit greater personal concerns for an individual whose race confers a lower life expectancy (Ayanian, 2015). The personal and institutional privilege and power in health care settings provides opportunities to either sustain racial health care privilege gaps or utilize them to effectively reduce health care quality disparities between minority and non-minority persons (Association of American Medical Colleges, 2009). Although tasked with serving all people, healthcare providers have the tendency to project values and provide services that meet the needs of the majority while not fully recognizing the needs of the minority (Goodwin & Landy, 2014). Recognizing privilege’s impact on personal and institutional engagement in patient care, education, and research in the patient care is the initial step for clinicians but should occur concurrently with other efforts to diminish privilege gaps or disparities in the quality of health care and all of the other components that constitute this service (Hobbs, 2018).

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Health Systems as a Determinant of Health Although clinical care plays an integral role in health outcomes, social and environmental factors proportionally contribute to the risk of premature death twice as much as health care does (Heiman & Artiga, 2015; McGinnis et al., 2002; Schroeder, 2007). In March 2002, the Institute of Medicine released a report that demonstrated that even in the face of equal access to health care, minority groups suffer differences in quality of health. The noted differences were organized into the categories of patient preferences and clinical appropriateness, the ecology of health systems and discrimination, bias, and stereotyping (Institute of Medicine and National Research Council, 2000). While health systems work to understand and address these differences, they must continue to appreciate the importance of moving beyond individualized care to care that affects families, communities, and populations (Derose et al., 2011). Consequently, healthcare providers must take a broader look beyond simply the individual they are offering care, but also their families and communities to truly understand the role of privilege in health and health care delivery. Continuing the momentum of improving access to culturally competent and linguistically appropriate care will be a crucial step to improving the health of populations. Culturally and linguistically appropriate care includes high-quality care and clear communication regardless of socioeconomic or cultural background. These attributes remove the sense of privilege often associated with health and clinical providers (Betancourt & Green, 2010). While there is limited research studying the link between culturally appropriate care and health outcomes, data do exist that indicate that behavioral and attitudinal elements of cultural competence facilitate higher-quality relationships between physicians and patients (Paez et al., 2009). Clinicians who undergo cultural competency training as part of their education or licensure requirements, have the potential to reduce barriers to care by translating these skills into increased access to care and improved health outcomes (Like, 2011). Some suggest that health professionals must understand their own privilege to ensure that they deliver equitable care to all clients (Witten & Maskarinec, 2015). According to Brown and White (2020) it is critical that health practitioners recognize privilege in their own lives and how such privilege can impact others and particularly vulnerable and marginalized populations with less advantages.

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Strategies for Healthcare Providers Healthcare providers play a critical role in (1) diagnosing disparities in community and practice, (2) innovating new models to address social determinants of health, (3) addressing health literacy of families and communities, (4) ensuring cultural competence and a culture of healthcare equity, and (5) advocating for issues that address the root causes of health disparities (Cheng et al., 2015). Delivering culturally competent care that is sensitive to the needs, health literacy, and health beliefs of individuals, families and communities can increase satisfaction, improve quality of care, and increase patient safety. With growing evidence that implicit bias in physician and clinician decision-making makes a significant contribution to perpetuating health care disparities, it is critical to find ways to reduce its impact. Although awareness is important, as with clinical efforts to change patients’ undesirable health behaviors and attitudes towards health care, it is not sufficient to reduce the automatic, habitual activation of stereotypes and the subsequent impact of implicit bias in medical decision-making (Prochaska & DiClemente, 1992). One strategy that appears effective in reducing implicit bias is individuating. Individuating involves conscious effort to focus on specific information about an individual, making it more salient in decisionmaking than that person’s social category (sex, race, etc) information (O’Donohue & Yeater, 2003). Another strategy to increase equity in health care delivery and mitigate the impact of implicit bias is perspective-taking. Perspective-taking is a conscious attempt to envision another person’s viewpoint and consider factors related to their social, geographic and household interactions (Galinsky & Moskowitz, 2000). Additional clinical care approaches to address social determinants of health and interrupting the intergenerational cycle of disadvantage include (1) screening for new health “vital signs” and connecting families to resources, (2) enhancing the comprehensiveness of services, (3) addressing family health in pediatric encounters, and (4) moving care outside the office into the community. Health system investment is required to support clinicians and practice innovation to ensure equity (Andermann, 2016).

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Moving Towards Addressing the Determinants of Health in the Communication Sciences and Disorders The goal of SLP/A’s and other health professionals is to assist their clients in achieving the best possible outcomes. In order for health professionals to achieve optimal health outcomes, health needs to be seen within its political, social, economic, and structural contexts. In the absence of such a view many individuals are not able to achieve health equity. According to Weil (2017), achieving health equity requires significant commitment from health professionals and the health systems that employ them to address the longstanding social disadvantages experienced by many Americans. Strategies are required to achieve health equity (Beadle & Graham, 2011). Strategies to achieve health equity must be intentional, comprehensive and coordinated. Consequently, it is incumbent that efforts designed to improve health equity be focused on dealing with the root causes of poor health-related outcomes that arise from determinants of health (National Academies of Sciences, Engineering, and Medicine, 2016). More specifically, SLP/A’s training is clinically oriented emphasizing disease-related curative models at the individual client level (National Academies of Sciences, Engineering, and Medicine, 2016). Consequently, many experienced and skilled clinicians do not carefully consider the role that determinants of health play in their client’s outcomes achieve. Further, SLP/A’s have a key role in population health where disease prevention and health promotion are key aspects of their clinical practices. More importantly, it is imperative that 47

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SLP/A’s carefully consider and understand how social, structural and political forces dictate the health and health-related outcomes of the clients they serve (National Academies of Sciences, Engineering, and Medicine, 2016). Ultimately, determinants of health impact the outcomes of every client seen and influences the prognosis offered and intervention provided (Rethorn et al., 2019). Some argue that determinants of health must be addressed at the client and community levels and research agendas should emphasize generalizing the results to a broader range of populations (Rethorn et al., 2019). World Health Organization Commission on Social Determinants of Health and The Lancet Commission on Education of Health Professionals suggest more comprehensive approaches to assisting health professionals in understanding the SSDH which included using best practice information drawn from a) interprofessional education, b) community-engaged learning, c) experiential education, and d) health outcomes research (World Health Organization, 2008; Frenk et al., 2010). The committees also specifically noted that transformative learning would be required to address SSDH which “involves vital shifts that would move health professional education from a traditional biomedical-centric approach to an approach that can provide a greater understanding of and competencies in addressing complex health systems in an increasingly global and interconnected world” (Committee on Educating Health Professionals to Address the Social Determinants of Health et al., 2016, p. 58). Recent reports suggest learning opportunities offer great opportunities to engage communities. Many learning programs offered a mix of experiential learning (community health assessments, development and implementation of projects, organization of educational session for community members, and caring for community residents) and nonexperiential learning such as lectures, group discussions, workshops, simulation experiences, reading assignments, online activities, presentations and research projects (National Academies of Sciences, Engineering, and Medicine, 2016). Understanding the complexity of determinants and their contributions to health-related outcomes particularly health professionals such as SLP/As can be extremely difficult. A range of approaches may be considered to understand how the determinants contribute to the clinical outcomes being measured. However, there is concern over a rush to identify general strategies to address health disparities when there is little research in the field designed to dictate best practices for examining and mitigating their short and long-term impact. There is also concern regarding lack of agreement in the field regarding operational definitions that are frequently taken from other disciplines and applied with due consideration to the nuance that may required in the field of SLP/A. However, the current literature suggests the field of CSD may be able to utilize a range of general strategies designed to increase awareness of the effects of the determinants of health. These include but are not limited to strategies that: 1) Engage system-wide approaches for clinicians and researchers to educate them on the impact of the determinants of health on clinical and general health related outcomes. 2) Engage in routine data collection related to the determinants of health. 3) Develop “clinical triggers” to alert clinicians to the likelihood that a determinant of health may impact the clinical outcome they are measuring. 4) Develop partnerships with community stakeholder to understand community resources and how the determinants of the community where they live impacts their general health outcomes and the clinical outcome being measured. 5) Consider the use of patient navigators, social workers, etc as part of the interdisciplinary team managing the client’s disorder or disability.

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6) Develop advocacy strategies at the local, state and national levels of the clinical disciplines engaged in care. 7) Develop programmatic and systematic research to determine the impact of the determinants of health on clinical outcomes in CSD. 8) Monitor uptake of health services by persons with speech, language, and intellectual disabilities and reasons for discrepancies, if present 9) Develop understanding of differences in the treatment of health problems in persons with speech, language, and intellectual disabilities 10) Understand the different and special needs of persons with speech, language, and intellectual disabilities in regard to communication, and learn to communicate with them and their families accordingly *Strategies adapted from White-Williams et al. (2020); Blackstone et al. (2011); Ouellette-Kuntz et al. (2005).

CONCLUSIONS The determinants of health are complex and the role they play in clinical outcomes can be difficult to capture in many clinical environments. The field of CSD has lagged behind other clinical and research field in developing a large-scale approach to addressing the determinants of health. It is critical now that the field move forward in a systematic process to explore the synergistic role that the determinants play in commonly measured clinical outcomes. Much is not known about the determinants of health; thus novel approaches are needed to answer a range of questions that are critical to achieving optimal outcomes in the clients being served in the field of CSD.

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Health Resources and Services Administration, Office of Health Equity. (2018). Health Equity Report 2017. U.S. Department of Health and Human Services. Available at: https://www.hrsa.gov/sites/default/ files/hrsa/health-equity/2017-HRSA-health-equity-report.pdf Healthy People 2020. (n.d.). An opportunity to address societal determinants of health. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at: https:// www.healthypeople.gov/sites/default/files/SocietalDeterminantsHealth.pdf Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at: https://health.gov/healthypeople/ objectives-and-data/social-determinants-health

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Heiman, H. J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. The Henry J. Kaiser Family Foundation. https://www.kff.org/racial-equityand-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-healthand-health-equity/ Hippisley-Cox, J., Coupland, C., Vinogradova, Y., Robson, J., Minhas, R., Sheikh, A., & Brindle, P. (2008). Predicting cardiovascular risk in England and Wales: Prospective derivation and validation of QRISK2. BMJ (Clinical Research Ed.), 336(7659), 1475–1482. doi:10.1136/bmj.39609.449676.25 PMID:18573856 Hobbs, J. (2018). White Privilege in Health Care: Following Recognition With Action. Annals of Family Medicine, 16(3), 197–198. doi:10.1370/afm.2243 PMID:29760020 Howard, G., Cushman, M., Prineas, R. J., Howard, V. J., Moy, C. S., Sullivan, L. M., D’Agostino, R. B. Sr, McClure, L. A., Pulley, L., & Safford, M. M. (2009). Advancing the hypothesis that geographic variations in risk factors contribute relatively little to observed geographic variations in heart disease and stroke mortality. Preventive Medicine, 49(2-3), 129–132. doi:10.1016/j.ypmed.2009.03.004 PMID:19285103 Howard, G., & Howard, V. J. (2020). Twenty Years of Progress Toward Understanding the Stroke Belt. Stroke, 51(3), 742–750. doi:10.1161/STROKEAHA.119.024155 PMID:32078485 Howell, R. T., & Howell, C. J. (2008). The relation of economic status to subjective well-being in developing countries: A meta-analysis. Psychological Bulletin, 134(4), 536–560. doi:10.1037/00332909.134.4.536 PMID:18605819 Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care (B. D. Smedley, A. Y. Stith, & A. R. Nelson, Eds.). National Academies Press. Institute of Medicine and National Research Council. (2000). From neurons to neighborhoods: The science of early childhood development (J. P. Shonkoff & D. A. Phillips, Eds.). National Academies Press. Johnson, A. G. (2001). Privilege, power, and difference. McGraw-Hill Companies, Inc.

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Jones, C. P., Truman, B. I., Elam-Evans, L. D., Jones, C. A., Jones, C. Y., Jiles, R., Rumisha, S. F., & Perry, G. S. (2008). Using “socially assigned race” to probe white advantages in health status. Ethnicity & Disease, 18(4), 496–504. PMID:19157256 Kates, J., Ranji, U., Beamesderfer, A., Salganicoff, A., & Dawson, L. (2018). Health and access to care and coverage for lesbian, gay, bisexual, and transgender individuals in the U.S. Henry J. Kaiser Family Foundation Issue Brief. Available at: https://files.kff.org/attachment/Issue-Brief-Health-and-Access-toCare-and-Coverage-for-LGBT-Individuals-in-the-US Kessler, R. C. (1982). A disaggregation of the relationship between socioeconomic status and psychological distress. American Sociological Review, 47(6), 752–764. doi:10.2307/2095211 PMID:7171158 Kim, T. J., & von dem Knesebeck, O. (2018). Income and obesity: What is the direction of the relationship? A systematic review and meta-analysis. BMJ Open, 8(1), e019862. doi:10.1136/bmjopen-2017-019862 PMID:29306894

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Koya, D. L., & Egede, L. E. (2007). Association between length of residence and cardiovascular disease risk factors among an ethnically diverse group of United States immigrants. Journal of General Internal Medicine, 22(6), 841–846. doi:10.100711606-007-0163-y PMID:17503110 Kuh, D., Power, C., Blane, D., & Bartley, M. (1997). Social pathways between childhood and adult health. In D. Kuh, S. Ezra, & Y. Ben Schlomo (Eds.), A life course approach to chronic disease epidemiology (pp. 69–198). Oxford Medical Publications. Like, R. C. (2011). Educating clinicians about cultural competence and disparities in health and health care. The Journal of Continuing Education in the Health Professions, 31(3), 196–206. doi:10.1002/ chp.20127 PMID:21953661 Lloyd-Jones, D., Adams, R. J., Brown, T. M., Carnethon, M., Dai, S., De Simone, G., Ferguson, T. B., Ford, E., Furie, K., Gillespie, C., Go, A., Greenlund, K., Haase, N., Hailpern, S., Ho, P. M., Howard, V., Kissela, B., Kittner, S., Lackland, D., ... Wylie-Rosett, J.American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2010). Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation, 121(7), e46–e215. doi:10.1161/CIRCULATIONAHA.109.192667 PMID:20019324 Lovasi, G. S., Moudon, A. V., Smith, N. L., Lumley, T., Larson, E. B., Sohn, D. W., Siscovick, D. S., & Psaty, B. M. (2008). Evaluating options for measurement of neighborhood socioeconomic context: Evidence from a myocardial infarction case-control study. Health & Place, 14(3), 453–467. doi:10.1016/j. healthplace.2007.09.004 PMID:17950024 Manrique-Garcia, E., Sidorchuk, A., Hallqvist, J., & Moradi, T. (2011). Socioeconomic position and incidence of acute myocardial infarction: A meta-analysis. Journal of Epidemiology and Community Health, 65(4), 301–309. doi:10.1136/jech.2009.104075 PMID:20841371 Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet, 372(9650), 1661–1669. doi:10.1016/S0140-6736(08)61690-6 PMID:18994664 McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The case for more active policy attention to health promotion. Health Affairs (Project Hope), 21(2), 78–93. doi:10.1377/hlthaff.21.2.78 PMID:11900188

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McMaughan, D. J., Oloruntoba, O., & Smith, M. L. (2020). Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. Frontiers in Public Health, 8, 231. doi:10.3389/ fpubh.2020.00231 PMID:32626678 Meilleur, A., Subramanian, S. V., Plascak, J. J., Fisher, J. L., Paskett, E. D., & Lamont, E. B. (2013). Rural residence and cancer outcomes in the United States: Issues and challenges. Cancer Epidemiology, Biomarkers & Prevention, 22(10), 1657–1667. doi:10.1158/1055-9965.EPI-13-0404 PMID:24097195 Merz, E. C., Wiltshire, C. A., & Noble, K. G. (2019). Socioeconomic inequality and the developing brain: Spotlight on language and executive function. Child Development Perspectives, 13(1), 15–20. doi:10.1111/cdep.12305

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Mishori, R. (2019). The Social Determinants of Health? Time to Focus on the Political Determinants of Health! Medical Care, 57(7), 491–493. doi:10.1097/MLR.0000000000001131 PMID:31107399 Murphy, J. M., Olivier, D. C., Monson, R. R., Sobol, A. M., Federman, E. B., & Leighton, A. H. (1991). Depression and anxiety in relation to social status. A prospective epidemiologic study. Archives of General Psychiatry, 48(3), 223–229. doi:10.1001/archpsyc.1991.01810270035004 PMID:1996918 Myers, C. A., Slack, T., Broyles, S. T., Heymsfield, S. B., Church, T. S., & Martin, C. K. (2017). Diabetes prevalence is associated with different community factors in the diabetes belt versus the rest of the United States. Obesity (Silver Spring, Md.), 25(2), 452–459. doi:10.1002/oby.21725 PMID:28009108 National Academies Press. (2017). Communities in Action: Pathways to Health Equity. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425845/ Neyer, J. R., Greenlund, K. J., Denny, C. H., Keenan, N. L., Casper, M., Labarthe, D. R., & Croft, J. B. (2005). Prevalence of stroke-United States, 2005. Morbidity and Mortality Weekly Report, 56(19), 469–474. PMID:17510610 O’Donohue, W., & Yeater, E. A. (2003). Individuating psychotherapies. Behavior Modification, 27(3), 313–321. doi:10.1177/0145445503027003004 PMID:12841587 Ottersen, O. P., Dasgupta, J., Blouin, C., Buss, P., Chongsuvivatwong, V., Frenk, J., Fukuda-Parr, S., Gawanas, B. P., Giacaman, R., Gyapong, J., Leaning, J., Marmot, M., McNeill, D., Mongella, G. I., Moyo, N., Møgedal, S., Ntsaluba, A., Ooms, G., Bjertness, E., ... Scheel, I. B. (2014). The political origins of health inequity: Prospects for change. Lancet, 383(9917), 630–667. doi:10.1016/S0140-6736(13)624071 PMID:24524782 Ouellette-Kuntz, H., Garcin, N., Lewis, M. E., Minnes, P., Martin, C., & Holden, J. J. (2005). Addressing health disparities through promoting equity for individuals with intellectual disability. Canadian Journal of Public Health = Revue canadienne de sante publique, 96(Suppl 2), S8–S22. doi:10.1007/BF03403699 Paez, K. A., Allen, J. K., Beach, M. C., Carson, K. A., & Cooper, L. A. (2009). Physician cultural competence and patient ratings of the patient-physician relationship. Journal of General Internal Medicine, 24(4), 495–498. doi:10.100711606-009-0919-7 PMID:19194767

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Petrelli, A., Gnavi, R., Marinacci, C., & Costa, G. (2006). Socioeconomic inequalities in coronary heart disease in Italy: a multilevel population-based study. Social Science & Medicine, 63(2), 446–456. doi:10.1016/j.socscimed.2006.01.018 Prochaska, J. O., & DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183–218. PMID:1620663 Rethorn, Z. D., Cook, C., & Reneker, J. C. (2019). Social Determinants of Health: If You Aren’t Measuring Them, You Aren’t Seeing the Big Picture. The Journal of Orthopaedic and Sports Physical Therapy, 49(12), 872–874. doi:10.2519/jospt.2019.0613 PMID:31789121 Rich, D. Q., Gaziano, J. M., & Kurth, T. (2007). Geographic patterns in overall and specific cardiovascular disease incidence in apparently healthy men in the United States. Stroke, 38(8), 2221–2227. doi:10.1161/STROKEAHA.107.483719 PMID:17600228

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Schroeder, S. A. (2007). Shattuck Lecture. We can do better—Improving the health of the American people. The New England Journal of Medicine, 357(12), 1221–1228. doi:10.1056/NEJMsa073350 PMID:17881753 Spencer, N. (2000). Poverty and child health (2nd ed.). CRC Press. Spencer, N., Thanh, T. M., & Louise, S. (2013). Low income/socio-economic status in early childhood and physical health in later childhood/adolescence: A systematic review. Maternal and Child Health Journal, 17(3), 424–431. doi:10.100710995-012-1010-2 PMID:22466716 Stuckler, D., & Basu, S. (2013). The body economic: Why austerity kills. Basic Books. Subramanian, S. V., Kim, D., & Kawachi, I. (2005). Covariation in the socioeconomic determinants of self rated health and happiness: A multivariate multilevel analysis of individuals and communities in the USA. Journal of Epidemiology and Community Health, 59(8), 664–669. doi:10.1136/jech.2004.025742 PMID:16020643 Tonne, C., Schwartz, J., Mittleman, M., Melly, S., Suh, H., & Goldberg, R. (2005). Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods. Circulation, 111(23), 3063–3070. doi:10.1161/CIRCULATIONAHA.104.496174 PMID:15939820 Vathesatogkit, P., Batty, G. D., & Woodward, M. (2014). Socioeconomic disadvantage and disease-specific mortality in Asia: Systematic review with meta-analysis of population-based cohort studies. Journal of Epidemiology and Community Health, 68(4), 375–383. doi:10.1136/jech-2013-203053 PMID:24407596 Weil, A. R. (2017). Pursuing Health Equity. Health Affairs (Project Hope), 36(6), 975. doi:10.1377/ hlthaff.2017.0583 PMID:28583952 White-Williams, C., Rossi, L. P., Bittner, V. A., Driscoll, A., Durant, R. W., Granger, B. B., Graven, L. J., Kitko, L., Newlin, K., & Shirey, M. (2020). Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association. Circulation, 141(22), e841–e863. doi:10.1161/CIR.0000000000000767 PMID:32349541 Witten, N. A. K., & Maskarinec, G. G. (2015). Privilege as a social determinant of health in medical education: A single class session can change privilege perspective. Hawai’i Journal of Medicine & Public Health: a Journal of Asia Pacific Medicine & Public Health, 74(9), 297–301. PMID:26468425

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Woodward, M., Brindle, P., & Tunstall-Pedoe, H. (2007). Adding social deprivation and family history to cardiovascular risk assessment: The ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart (British Cardiac Society), 93(2), 172–176. doi:10.1136/hrt.2006.108167 PMID:17090561 World Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health, final report. WHO Commission on Social Determinants of Health. https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf World Health Organization. (2021). Social determinants of health. World Health Organization. https:// www.who.int/teams/social-determinants-of-health

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ADDITIONAL READING Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129(1, Suppl 2), 5–8. doi:10.1177/00333549141291S203 PMID:24385658 Dawes, D. E. (2020a). The political determinants of health. John Hopkins University Press. Dawes, D. E. (2020b). Health inequities: A look at the political determinants of health during the COVID-19 pandemic. American Journal of Health Studies, 35(2), 77–82. Derose, K. P., Gresenz, C. R., & Ringel, J. S. (2011). Understanding disparities in health care access— and reducing them—through a focus on public health. Health Affairs, 30(10), 1844–1851. doi:10.1377/ hlthaff.2011.0644 PMID:21976325 Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care (B. D. Smedley, A. Y. Stith, & A. R. Nelson, Eds.). National Academies Press. Ottersen, O. P., Dasgupta, J., Blouin, C., Buss, P., Chongsuvivatwong, V., Frenk, J., Fukuda-Parr, S., Gawanas, B. P., Giacaman, R., Gyapong, J., Leaning, J., Marmot, M., McNeill, D., Mongella, G. I., Moyo, N., Møgedal, S., Ntsaluba, A., Ooms, G., Bjertness, E., ... Scheel, I. B. (2014). The political origins of health inequity: Prospects for change. Lancet, 383(9917), 630–667. doi:10.1016/S0140-6736(13)624071 PMID:24524782 Weil, A. R. (2017). Pursuing health equity. Health Affairs, 36(6), 975. doi:10.1377/hlthaff.2017.0583 PMID:28583952

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KEY TERMS AND DEFINITIONS Health Disparities: Higher burden of illness, injury, disability experienced by one group of individuals relative to another. Healthcare Disparities: Differences in access to or availability of healthcare services between population groups that are influenced by such factors as socioeconomic status, race/ethnicity, or sex/gender. Political Determinants of Health: The implications of politics and policy that influence the social conditions in which people live and the health outcomes they experience. Privilege: Instances where one population group has something of value that others are denied simply based on the population groups they belong to. Social Determinants of Health: The life circumstances in which people are born, grow, live, work, and age over time. Structural Determinants of Health: The root causes of health disparities which include governing processes and economic/social policies that affect income, working conditions, housing, and education, among others. Vulnerable Populations: Population groups that are at greater risk for poorer health, less healthcare access and who experience disparities in life expectancy.

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Section 2

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Concepts and Theories Oriented Towards Justice

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Chapter 4

The Power of Words:

A Preliminary Critical Analysis of Concepts Used in Speech, Language, and Hearing Sciences Yvette D. Hyter https://orcid.org/0000-0002-6910-8576 Western Michigan University, USA

ABSTRACT Recently, speech, language, and hearing sciences (SLHS) programs became increasingly aware of structural racism, inequity, and injustice in the professions and world. Although a consistent experience for many people of color, this current reality requires scholars and educators to interrogate concepts and employ more transformative concepts ftting for this new era. Concepts are the basis of thought, essential for communication, necessary for building knowledge, and the building blocks of theory. Critical theory was used to conduct a preliminary analysis of fve concepts used in SLHS. The concepts were analyzed keeping in mind the historical, political, and cultural infuences on how the concepts are used and understood in SLHS. The analysis revealed that these concepts were typically not defned in SLHS literature, and without collective critical refection, the continued use of those concepts could lead to inequities and/or exclusion. Suggestions for more equitable concepts are provided.

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INTRODUCTION Children in the 1960s often sang a rhyme - “Sticks and stones may break my bones, but words will never hurt me.” This rhyme was used to let people know that if they called a person a bad name or bullied a person with words, that person would be able to shirk it off and go on with life, unaffected. It is common knowledge now that the words in that little rhyme ring hollow. Words, and more importantly the concepts or underlying meanings of words, are powerful. Two different words can refer to the same concept, such as Ναί in Greek and Si in Spanish. Although these words are different, they express the same concept - agreement or affirmation (e.g., yes in English). DOI: 10.4018/978-1-7998-7134-7.ch004

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 The Power of Words

Concepts are important in thinking, communicating, learning, and in theory building and implementation (Giddens et al., 2020). Without concepts humans would not be able to communicate ideas with others. Also, concepts provide a link between thinking and behaviors. The meanings (underlying concepts) that we have for things, drives how one behaves or acts toward those things (see Hamilton et al., 2018 as an example). Let’s review two concepts (riot versus rebellion [or insurrection]) that will be helpful in understanding the impact that the underlying meaning of concepts have on behavior. Generally, both are considered a response by the populace to an injustice, perceived or real, committed by an authority such as the government. Riot is typically perceived to be a disorganized violent outburst that is not a legitimate form of expression. The media typically labels rebellions initiated by people of color as riots and the police respond with extreme violence and suppression. The riot that took place on 6 January 2021 in the U. S. at the U. S. Capitol in Washington, D.C., by mostly white people was labeled by the media as an insurrection – a legitimate form of expression. The police response was a much kinder, gentler, non-violent response to the 6th January event when compared to the police response to the largely organized and peaceful protests of groups that are comprised of primarily people of color. Concepts are not understandable in isolation. They “must be related to contexts such as theories, discourses or speech communities” (Risjord, 2009, p. 685). To fully understand concepts, it is necessary to determine how they are used in a particular context (Risjord, 2009; Wittgenstein, 1953). When the context changes the concept’s underlying meaning also changes (Risjord, 2009; Rodgers, 1989; 2000). For example, in linguistics and speech, language and hearing sciences, the concept used to refer to a language variation spoken by many (but not all) African Americans has changed in concert with changes in the social and political context. Such concepts have included Negro dialect, American Negro speech, Black English, African American vernacular English, and African American English (Green, 2002). Concepts are also an essential component of learning and implementing what is learned across diverse contexts (Giddens et al., 2020). The power that concepts hold is dependent on the systems/ social structures that maintain the inherent meaning of those concepts. For example, a racialized slur is meaningless without the history of systemic racism and racialized exploitation, oppression, and exclusion (Santiago-Valles, 2019). The objectives of this chapter are to:

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1. Identify five concepts used in SLHP that have outlived their usefulness for the time in which we are living 2. Critically analyze those five concepts, and explain how their continued use can oppress and exclude members of the SLHP discipline 3. Argue that SLHPs need transformative concepts, and without these concepts we will be relegated to policies and practices that continue to exploit, oppress and exclude people of color in the discipline. Before discussing the background, methodology and results of the study, it is important to inform the reader of my positionality with regard to the topic and the research methodology. A positionality statement is an explanation of the researcher’s perspectives or lenses with regard to the research process and interpretation of the data, and how these perspectives may have influenced the research process and interpretation (Gary & Holmes, 2020).

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POSITIONALITY STATEMENT I identify as a Black woman who was raised by two parents who moved “north,” i.e., Michigan from the “deep south,” i.e., Alabama during The Great Migration between 1916 and 1970s a time in the history of the U. S. when 6 million Black families moved north to find better prospects for their life that were not available to them in the south. (escaping poor economic conditions and racism of Jim Crow Laws [see Wilkerson, 2011]). My parents were not able to fulfill their first dreams due to racism but were privileged to build a wonderful life together in spite of it. These experiences had a significant impact on how they raised their offspring to ensure that “no one” could “ever tell us” what we could not do. Love and grit have sustained me as I experienced my own bouts with racism while a Black student, professional, and professor in a field that is predominantly white (see American Speech, Language, Hearing Association [ASHA], 2021). Although I was privileged to pursue and earn university degrees and recognition in my field, I was also marginalized throughout my education in speech, language and hearing sciences by some peers, some of my professors, and also by some of my colleagues. This history and these experiences have driven my pursuit of a more equitable and just profession in every aspect of speech, language and hearing sciences. The lens that primarily guided my work on this particular chapter is that of a scholar who approaches my work and research from a critical epistemological framework based on the premise that reality is based on conflicting interests and unequal distributions of power. My goal as a critical social theorist is to reveal (expose) inequitable conflicts (racial, cultural, economic, political for example) and systemic forms of exclusion and injustice, dismantle them, and transform policies and practices to be more equitable and just. I believe the usage of concepts reveal our innermost ideologies, often expressed by the way we behave. I spend a lot of time questioning my own concept usage, and this chapter is a natural outgrowth of that thinking.

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BACKGROUND Choosing concepts that are accurate, appropriate, and non-offensive can take effort, but it is in the struggle where we learn, and where transformation happens. There are many concepts about race, ethnicity, and culture to navigate. Some of those concepts will be used in this chapter but are not part of the concept analysis. One such concept is people of color (which for some “centers whiteness” and uniquely an “American experience” see Lim, 2020). Others are pathology which centers ableism, and clients and service providers that render the individuals and families with whom we collaborate void of agency. For this paper, pathology, clients and service providers will be avoided. The concept, people of color will be used, and a discussion will occur later about the value of using global majority (Johnson & Campbell-Stephens, 2012; Lim, 2020), which assumes an international and interconnected perspective and acknowledges that the majority of people in the world are people who identify as people of color. Many concepts used by Speech, Language, and Hearing Science professionals and scholars (SLHSs) are shrouded in nuances, and also are upheld by systems (regulations, policies, and status quo practices) of exploitation, oppression and exclusion of professionals, scholars and students from a variety of racialized groups including Black, Indigenous, Latinx, Palestinian, Asian and Pacific Islanders and from many other marginalized cultural, linguistic, racial, and ethnic backgrounds. Some concepts, particularly those 62

 The Power of Words

employed in our professional literature about race, ethnicity, and culture seldom have common or clear definitions, and historically have not typically been submitted to a critical analysis. SLHS has not been immune to the racists, unequal, and inequitable rules, regulations, policies and practices that exclude people of color who are members of this discipline. Some concerns in the field, which were always present, came to light anew after the extra-judicial killing of Mr. George Floyd in Minneapolis, Minnesota on May 2020 (https://www.thecut.com/2020/08/man-pinned-down-by-minneapolis-police-officer-dies.html#:~:text=On%20May%2025%2C%20a%20black,captured%20in%20 a%20bystander%20video). His death seemed to be the 21st century’s proverbial “straw that broke the camel’s back” and sparked an outpouring of protests in the U. S. as well as around the world (CNN, 2020). In SLHS the response of students, faculty, and scholars of color mirrored the response nationally and internationally. The American-Speech-Language-Hearing Association (ASHA) was pressed by its members to produce a strong statement against racism. Several “listening sessions,” were implemented by professional SLHS organizations for “leaders in CSD” to hear how racism in the discipline had, has, and continues to impact members so that an action plan could be developed. In addition to the listening sessions a Diversity Equity and Inclusion Task Force was created by the Council on Academic Programs in Communication Sciences and Disorders (CAPCSD), and as of January 2021 the “cultural competence” standards of the Council on Academic Accreditation (CAA) are being revised. In the current social and political contexts in which we are living, SLHSs of color and our allies need changes in the discipline that are transformative and relevant. Transformation is a radical process. From the perspective of Critical Theory1 transformation means releasing oneself from the status quo (or the way things have always been done), working across disciplines (i.e., in transdisciplinary groups, for example) to dismantle and eliminate structures that maintain inequity and injustice, and to build processes and systems that are equitable and just (Gaztambide-Fernandez, 2012). Transformation causes a complete shift in perspective (Weimer, 2014). Transformative changes in SLHS are not possible if SLHS faculty, clinicians, and scholars continue to use concepts that are no longer relevant for the current political and social contexts in which we live, learn and practice. The framework of Doreen Massey, a British geographer, who worked from Marxist and feminist theoretical perspectives, is used to define relevance (Massey, 2000, 2008). Relevance refers to (a) challenging the dominant ways of thinking, (b) understanding that politics2 is an essential part of our work as SLHSs (my work as an SLHSs is informed by political engagement in human rights, social justice, and equity), (c) engaging in the work that affects the daily lives of those to whom we are accountable, and (d) identifying causes of and solutions to inequities and injustices (Massey, 2000, 2008; Santiago-Valles, 2019).

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MAIN FOCUS OF THE CHAPTER The main focus of this chapter is twofold. The first goal is to clarify the meaning of concepts, that when accompanied by the current systems of racism and inequity can serve to exclude or make invisible students, faculty, and scholars of color. The concepts of focus are minority, minorities, multicultural, poverty, and cultural competence. The second goal is to challenge the continued use of these concepts in SLHS as a preliminary step in dismantling inequities in the discipline, and to support the use of more liberating and equitable concepts in teaching, research, and practice.

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 The Power of Words

Theoretical Framework Critical Theory was used to guide the study presented in this chapter. A basic premise of Critical Theory is that context clarifies meaning. Critical Theory allows one to acknowledge totality - the relationship between history, economic (access to resources), political (the power to make decisions in one’s own interest), and social-cultural determinants (Bronner, 2011; Delanty, 2020; Hyter, 2014; Hyter & SalasProvance, 2019; Jefferies, 2017). Therefore, using Critical Theory in this chapter provides an opportunity to consider those aforementioned contexts when examining the meaning of the targeted concepts. Additionally, Critical Theory’s focus is not only on identifying unequal power relations, and forces of economic exploitation, political domination, and social-cultural exclusion, but on examining the causes of those forces, what maintains them, and provides solutions for dismantling those forces within SLHS (Bronner, 2011; Delanty, 2020; Hyter, 2014; Hyter & Salas-Provance, 2019; Jefferies, 2017).

METHOD Approach to Concept Analysis Rodgers’ (1989) approach to concept analysis was the framework utilized in this study. This approach is frequently cited in nursing literature about concept analyses. Rodgers’ approach includes seven noncontiguous phases and is appropriate for an inductive approach to concept analysis (McEvoy & Duffy, 2008; Foley et al., 2017; Rodgers, 1989). Since this chapter focuses on a preliminary concept analysis and is not focused on the use of this analysis for theory building, this chapter focuses on four of Rodgers seven phases: 1. 2. 3. 4.

identifying the concepts of interest, identify surrogate terms and relevant uses of the concept, conducting a preliminary examination of a concepts in the context of their use in SLHS, and determining the meanings of those concepts based on historical, political and socio-cultural influences, which is consistent with a Critical Theory approach to concept analysis.

The last part of the analysis, which is not part of the Rodgers (1989) method will suggest alternative and more equitable concepts to replace the target concepts.

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Concepts of Interest and Preliminary Analysis Phase one focused on identifying the concepts of interest. The concepts of interest in this paper are minority, minorities, multicultural, poverty, and cultural competence. These concepts were the focus of this paper because they are often utilized in articles and writings about communication abilities of and clinical practices with people of color. These concepts have circulated in the SLHS for decades and have not been updated given the shifting social and political landscape in the U. S. or abroad.

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 The Power of Words

Preliminary Literature Search The preliminary literature searches of these concepts were completed by conducting a search only of ASHA journals and documents (e.g., letters to the editor, news items) published on the ASHA webpage. The journals included in the analysis are presented in Table 1. Table 1. A list of journals included in the chapter search and analysis      • American Journal of Audiology      • American Journal of Speech-Language Pathology      • Journal of Speech, Language and Hearing Research      • Language, Speech, and Hearing Services in Schools      • The ASHA Leader      • SIG Perspectives

Each of the concepts was searched individually using quotation marks, e.g., minority to locate exact match for the term. The advanced search engine was used, and the “anywhere” option was selected to identify where the concept could be located in the article or document. Phase two was a random sampling and review of five articles/documents that included each target concept resulting in a review of a total of 25 articles/documents (Rodgers, 1989). An online random number generator (http://www.random.org) was utilized for each concept. For example, there were 1177 occurrences of minority. For that concept the numbers 1 and 1177 were put into the random number generator and resulted in 1177 unique randomized numbers. The first five numbers were selected (i.e., 492, 583, 641, 647, 582). The articles that coincided with these randomized numbers were the articles or documents included in this review and coded with the randomized number.

Analysis of Literature and Concepts

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The analysis of the literature and target concepts in contexts in which they were used by the authors of the articles/documents comprised phase three of this study (Rodgers, 1989). Specifically, the concept was searched for in the article using the computer search function (i.e., “command + F” on a MacBook Pro), and then the sentence in which the targeted concept was used was entered into a table. The following information was obtained from each article/document: • • • • • •

code #, article citation, publication type (e.g., research article or letter), concept of interest (e.g., “cultural competence”), context (i.e., quote from the article/document), and defnition of the concept (as defned in the article).

The last column of table includes the underlying meaning of the concept and what the concept could be a surrogate for (i.e., code for) based on the historical, political and social-cultural use of the word (Knechel, 2015).

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 The Power of Words

Finally, alternative and more equitable and inclusive concepts are suggested to replace the targeted concepts. These alternative concepts have been identified in literature of other disciplines, such as nursing or sociology, and are beginning to be used more frequently in SLHS.

RESULTS A preliminary concept analysis was conducted on five concepts that frequently occur in SLHS literature and documents on ASHA’s web page. The initial search of the ASHA web site revealed a total of 2953 mentions of the targeted concepts combined. This section of the chapter is presented in three parts that correspond to the phases of the analyses: description of the concepts of interest, summary of the article reviews, concept analyses.

Descriptions of the Concepts of Interest Table 2 shows the total number of occurrences of each concept, the years in which the concept was mentioned, and the year where the concept was mentioned most often. The targeted concepts have been used in the SLHS literature for decades. The concept that has been used for the longest period of time and has been used most frequently is minority, which has been in circulation in the SLHS literature since 1937 and showed up 1177 times. The concept, cultural competence is the most recent concept and has been in the SLHS literature since 1991. The concepts used most frequently following minority, are multicultural, and poverty. Four (i.e., minority, poverty, minorities, and cultural competence) of the five concepts have had their highest number of mentions between 2017 and 2020, which is an indication that they are not “going out of style,” but continue to be readily incorporated into the literature in SLHS.

Table 2. Total Number of occurrences of targeted concepts in ASHA journals, and the years the concept was mentioned followed by the number of mentions Times the Concept Occurred in the Title of Publications

Range of Years in which the Concept was Mentioned (Year[s] of highest mentions)

Minority

1177

1937 - 2020 (2018 with 74 mentions)

Poverty

579

1941 - 2020 (2017 with 43 mentions)

Minorities

251

1971 - 2020 (2020 with 15 mentions)

Multicultural

624

1972 - 2020 (2003 with 48 mentions)

Cultural Competence

322

1991 - 2020 (2018 with 27 mentions)

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Concept of Interest

66

 The Power of Words

Table 3. Details of the articles sampled Code # Article Citation

641 Grossman, F. M. & Franklin, N. K. (1998). Bias effects in speech-language assessment and decision making. Language, Speech, and Hearing Services in Schools, 19(2), 153 - 159.

582 Edwin, R. (2002). Children are singing. Perspectives in Voice and Voice Disorder, 12(2), 11 - 14.

492 Scott, S. & Lee, J. H. (2003). Serving Clients who use sign language. The ASHA Leader, 8(6),

Code # Article Citation 647 Blessing, P. (2007). From bench to blackboard: Bringing the NIHL message to K-12 students. Perspectives on Hearing Conservation and Occupational Audiology, 11(1), 6 - 9

Publication Type

Research Article

Article

Context

Minority

The child’s racial-ethnic label significantly affected the degree to which school psychologists thought that a child should have been classified as educable mentally retarded. Similarly, Zucker and Prieto(1977) used a bogus case study of a child to show that children of a minority group, in this case Mexican American children, were judged to be in need of special class placement more often than white children.” (p. 154)

Defined as Mexican American children

A specific ethnic group Code For? • Scarcity • Insignificance

Minority

“I have presented the minority case for child vocal pedagogy . . . “ (p. 11)

No explicitly defined

Smaller number Not frequent occurrence Code for • Scarcity • Insignificance

Not explicitly defined

Smaller number Not a significant group Code for • Scarcity • Insignificance • Blacks & Latinos and perhaps Indigenous groups

Feature Article

Minority

Publication Type

Target Concept

Descriptive Article

Minority

“The Deaf Community considers itself a minority group . . “.(p. 4)

Context

“A third study, recently funded through a trans-NIH program to enhance clinical research in minority communities, examines …” (p. 7)

Definition

Underlying Meaning (Code for?)

Concept

Definition Provided

Underlying Meaning (Code for?)

No explicitly defined

Smaller number Not a significant community Code for • Scarcity • Insignificance • Blacks & Latinos and perhaps Indigenous groups

Not explicitly defined

Problematic condition Can be a result of language biases in assessments Code for • At risk for language impairments; disorders; problems? • Blacks and Latinos & possibly Indigenous groups

Defined as Racial and ethnic groups

Smaller or insignificant group Code for • Scarcity • Insignificant • Blacks and Latinos and possibly Indigenous groups

“The 25 risk categories were . . . . minority status . . . “ (p. 1000)

583 Rudolph, J. M. (2017). Case history risk factors for specific language impairment: A systematic review and meta-analysis. American Journal of Speech- Language Pathology, 26(3), 991 - 1010.

32 Newman-Ryan, J., et al. (1995). Testing balance function in Spanish-speaking patients: Guidelines for non-Spanish-speaking clinicians. American Journal of Audiology, 4(2), 15 - 23.

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Code # Article Citation

94 Walters, S. Y., & Geller, E. F. (2002). The evolution of an urban bilingual/multicultural graduate program in speech-language pathology. Contemporary Issues in Communication Science and Disorders, 29, 185 - 193.

“Thus, once the effect sizes were categorized and trimmed, 11 risk categories were excluded. These were …. minority status” (p. 1002). Review Article

Minority

“Among the 11 risk categories that could not be included in meta-analysis, five met criteria for clinical significance . . . These were . . . minority status” (p. 1007) “As such, the association between, for example, maternal education or minority status and SLI may be confounded as a result of language biases inherent in the assessment instruments that were used.” (p. 1008)

Grand Rounds

Minorities

“The 1990 census . . . revealed greater numbers of racial/ethnic minorities than in previous years, . . .” (p. 15) “ASHA Committee on the Status of Racial Minorities, 1988” (p 15)

Publication Type

Target Concept

Context

Descriptive Article

Definition Provided

Underlying Meaning (Code for?)

“ ASHA Committee on the Status of Racial Minorities, 1987” (p. 185, 189) “

Not explicitly defined

Smaller or insignificant group Code for • Scarcity • Insignificance • Blacks and Latinos and possibly Indigenous groups

More than one-third of our 2001 incoming class were members of underrepresented minorities, including African Americans, Asians, and Latinos.” (p. 191)

Defined as African Americans, Asians, and Latinos

Smaller under-represented group Code for • Scarcity • insignificance

Minorities

continued on following page

67

 The Power of Words Table 3. Continued Code # Article Citation

Publication Type

Concept

Context

Definition

Underlying Meaning (Code for?)

Minorities

“For instance, health care disparities in racial and ethnic minorities in the United States can no longer be discounted or ignored.” (p. 1)

Defined as Racial and ethnic groups

Smaller or insignificant racial/ethnic groups Code for • Scarcity • Insignificance

Policy Analysis

Minorities

“.. and for different subgroups of students (English-language learners, students in special education, racial minorities, those in poverty” (p. 4)

Defined as racial groups

Smaller or insignificant racial groups Code for • Scarcity • Insignificance

Code # Article Citation

Publication Type

Target Concept

247 Jiang, H., & Logan, J. (2019). Improving reading comprehension in the primary grades: Mediated effects of a language-focused classroom intervention. Journal of Speech, Language and Hearing Research, 62, 2812 - 2828

Research Article

Minorities

280 Lemke, A. (2009). Diverse Caucuses Benefit ASHA. The ASHA Leader

Letter

Multicultural

133 Moxley, A., et al. (2004). Cultural competence in health care. The ASHA Leader, 9(7) 101 Snyder, N. (2016). The new education law and ASHA members. The ASHA Leader, 21(2)

21 Moxley, A. & Polovoy, C. (2009). New century brings multicultural growth at ASHA. The ASHA Leader, 14(11),

Feature Article

ASHA News

Multicultural

Context

Definition Provided

Underlying Meaning (Code for?)

“Across all grade levels, 51%-53% of the students were female, and 29%-43% were identified as ethnic minorities.” (p. 2816)

Defined as Ethnic groups

Smaller or insignificant ethnic groups Code for • Scarcity • Insignificance

“ASHA values the inclusion of various multicultural constituency groups, including L’GASP-GLBT …”

Defined as Gender groups

Groups with many cultures Code for • People of color

Not explicitly defined

Activities pertaining to many cultures Code for • Code for people of color

“I am writing in response to the letter from Mary Estlack expressing her ‘increasing concerns regarding multicultural constituency groups, more specifically, the L’GASP-GLBT caucus”

Not explicitly defined

Groups with people from many cultures Code for • People of color

By not responding … The ASHA Leader neglected an important opportunity to education the membership about the need for the multicultural constituency groups . .”

Not explicitly defined

Groups with people from many cultures Code for • People of color

“Kohnert, whose research focuses on speech-language development and use in bilingual children and adults, has received two ASHA grants for projects on multicultural activities and received ASHA’s 2006 award for Special Contributions in Multicultural Affairs” “ASHA embraced the available research and its findings, infusing multicultural issues into its documents.”

165 Ouellette, P. (2010). Unbiased service for clients. The ASHA Leader, 15(3)

Code # Article Citation

Definition Provided

Underlying Meaning (Code for?)

Context

Multicultural

“The author pays special attention to multicultural issues in bilingual children who stutter.” (p. 15) “We should be mindful that these unique conditions might lead to stuttering onset or a temporary increase in stuttering in some children from multicultural and bilingual backgrounds.” (p. 18)

No explicitly defined

Groups with people from many cultures Code for • People of color

Descriptive Article

Multicultural

“Multicultural issues in service deliver have been officially. Recognized as a vital area of knowledge and study for practicing speech language pathologists . . “ (p. 142) “SLPs must demonstrate competencies in multicultural issues as related to technology in order to be effective in delivering appropriate AAC services.” (p. 142)

Not explicitly defined

Issues pertaining to people from a range of cultural backgrounds Code for • People of color • People who are not white

Code # Article Citation

Publication Type

Target Concept

Context

Definition Provided

Underlying Meaning (Code for?)

329 Seymour, H.N., et al. (1986). The effect of race on language elicitation. Language, Speech and Hearing Services in Schools, 17(3), 146 - 151

Research Article

Poverty

Not explicitly defined

A state

294 Harris, O. (2015). A cultural basis to develop strong advocates for client family involvement in the speech-generated device evaluation and funding process. Perspectives on Augmentative and Alternative Communication, 24, 142 - 146.

Publication Type

Multicultural

Target Concept

72 Shenker, R. C. (2013). When young children who stutter are also bilingual: Some thoughts about assessment and treatment Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations,20(1) 15 - 23

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Letter

Theoretical Article

Occurs in a citation - Labov, W. (1970). The logic of non-standard English. In F. Williams (Ed.), Language & Poverty (pp. 153 - 189). Chicago, IL: Markham.

continued on following page

68

 The Power of Words Table 3. Continued Code # Article Citation 417 King, D. F., & Goodman, K. S. (1990). Whole language: Cherishing learners and their language. Language, Speech and Hearing Services in Schools, 21, 221 - 227. 455 Scott, D. (2004). An examination of research issues in hearing for children from culturally and linguistically diverse populations. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 11(3), 2 - 12. 525 Woods, J. J., Wilcox, M. J., Friedman, M., & Murch, T. (2011). Collaborative consultation in natural environments: Strategies to enhance family-centered supports and services. Language, Speech and Hearing Services in Schools, 42(3), 379 - 392. Code # Article Citation 564 Stockman, I. J., et al.. (2013). Toward validation of a minimal competence core of morphosyntax for African American children. American Journal of Speech-Language Pathology, 22, 40 - 56.

110 Salas-Provance, M. (2007). From the Coordinator. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 14(1), 1-2

32 Davis-McFarland, E. (2008). Family and cultural issues in a school swallowing and feeding program. Language, Speech and Hearing Services in Schools, 39(2), 199 - 213.

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Code # Article Citation

Publication Type

Context

Poverty

“The life experiences of some learners may reflect rich cultural traditions as well as despair and poverty.” (p. 223)

No explicitly defined

A state of living and/or existence; A life experience Code For • Brought about by one’s own doing

Poverty

“The U. S. Bureau of the Census (2001) data indicate that African American, Hispanic, and American Indian children are more likely to live in poverty, and have less access to health care, thus increasing the changes of the children being exposed to CMV” (p. 7)

Not explicitly defined

A state of living and/or existence Code For • Brought about by one’s own doing

Review Article

Poverty

“Underrepresented families, such as those living in poverty and minorities, were more likely . . “ (p. 381)

Not explicitly defined

A state of living and/or existence. Code for • Brought about by one’s own doing

Publication Type

Target Concept

Context

Definition Provided

Underlying Meaning (Code for?)

Defined as relating to one’s financial situation

A state of one’s financial situation. Code For • Brought about by one’s own doing

Review Article

Review Article

Research Article

From the Coordinator

Clinical Forum

Publication Type

Definition

Underlying Meaning (Code for?)

Concept

Poverty

“The children also presented risk histories related to health (15%) and environmental (more than 40%) threats to development and well-being that extended beyond economic poverty.

Cultural Competence

“Dr. Goldberg in her article ‘Service learning as a tool to facilitate Cultural Competence,’ makes a compelling case for cultural competence as a mutual aspect of communication” (p. 2) “In the case of the preparation of college students to be culturally competent, she presents an excellent service-learning model that incorporates reflective thinking. . . . “ (p. 2)

No explicitly defined

An aspect of communication It can be facilitated by service-learning activities There are ways to learn it - a skill that can be learned Code for • A skill

“This article provides an overview of cultural, religious, and health beliefs of several ethnic groups, as well as information on the dynamics and requirements of cultural competence and family focused intervention” (p. 199)

Not explicitly defined

It is stimulated and supported by cultural desire Code for • A skill

“… defines cultural competence as the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of the client (p. 210)

Defined as the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of the client

Constant process; dynamic Continual striving to work effectively within the client’s cultural context. Code for • A process or way of life

Cultural desire is the foundation for the cultural competence journey… Cultural desire stimulates cultural competence (p. 210)

Not explicitly defined

Need to have desire before you can have competence Code for • A process or way of life

Definition Provided

Underlying Meaning (Code for?)

Cultural Competence

Target Concept

Context

continued on following page

69

 The Power of Words Table 3. Continued Code # Article Citation

62 Preis, J. (2013). The effects of teaching about white privilege in speech-language pathology. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 20(2), 72 - 83.

Code # Article Citation

Publication Type

Descriptive article

Publication Type

Concept

Cultural Competence

Target Concept

Context

Code # Article Citation

Descriptive article

Publication Type

Cultural Competence

Target Concept

Underlying Meaning (Code for?)

“”For many students in speech-language pathology, cultural competence may solely imply learning about other cultures” (p. 72)

Not explicitly defined

Implies that learning about other cultures is important Code for • A Skill

“The ongoing development of cultural competence for speech-language pathologists (SLPs) is an issue that extends beyond certification; it is directly connected to ethical practice” (p. 72)

Not explicitly defined

An aspect of being an ethical practioner Code for • A skills or competency?

“There are a variety of means for current practioners to assess their cultural awareness, attitudes, and knowledge (e.g., Cultural Competence Health Practioner Assessment . . “ (p. 72)

Not explicitly defined

It is something that can be assessed There are tools to assess

ASHA provides its members with a number of assessments, resources, and guidelines to support the development of cultural competence” (p. 73)

Not explicitly defined

A skill that can be developed Code for • A skill

… because students are typically in an early stage of cultural competence (p. 73)

Not explicitly defined

Develops in stages Code for • Requires certain steps to get there

“… As ASHA recently noted, cultural competence includes attitudes and behaviors that develop across a continuum and progress over time (ASHA, 2011a)” (p. 73)

Not explicitly defined

Includes attitudes and behaviors that develop along a continuum and over time

Definition Provided

Underlying Meaning (Code for?)

Not explicitly defined

Can imply only learning about other cultures One needs to recognize one’s own cultural influences Code for • A skill

“There, it seems that direct instruction to students, particularly White students, on bias, discrimination, and privilege could provide a critical first step that is necessary foundation to the development of cultural competence” (p. 74)

Not explicitly defined

Certain information is more important for white students than others White students understanding privilege and discrimination is critical to development Code for It’s a white person’s problem

“It is assumed that speech-language pathology programs are supported by their institutions of higher education to include courses or experiences that address the broad concepts of diversity and cultural competence” (p. 74)

Not explicitly defined

May be supported by universities to be included in academic content

Definition Provided

Underlying Meaning (Code for?)

Context “Even when race is considered, for many students, cultural competence may solely imply learning about other cultured, not recognizing the influences of one’s own cultural, and particularly one’s own racial, lens” (p. 73)

62 Preis, J. (2013) (continued)

Definition

Context

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continued on following page

70

 The Power of Words Table 3. Continued Code # Article Citation

Publication Type

Concept

Context “The primary tool for assessing changes in students’ level of cultural competence and awareness was ….” (p. 78)

Descriptive article

Has different levels of learning/acquisition

Not explicitly defined

Has various components or domains Is comprised of three different domains, which are (a) white privilege, (b) awareness of racial discrimination, and (c) awareness of institutional racism Code for A complex skills or ability

Not explicitly defined

Has various components, some more essential than others Should include white privilege because majority of SLHSs are white Code for A complex skill or ability

Not explicitly defined

Content not mandated or suggested by ASHA Determined by individual institutions Code for ancillary and not essential information

Definition Provided

Underlying Meaning (Code for?)

Not explicitly defined

Something that clinicians need to develop Clinicians need to be prepared to develop this skill Code for A complex skill

Not explicitly defined

Important to be developed and valuable skills Should be part of preparation to be an SLP Code for Important to learn while learning to be an SLP

“Kohnert (2013) purports how clinical cultural competence requires extensive knowledge across three specific areas: Knowledge of self, knowledge of others, and evidence-based theoretical knowledge of dual-language development and communication disorders” (p. 1534)

Not explicitly defined

Requires Knowledge of self, knowledge of others, and evidenced-based theoretical knowledge of dual language development and disorders Code for A complex skill

“Of important to clinicians is the development and maintenance of clinical cultural competence and the ability to understand and adapt to the needs of prospective clients . . “ (p. 1534)

Not explicitly defined

Important to develop and maintain this skill

“Undergraduates are exposed to the cultural competence continuum . . .” (p. 1534)

Not explicitly defined

There is a continuum Code for A linear process

Not explicitly defined

Obtaining cultural competence is an achievement Code for Something valuable and/or worthwhile

Definition Provided

Underlying Meaning (Code for?)

Not explicitly defined

Knowledge of self is valuable, but knowledge of others is more important Code for Really about what’s happening outside of yourself

Cultural Competence “In a profession where the vast majority of its students and practioners are white, this may be a critical component to include in training on cultural competence” (p. 79)

“ASHA does not mandate or even suggest the content of such instruction, again allowing institutions freedom to decide what should be included in an academic course, clinical practicum, or other experience aimed to address cultural competence” (p. 79) Code # Article Citation

Publication Type

Target Concept

Context “Since 1985, ASHA has established numerous approaches to better prepare clinicians to develop cultural competence . . . “ (p. 1532)

“With certainty, the development of clinical cultural competence is a valuable and important component in the preparation and training for clinical work . . . “ (p. 1532)

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65 Greene, K. et al. (2019). The Los Angeles Diversity Project: The promotion of cultural and linguistic competence via a university community learning project. Perspectives of the ASHA Special Interest Groups, 4, 1531 - 1539.

Clinical Focus

Cultural Competence

“the achievement of cultural precompetence and cultural competence becomes an overriding goal of achievement (p. 1535)

Code # Article Citation

65 Greene, K. et al. (2019). (continued)

Underlying Meaning (Code for?)

Not explicitly defined

“Results … in Table 2, show that the White students enrolled in the course demonstrated a statistically significant increase in awareness (or decrease in color blindness or unawareness) in two of the three domains of cultural competence” (p. 78) --= awareness of white privilege, awareness of racial discrimination 62 Preis, J. (2013) (continued)

Definition

Publication Type

Target Concept

Context

Clinical Focus

Cultural Competence

“Although the development and knowledge of self is valuable, knowledge of others becomes a key component and specific to cultural competence” (p. 1535)

continued on following page

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 The Power of Words

Table 3. Continued Code # Article Citation

Publication Type

310 Kleinhans, K. A., et al. (2020). Deliberate Supervision: Practical Strategies for Success. Perspectives of the ASHA Special Interest Groups, 5(1), 206 - 215.

Clinical Focus

Concept

Cultural Competence

Context “Clinical supervisors are reminded the developmental stages can be applied to all knowledge and skills necessary for professional practice as identified by the CFCC (2018), such as professional interaction skills, developing cultural competence, working collaboratively . . “ (p. 209)

Definition

No explicitly defined

Underlying Meaning (Code for?)

• Skills that can be developed • Develops in stages

Summary of Article Reviews Of the 2953 articles/documents that contained the five targeted concepts, 25 articles were reviewed, and the meanings of each concept was identified and defined based on how the concept was defined in the reviewed article or document. Additionally, historical, political, and socio-cultural influences were used to infer what the examined concepts might be a surrogate (or code) for is identified in the last column of Table 3. As indicated in Table 3, some articles mentioned the target concept a number of times. For example, minority, was mentioned in one article (Rudolph, 2017) four different times. When the multiple mentions of a concept occurred, each mention was submitted to the same questions as outlined in the column heads of Table 3. This resulted in eight entries for minority, six for minorities, eight for multicultural, five for poverty, and 26 entries for cultural competence, resulting in a total of 53 entries for the targeted concepts combined. Of these 53 entries, only nine (17%) of the entries were defined in the literature. Table 4 shows definitions presented in the articles reviewed for this study that pertain to the concepts examined in this chapter. Overall, the concept that was defined most often was minorities and comprised 56% of all of the concept definitions.

Concept Analyses

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Minority and Minorities The concepts minority and minorities mean a small or smaller number or amount of something. The etymology of minority is the “state of being smaller” or “minor” (Klein, 1971), and is particularly offensive (APA, 2019). These concepts are frequently interpreted as something being insignificant or ancillary. Often the concept “minority” is used as a surrogate for certain racial/ethnic groups, such as Blacks, African Americans, Arabs, Asians, Pacific Islanders, Latinx, Indigenous Americans; but not other racial/ethnic groups, e.g., whites, caucasians or European Americans. This use of minority is especially problematic when the groups referred to as minorities are actually the majority in a school or city or region. For example, members of the Latinx communities are referred to as minorities while they are the majority of people living in New Mexico (U. S. Census, 2019). Blacks are referred to as minorities although we make up the majority of people living in the District of Columbia (U. S. Census, 2019). If one takes a world view, the majority of people in the world are people of color. The concept of minority seems to be a surrogate for (code for) those who do not have decision making power (politically oppressed), access to resources or who do not receive adequate compensation for their labor (economically

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exploited), or who generally have some deficit based on their racialized backgrounds and are therefore, experience social cultural exclusion. Table 4. Definitions used in articles to define concepts examined in this chapter Concept Minority

Minorities

Definition

Citation

Mexican American children

Grossman & Franklin, (1998), p. 154

Racial and ethnic groups

Newman-Ryan et al., (1995), p. 15

African Americans, Asians, and Latinos

Walters & Geller (2002), p. 191

Racial and ethnic groups

Moxley et al. (2004), p. 1

Racial groups

Snyder (2016), p. 4

Ethnic groups

Jiang & Logan (2019), p. 2816

Multicultural

L’GASP+GLBT

Lemke (2009), p. 1

Poverty

Relating to one’s financial situation

Stockman et al. (2013)

Cultural Competence

the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of the client

Davis-McFarland (2008), p. 210

Multicultural Multicultural means many or numerous cultures (Klein, 1971), and is often used to refer to the racial and ethnic diversity. It is typically a surrogate for people of color or LGBTQIA+ communities, but typically does not include white people in its common use. One case, which was in the news is a reminder of why we need to be clear about how concepts are defined. In February 2020 Black students at the University of Virginia complained that there were “too many white people” using the newly opened “multicultural center” (Neelakantan, 2020). Clearly in the minds of the Black students at that university, and in the minds of many people living in the U. S., multicultural is code for people of color, people who are not white and/or people who are members of the LGBTQIA+ communities (Lemke, 2009; Moxley & Polovoy, 2009; Ouellette, 2010; Shenker, 2013; Harris, 2015).

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Poverty Poverty typically refers to one’s economic state. It is a noun and refers to the state of being without economic support; being in need of money and or resources. Unfortunately, the concept of poverty does not provide information about why a person may be in that economic state, or how one entered into poverty. The real danger in the use of poverty, is that some may perceive that the person or group being described with that concept is in poverty by their own doing.

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Table 5. Suggested concepts to incorporate into teaching, scholarly activities, and practice Use This Global Majority (member of, people of) Use the name of the cultural, ethnic or racialized group Impoverished Culturally Responsive (culturally sustaining, culturally consistent)

Not That Minority or Minorities Multicultural Poverty Cultural Competence

Cultural Competence Cultural competence is a concept that began to show up in the SLHS literature in 1991 and is the concept that was most well defined in the literature sampled for this preliminary concept analysis. DavisMcFarland (2008) quoted Campinha-Bacote who defined cultural competence as “the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of the client.” (p. 209-210) In this definition Campinha-Bacote (1994) and Davis-McFarland (2008) took great care to include the iterative process of becoming culturally competent. Unfortunately, the concept competent or competency is also used to indicate a learned skill that you acquire, and once acquired you always have that skill. When engaging in cultural competence, competency is context specific. For example, someone who has traveled, worked and studied in west African countries for the last 20 years (pre COVID-19), may understand cultural nuances so well in those countries, and may engage in behaviors, thinking, and interactions that would qualify as being culturally competent. If this same person were to travel to Singapore, having never been to the continent of Asia or to the country of Singapore, that person who was culturally competent in we African countries, would be beginning anew with regard to learning how to be culturally competent in that new context. Cultural Competence also requires dynamic processes and continued vigilance for engaging in cultural humility (recognizing that values that are not your own are valid), obtaining cultural knowledge (your own and understanding others), critical self-reflection (being able to deconstruct your own values and belief systems), and cultural reciprocity (being able to resolve inconsistencies and to be able to incorporate other values, beliefs and assumptions into your practice) (Hyter, 2014; Kalyanpur & Harry, 2012; Ortega & Faller, 2011).

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RECOMMENDATIONS This section of the chapter provides recommendations about concepts that are more equitable than the ones currently in circulation in SLHS. Recommendations are provided for each of the concepts targeted in this study.

Discontinue use of Minority and/or Minorities; Use Global Majority Some concepts that are gaining more recognition and being used more frequently in literature are concepts such as people of color, people of the global majority, or global majority (my personal favorite). People

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of color seems to be a particularly unique perspective of people living in the U. S. (Lim, 2020). In this current stage of globalization (i.e., worldwide interdependence) it is difficult to focus only on the U. S. If asked, many people would prefer to be referred to how they self-identify. For example, some people of African descent who are living in the U. S. but did not grow up in the U. S. or who do not identify with capitalist values that are so strong in the U. S. may prefer to be called Black, rather than African American. For example, I prefer to refer to myself as Black and recognize that others may prefer African American, so try to use both in my writing. Global majority is a new concept increasingly being used in sociology, political science, international studies and discussions about globalization and social justice (Coicaud & Sieger, 2019). It demonstrates a global perspective and recognizes that the majority of people in the world are people of color - the global majority (Ritzer & Dean, 2014). In SLHS a similar term is has been introduced to refer to countries where the majority of the world’s population live - Majority World countries and Minority World countries. Majority world countries are countries where the majority of the people in the world live, and often have histories of being colonized and where access to their own resources is often strained due to global processes (Hyter & Salas-Provance, 2019, p. xi; Freedman & Crépeau, 2017). Such countries include those in sub-Saharan Africa, Latin American, Central America, some parts of Asia and India. Minority world countries on the other hand are countries where the minority (fewer) people in the world live, where the countries have had experiences being the colonizer, and include countries such as United States, Canada, and many countries in Europe, but also Australia, Israel, Japan, parts of China, and New Zealand (Hyter & Salas-Provance, 2019).

Discontinue use of Multicultural (and Diversity); Use the Name of the Social, Cultural, Racialized, Ethnic, Identity Group Critiques of multicultural and multiculturalism (and diversity) from a Critical Theory perspective point out that multiculturalism can possibly be used to minimize real cultural differences. It is a rather palatable, often non-threatening concept, that can undermine the real exploitation, oppression and exclusion of people based on their racial, ethnic, cultural histories and experiences. Also, representation does not equal transformation. In other words, including more people from diverse cultural or ethnic groups in decision-making, in literature, in departments does not change unequal power relations or transform inequitable unjust systems and structures into equitable and just ones. Rather than using multicultural as a catch all phrase naming the cultural, racial, ethnic, and identity groups being referred to or included is probably the best option.

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Discontinue use of Poverty; Use Impoverishment As mentioned earlier, poverty hides the causes of one’s impoverishment, and therefore, it is all too easy and convenient to think that the impoverished person is in that particular economic state due to their own, individual choices rather than to some larger inequitable structures. Although people who are impoverished are racially and ethnically diverse, the perception in the U. S. of those who are impoverished is negative and more negative traits are attributed to the global majority. As only one example, in 2016 the Los Angeles Times (Lauter, 2016) presented an exposé on the perceptions of people in the U. S. about people who are “poor.” Lauter found that people attributed negative stereotypes to “poor people” such as them being “lazy,” and preferring to receive government assistance than to find a job. These 75

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attitudes were along racialized lines. In other words, “blue-color whites” perceived the impoverished people “prefer to stay on welfare,” and that government programs made poverty worse. Rather than using the concept poverty, impoverishment reveals that there are more often than not economic, political and social processes, social injustice, and inequities that maintain and reproduce impoverishment (Crane et al., 2020; Hyter & Salas-Provance, 2021).

Discontinue use of Cultural Competence; Use Culturally Responsive or Culturally Sustaining Practices A concept that seems to be more fluid, rather than static, and seems to inherently include the requirement to “continually strive” to work within the “cultural context of the client” (Davis-McFarland, 2008, p. 210) is culturally responsive or culturally sustaining practices (Hyter & Salas-Provance, 2019). Culturally responsive practice refers to is making every effort to respond to the cultural perspective, values, beliefs of those with whom we collaborate in their care (Hyter & Salas-Provance, 2019). The goal is to consider others’ beliefs, values and perspective in all aspects of your practice. Culturally sustaining pedagogies or practices is similar to cultural responsiveness in that one is being responsive to the family’s culture and cultural context and the goal is to “sustain linguistic…. and cultural pluralism” (Paris, 2012, p. 93).

FUTURE RESEARCH DIRECTIONS

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The study presented in this chapter focused on only 25 occurrences of five concepts used in SLHS literature. Future research should include the following three topics: 1. A more in-depth analysis of concepts is required. To start, this more in-depth analysis should include all occurrence of the same five concepts focused on in this chapter. The concepts occurred in a total of 2953 articles and/or documents published in ASHA journals. 2. Future research should analyze additional problematic concepts, such as diversity, pathology, services, and clients. Each of these concepts have troubling connotations for that way SLHSs approach practice, teaching and scholarship in the field, particularly since concepts are the basis of learning, thinking, and theory building. 3. Finally, for scholars, faculty, and clinical SLHSs to become more conscious of the inherent racism within the policies, practices, and concepts used in SLHS it is important to examine the colonial history of the field that produced and maintains the current use of concepts such as minority, minorities, multicultural, poverty, and cultural competence. (See Abrahams et al., 2019; Hyter, 2020; Hyter & Salas-Provance, 2019; Pillay & Kathard, 2018; Staley et al., 2020)

CONCLUSION This chapter explains a preliminary concept analysis of five concepts frequently used in SLHS literature and documents published on ASHA’s web site. These five concepts were minority, minorities, poverty, multicultural, and cultural competence. These concepts, frequently used in literature about culture, race, ethnicity in SLHS, are often not clearly defined or closely examined. Concepts, however, can play a 76

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significant role in the progressive transformation of policies and practices from those that are inequitable and unjust to those that are more liberating, equitable, and just. Transformation is difficult if we still rely on old and ineffective concepts to explain our practice and support our writing. The concepts analyzed in this chapter should be moved aside so that there is room for building blocks (i.e., concepts) that may lead to transformative thinking, teaching, scholarly activities, practice, and ultimately more equitable policies. Table 5 shows a beginning list of concepts to discontinue and to incorporate into our conceptual frameworks guiding our practice.

ACKNOWLEDGMENT I would like to acknowledge Betty Yu, Ph.D., CCC-SLP, Associate Professor at San Francisco State University, who was instrumental in my coming to recognize that the concept of pathology in the name of our profession centers ableism. I would also like to acknowledge Chisomo Selemani, M. A., CCCSLP, Associate Professor at Baldwin Wallace University, who helped me understand the problematic connotations of the concept of providing services for clients. Finally, I would like to thank the reviewers who helped make this a better chapter.

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Hamilton, M. B., Mont, E. V., & McLain, C. (2018). Deletion, omission, reduction: Redefining the language we use to talk about African American English. Perspectives of the ASHA Special Interest Groups SIG 1, 3(1), 107 - 117. doi:10.1044/persp3.SIG1.107 Harris, O. (2015). A cultural basis to develop strong advocates for client family involvement in the speech-generated device evaluation and funding process. Perspectives on Augmentative and Alternative Communication, 24(4), 142–146. doi:10.1044/aac24.4.142 Hyter, Y. D. (2014). A conceptual framework for responsive global engagement in Communication Sciences and Disorders. Topics in Language Disorders, 34(2), 103–120. doi:10.1097/TLD.0000000000000015 Hyter, Y. D. (2020, November 30). Speech, Language and Hearing Sciences through a social justice lens. Presentation at Adelphi University, Garden City, NY.

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Lim, D. (2020, May 10). I’m embracing the term “people of the global majority”. Medium. Retrieved on January 17, 2021 from https://regenerative.medium.com/im-embracing-the-term-people-of-the-globalmajority-abd1c1251241 Massey, D. (2000). Practicing political relevance. Transactions of the Institute of British Geographers, 25(2), 131–133. doi:10.1111/j.1467-8330.2008.00619.x Massey, D. (2008). When theory meets politics. Antipode, 40(3), 492–497. doi:10.1111/j.14678330.2008.00619.x McEvoy, L., & Duffy, A. (2008). Holistic practice - A concept analysis. Nurse Education in Practice, 8(6), 412–419. doi:10.1016/j.nepr.2008.02.002 PMID:18362085

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Moxley, A., Mahendra, N., & Vega-Barachowitz, C. (2004). Cultural competence in health care. ASHA Leader, 9(7), 6–22. Advance online publication. doi:10.1044/leader.FTR3.09072004.6 Moxley, A., & Polovoy, C. (2009). New century brings multicultural growth at ASHA. ASHA Leader, 14(11), 24–25. Advance online publication. doi:10.1044/leader.AN1.14112009.24 Neelakantan, S. (2020, February 16). University of Virginia caught in race row after Black student’s comment. Diverse Education. Retrieved on 19 January 2021 from https://diverseeducation.com/article/167184/ Newman-Ryan, J., DeLeon Northrup, B., & Villarreal-Emery, C. (1995). Testing balance function in Spanish-speaking patients: Guidelines for non-Spanish-speaking clinicians. American Journal of Audiology, 4(2), 15–23. doi:10.1044/1059-0889.0402.15 Ortega, R. M., & Faller, K. C. (2011). Training child welfare workers from an intersectional cultural humility perspective: A paradigm shift. Child Welfare, 90(5), 27–49. PMID:22533053 Ouellette, P. (2010). Unbiased service for clients. ASHA Leader, 15(3), 38. Advance online publication. doi:10.1044/leader.IN4.15032010.38 Paris, D. (2012). Culturally sustaining pedagogy: A needed change in stance, terminology, and practice. Educational Researcher, 41(3), 93–97. doi:10.3102/0013189X12441244 Preis, J. (2013). The effects of teaching about white privilege in speech-language pathology. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 20(2), 72–83. doi:10.1044/cds20.2.72 Risjord, M. (2009). Rethinking concept analysis. Journal of Advanced Nursing, 65(3), 684–691. doi:10.1111/j.1365-2648.2008.04903.x PMID:19222666 Ritzer, G., & Dean, P. (2014). Globalization: A basic text (2nd ed.). John Wiley & Sons. Rodgers, B. L. (1989). Concepts, analysis, and the development of nursing knowledge: The evolutionary cycle. Journal of Advanced Nursing, 14(4), 330–335. doi:10.1111/j.1365-2648.1989.tb03420.x PMID:2661622 Rodgers, B. L. (2000). Concept analysis: An evolutionary view. In B. L. Rodgers & K. S. Knafi (Eds.), Concept development in nursing: Foundations, techniques, and applications (pp. 77. - 102). Philadelphia, PA: W. B. Saunders Company.

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Rudolph, J. M. (2017). Case history risk factors for specific language impairment: A systematic review and meta-analysis. American Journal of Speech-Language Pathology, 26(3), 991–1010. doi:10.1044/2016_ AJSLP-15-0181 PMID:28672377 Salas-Provance, M. (2007). From the Coordinator. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 14(1), 1–2. doi:10.1044/cds14.1.1 Santiago-Valles, W. F. (2019). Afterword. In Breaking the chains, Forging the nation: The Afro-Cuban fight for freedom and equality, 1812 - 1912 (pp. 293- 313). Baton Rouge, LA: Louisiana State University Press.

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Scott, D. (2004). An examination of research issues in hearing for children from culturally and linguistically diverse populations. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 11(3), 2–12. doi:10.1044/cds11.3.2 Scott, S., & Lee, J. H. (2003). Serving Clients who use sign language. ASHA Leader, 8(6), 6–36. Advance online publication. doi:10.1044/leader.FTR1.08062003.6 Seymour, H. N., Ashton, N., & Wheeler, L. (1986). The effect of race on language elicitation. Language, Speech, and Hearing Services in Schools, 17(3), 146–151. doi:10.1044/0161-1461.1703.146 Shenker, R. C. (2013). When young children who stutter are also bilingual: Some thoughts about assessment and treatment. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 20(1), 15–23. doi:10.1044/cds20.1.15 Snyder, N. (2016). The new education law and ASHA members. ASHA Leader, 21(2), 26–27. Advance online publication. doi:10.1044/leader.PA.21022016.26 Stockman, I. J., Guillory, B., Seibert, M., & Boult, J. (2013). Toward validation of a minimal competence core of morphosyntax for African American children. American Journal of Speech-Language Pathology, 22(1), 40–56. doi:10.1044/1058-0360(2012/11-0124) PMID:22878511 United States Census. (2019). Quick Facts. Retrieved on January 17, 2021 from https://www.census. gov/quickfacts/fact/table/DC,CA/PST045219 Walters, S. Y., & Geller, E. F. (2002). The evolution of an urban bilingual/multicultural graduate program in speech-language pathology. Contemporary Issues in Communication Science and Disorders, 29(Fall), 185–193. doi:10.1044/cicsd_29_F_185 Weimer, M. (2014, November 7). Threshold concepts: Portals to new ways of thinking. The Teaching Professor, 27(2). Retrieved on May 19, 2021 from https://www.facultyfocus.com/articles/teaching-andlearning/threshold-concepts-portals-new-ways-thinking/ Wilkerson, I. (2011). The warmth of other suns. Vintage Books. Wittgenstein, L. (1953). Philosophical investigations (G. E. M. Anscombe, Rans.). New York: Macmillan Publishing Company.

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Woods, J. J., Wilcox, M. J., Friedman, M., & Murch, T. (2011). Collaborative consultation in natural environments: Strategies to enhance family-centered supports and services. Language, Speech and Hearing Services in Schools, 42(3), 379 - 392. (2011/10-0016 doi:10.1044/0161-1461

ADDITIONAL READING Abrahams, K., Kathard, H., Harty, M., & Pillay, M. (2019). Inequity and the professionalization of Speech-Language Pathology. Professions & Professionalism, 9(3), e3285. doi:10.7577/pp.3285

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Hamilton, M. B., Mont, E. V., & McLain, C. (2018). Deletion, omission, reduction: Redefining the language we use to talk about African American English. Perspectives of the ASHA Special Interest Groups SIG 1, 3(1), 107 - 117. doi:10.1044/persp3.SIG1.107 Hyter, Y. D. (2014). A conceptual framework for responsive global engagement in Communication Sciences and Disorders. Topics in Language Disorders, 34(2), 103–120. doi:10.1097/TLD.0000000000000015 Hyter, Y. D., & Salas-Provance, M. B. (2019). Culturally responsive practices in Communication Sciences and Disorders. Plural Publishing. Hyter, Y. D., & Salas-Provance, M. B. (2019). Culturally responsive practices in Speech, Language and Hearing Sciences. Plural Publishing. Pillay, M., & Kathard, H. (2015). Decolonizing health professionals’ education: Audiology and speech therapy in South Africa. African Journal of Rhetoric, 7, 193–227. Pillay, M., & Kathard, H. (2018). Renewing our cultural borderlands: Equitable population innovations for communication (EPIC). Topics in Language Disorders, 38(2), 143–160. doi:10.1097/ TLD.0000000000000151 Staley, B., Hickey, E., Rule, D., Barrett, H., Salter, C., Gibson, R., & Rochus, D. (2020). Speech-language pathology and ethical practice in global contexts. International Journal of Speech-Language Pathology. Advance online publication. doi:10.1080/17549507.2020.1743358 PMID:32308047

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KEY TERMS AND DEFINITIONS Equity: When all people in a society have what they need to be effective contributors to that society. Global Majority: Refers to the group of people (people of color) who make up the majority of people in the world. This concept supports an interconnected and international perspective. Human Rights: Privileges that all human beings should have regardless of social situation, identity, or racialized background. Such privileges include such things as a right to housing, health care, healthy food, and an ability to communicate in one’s preferred language. Relevance: Working in ways that deconstruct the common way of thinking (the status quo); recognizing that politics (having the power to make decisions within a group in the interest of those in your group), social justice, and equity, are necessary elements in the work we do as SLHSs, and that we are accountable to the communities in which we work and should always engage in efforts to dismantle inequities, injustices, and exclusion in our discipline. Social Justice: A concept that refers to the valuing of every life so that all people regardless of social status or identity characteristics have access to all resources and opportunities. The Arcus Center for Social Justice Leadership says it best, “Social justice recognizes the inherent dignity of all people and values every life equally. It calls for both personal reflection and social change to ensure that each of us has the right and the opportunity to thrive in our communities, regardless of our identities. When we acknowledge that oppression exists and work together to end systemic discrimination and structural inequities, we increase the promise of a more just world.” (Arcus Center for Social Justice Leadership, 2018, Retrieved from https://arcuscenter.kzoo.edu/).

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Structural Racism: When policies, standards of practice, and social norms systematically penalize members of the global majority and systematically privileges people who identify as white. Structural racism perpetuates racial inequities in all forms and is inherent in economic, political, and social systems. Transformative: A complete change/shift in perspective and thinking, followed by a similar shift in behavior.

ENDNOTES

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Critical theory focuses on collaborative reflection, analysis, and practice (i.e., action) in order to change the unequal relations of power that affect all aspects of life (Hyter & Salas-Provance, 2019). Politics is the exercise of power in the interest of one’s group (Hyter, 2014; Hyter & Salas-Provance, 2019).

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Chapter 5

Critical Race Theory for Speech-Language Pathology: How Race-Conscious Practice Mitigates Disparities Chelsea Privette University of Arizona, USA

ABSTRACT

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Race has yet to be discussed as a signifcant factor in the feld of speech-language pathology. Race is often confated with nonmainstream dialects and discussed in purely linguistic terms. However, the terms we use to describe dialects are highly racialized, centering white mainstream norms and treating nonmainstream varieties of English as “diferent” and, therefore, inferior. Hierarchical thinking about language contributes to the misdiagnosis in Black and other communities of color because racialized language ideologies have been left unstated. This chapter demonstrates through a critical race theory approach how structural racism shapes the feld’s conceptualization of language and competence. Using an intersectional lens in particular, this chapter discusses race, disability, and language ideology as systems of domination that compound the efects of racism for communities of color. CRT is then used to reveal, critique, and intervene on the historically embedded racist structures that continue to manifest in speech-language pathology research, teaching, and practice today.

I think knowing one’s history leads one to act in a more enlightened fashion. I can not imagine how knowing one’s history would not urge one to be an activist. -John Hope Franklin

DOI: 10.4018/978-1-7998-7134-7.ch005

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INTRODUCTION The field of speech-language pathology has yet to adopt a systematic framework for addressing racism. Because race is traditionally omitted from the ideological discussions that inform research, pedagogical, and clinical practices, any efforts to integrate race result in assimilation (Gotanda, 1991). As a result, the demographics of the profession continue to be predominantly white (92%; American Speech-LanguageHearing Association [ASHA], 2019); research on nonmainstream populations remains underpublished (Kohnert & Medina, 2009); multicultural/multilingual issues (MMI) are glossed over in the curriculum (Stockman, Boult, & Robinson, 2008); and clinicians are unprepared for the diversity of their caseloads by their own admission (Privette et al., 2017). Until traditional policies and administrative practices are critically evaluated through the lens of race, the profession will continue to lag behind the cultural and linguistic diversity that has always existed in this country. Meaningful and lasting change requires systemic intervention. This chapter assumes a substantial knowledge of and agreement with the concept of systemic, or institutionalized, racism on the part of the reader. The purpose of this chapter is to provide researchers, instructors, and clinicians with an understanding of Critical Race Theory (CRT) as a tool for interrogating the systems that inform the research, teaching, and practice of speech-language pathology and for implementing effective strategies that are antiracist and inclusive.

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Defining Critical Race Theory (CRT) CRT was birthed out of legal studies in the 1970s by Black legal scholars who observed the constraints that the law imposes on the civil rights of Black people, even when practiced by progressive lawyers working to expand those rights. In response to the courts’ ability to stagnate - even reverse - the advancement of Black people in the United States using “race-neutral” language, race critics sought to expose how racism influences - and, at times, explicitly motivates - judicial decisions. While CRT has “no canonical set of doctrines or methodologies,” a CRT approach starts with an understanding of the institutional production of white supremacy and ends with an intervention that is liberatory in nature (Crenshaw et al., 1995, p. xv). Known as a movement, a framework, and a lens, CRT empowers one to reveal, critique, and intervene on racialized power structures (see Crenshaw et al., 1995 for a full discussion). A foundational knowledge of the history of racism in the US is fundamental to utilizing CRT as a tool for correcting the institutional bias that rewards whiteness and punishes Blackness. The establishment of racism in the US depends on two basic elements: white supremacy and anti-Blackness (Charmantier, n.d.). Therefore, CRT centers the Black experience in its analysis of racist structures as an anchor for understanding how racism is imposed upon other communities of color. The next section provides an overview of the evolution of racism that is particularly relevant to the field of speech-language pathology. This overview is by no means comprehensive. Rather, it is a starting point for understanding the mechanisms that underlie racist practices in the US and a bridge to developing antiracist practices within the profession.

BACKGROUND: THE NEED FOR CRT Speech-language pathologists (SLPs) practice at the intersection of education and healthcare. Regardless of setting or clinical population, the systemic roots of the educational and healthcare systems shape our 85

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understanding of language and the subjective values that we place on various forms of communication. The title pathologist, one who studies diseases (American Psychological Association [APA] Dictionary of Psychology, n.d.), makes the profession’s emphasis on disorder evident. The profession’s power to pathologize cannot be considered outside of the healthcare system; and the application of normative standards of development cannot be considered outside of the education system. Thus, it is important to understand how the history of racism in each of those systems impacts their operation today.

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Racism in Healthcare Physicians were the first to use the term ‘race’ to categorize humans in hierarchical terms. The work of Swedish physician Carl Linnaeus and German physician Johann Friedrich Blumenbach provided the foundation for the European enslavement of Black people in the US. While slavery existed long before the 18th century, the practice was not implemented on purely racial terms (Johnson, 1983). However, the Age of Enlightenment (1715-1789) raised moral questions regarding human interaction. Desperate to maintain economic power, European settlers in the US looked to the work of Linneaus and Blumenbach to justify chattel slavery by entrenching the already common practice of enslaving darker-skinned people and writing it into law. The practical implementation of race, therefore, was intended to serve the purpose of racism, most egregiously in the form of chattel slavery. For this reason, there are some who refuse to acknowledge race for fear of being called a racist (i.e., demonstrating colorblindness). However, it is unhelpful - indeed, counterproductive - to deny a reality that must be changed. Although race is a social construction, it’s implications for the human experience - including health, education, wealth, employment, housing, and safety - are very real. Scientific racism refers to the theories propagated by 19th century scientists who were invested in concocting evidence for the biological necessity of slavery in order to preserve its capitalist function (Phelan, Link, & Feldman, 2013). Despite the abolition of slavery in 1865, eugenicists fabricated racialized pathologies in order to justify selective breeding and racial cleansing (Kendi, 2016). In the 20th century, the medical community capitalized on scientific racism by conducting harmful experiments on the Black community (Washington, 2006). The medical community continues to exploit the bodies of people of color in the name of medical advancements that are least likely to benefit the populations that are sacrificed to gain them (Washington, 2006). The higher incidence of chronic illnesses within the Black community provides the ill-conceived rationale for the continuation of medical discrimination. Today, race continues to be used as a biological category in medicine despite modern research that debunks all theories that race is genetically-determined (Lin & Kelsey, 2000). The use of race as a medical category obscures the fact that it is the social determinants of health that produce biological differences between what are perceived as racial categories (Corbie-Smith et al., 2008). The study of genetic changes that result from social conditions is called epigenetics, and stress is a leading factor for the epigenetic changes that lead to chronic disease (Johnstone & Baylin, 2010; Meloni, 2017). The traditional practice of treating race as the cause of biological differences leaves the disparities at the root of the issue untouched (Garrod, 2006); and communities of color continue to suffer the consequences. Pseudoscientific rationalizations abound in the care (or lack thereof) of Black and other patients of color. The resulting bias causes healthcare providers to minimize the pain of Black and Latinx patients - leaving them without adequate treatment - and to provide less patient-centered care in which clinicians verbally dominate the visit and preclude Black patients from contributing their input (Anderson, Green, & Payne, 2009; Cooper et al., 2012). This disparate treatment has been linked to false beliefs held by 86

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medical students and residents regarding biological difference between Black and white patients (Hoffman et al., 2016). The distrust that many communities of color have towards the medical community is well-founded. These communities carry the historical trauma inflicted on them by the healthcare system into their clinical encounters (Kirmayer, Gone, & Moses, 2014; Corbie-Smith, 1999; Scharff et al., 2010). The field of speech-language pathology is not exempt from racist practices that fuel the distrust. Research in speech-language pathology has emphasized monolingual Mainstream American English as the norm for typical development and cast the language development and linguistic practices of Black and other communities of color as pathological. Consequently, Black and Latinx students continue to be over-represented in speech-language pathology services (Robinson & Norton, 2019). The next section considers how racism in the education system informs SLPs’ understanding of competence and sustains the racial disparities that encumber the profession.

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Racism in Education From the time enslaved Africans arrived on the shores of the colonies, they were intentionally separated from their linguistic communities in order to prevent organizing efforts. Additionally, they were prohibited from learning to read and write in an attempt to bar access to material that would inspire liberatory movements. The South Carolina General Assembly passed the first piece of legislation to prohibit the literacy of Black people (1740 Negro Act; Brander Rasmussen, 2010). Virginia was the first state to amend its antiliteracy laws to include the death penalty and became the model for state law (Brander Rasmussen, 2010). During the period after the Civil War, known as Reconstruction, the Bureau of Refugees, Freedmen, and Abandoned Lands (the Freedmen’s Bureau) was created to facilitate the civic transition of freed people, including their education (Parker, 1954). Despite their efforts, the withdrawal of Union forces from the South after Abraham Lincoln’s assassination set the stage for President Andrew Johnson to halt and reverse the progress made during Reconstruction (Anderson, 2016). Black students - adults and children - were relegated to abandoned buildings with little resources, often with no plumbing or air conditioning. Black schools were stoned and burned down; and teachers and students were violently harassed (Parmet, 1971). With fledgling public and congressional support, the Bureau was forced to dissolve in 1870, leaving Black schools without state or federal funding. Black schools relied on philanthropists and missionaries to survive. In the 1930s, the National Association for the Advancement of Colored People (NAACP) organized to overturn Plessy v Ferguson, the 1896 Supreme Court ruling that declared segregation constitutional. The Court decided that public institutions could deny Black people access as long as the separate facilities provided for Black people were equal. The schools provided for Black students were so grossly unequal that the NAACP determined that education was the vehicle that would bring an end to segregation (Anderson, 2016). The case that they prepared, Brown v Board of Education of Topeka (1954), is one of the most widely known Supreme Court cases in US history. However, the ruling did not prove to be the sweeping victory that it is commonly believed to be. Instead of inducing a national desegregation movement, the ruling ignited what came to be known as the “era of ‘massive resistance’” (Bell, 1995, p. 6). The most common method used to dodge Brown was freedom of choice (Anderson, 2016). By this method, states privatized schools and provided white parents with vouchers that allowed them to send their children to the school of their choice - a choice that Black parents did not have. In addition, pupil placement laws allowed schools to deny admission to students based on “fit” and “ability.” Given that Black students had received little formal education, the policy effectively discounted all Black children 87

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from gaining entrance into white schools. Finally, residential segregation - achieved by denying Black families loans and only allowing white families to purchase homes in suburban areas (i.e., redlining) allowed the formation of neighborhood schools in order to maintain the status quo with no additional educational policies necessary. To this day, redlining, redistricting, and property tax funding for schools work in concert to maintain a segregated school system. Sixty percent of Black students attend schools that are segregated and underresourced compared to 8.4% of their white counterparts. Black eighth-graders in such schools score an average of 20 points lower on standardized math assessments than Black eight-graders at under-resourced schools that are majority white. Further, the disparities in test scores between Black and white students in the same school are greater in under-resourced schools with larger Black student populations than in under-resourced schools with majority white populations (García, 2020). Educational disparities are further exacerbated by race-based discrimination in disciplinary action. Black students are 3.8 times more likely to be suspended than their white peers; and they are more likely to be punished for behaviors that are subjectively described as defiant or problematic (Riddle & Sinclair, 2019; U.S. Department of Education Office for Civil Rights, 2016). These disparities have been linked to both explicit and implicit bias against Black students (Okonofua & Eberhardt, 2015). Education has direct effects on employment, wealth, housing, and health outcomes (Anderson, 2016). Thus, the consequences of undereducation are far-reaching. SLPs have historically complied with and reinforced racialized notions of ability. Early research in child language development labeled the linguistic and cultural practices of families of color as deficient, impoverished, and deprived (e.g., Bartel, Grill, & Bryen, 1973). SLPs were not - and are not - wholly convinced that nonmainstream dialects are as complex as Mainstream American English. In fact, those who did believe in the linguistic integrity of nonmainstream dialects still perceived them as divergent, and thus an impediment to academic achievement. When assessed according to the white, mainstream norms by which standardized assessments are constructed, Black and Latinx children are overdiagnosed with speech and language disorders (Cole & Taylor, 1990; Goldstein & Iglesias, 2001; Peña & Quinn, 1997; Washington & Craig, 1992). Applications of CRT in healthcare and education inform a constructive critical race approach to speech-language pathology that can mitigate these disparities.

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DISCUSSION: APPLYING CRT The introduction of CRT to health care and education is relatively recent (Braun, 2017; Ladson-Billings & Tate, 1995). As a health science profession with a significant presence in the educational system, SLPs have much to learn from these applications. Education and health sciences are certainly not the only relevant disciplines for learning the value of CRT for speech-language pathology. In addition to the origins of CRT in legal studies, applications in public health, political science, sociology, gender studies, and psychology all have wisdom to offer to critical race theorists. The scholarship presented in this section provides a foundation that has direct implications for how CRT can function in speechlanguage pathology.

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Foundations in Healthcare The study of race in health sciences has been incentivized by agencies such as the National Institutes of Health (NIH). However, “reductionist racialized medicine,” Braun (2017) says, “has re-vitalized notions of race-as-biology and informed knowledge production about racial inequality in health” (p. 245). Thus, health science needs research and practices that counter the reification of Black inferiority and white supremacy. In a special issue of the American Journal of Law & Medicine dedicated to critical race perspectives in the health sciences, the editors state that “CRT normalizes the practice of documenting inequitable power formations in biomedical institutions and the professional fields that sustain them” and “prompts us to go beyond the quantitative measures fetishized in medical and scientific research” (Bridges, Keel, & Obasogie, 2017, pp. 180-181). CRT, then, is a vehicle by which the health science professions can achieve greater equity and inclusion. Specifically, centering anti-Black racism within the history of racial subjugation provides clearer and more complete analyses of health disparities (Braun, 2017). Outside of this paradigm, health science professions will continue to reconstruct race as a natural order and allow the social structures that cause disparate health outcomes to remain. Traditional approaches to race in the health sciences are embedded in what Benjamin (2017) calls “culture talk.” Within the culture talk paradigm, attention is directed towards cultural traits that are treated as issues to be overcome without interrogating institutional barriers to quality care. The “cultural explanations” that are employed to absolve the institution and its agents of the injustices encountered in the clinic are rooted in racist ideologies that maintain and reproduce racial hierarchy based on the conflation of difference and pathology. In other words, “culture talk” reifies race under the guise of inclusion. It posits individuals as fixed entities within structural hierarchies that reinforce hegemonic assumptions about communities of color in relation to normalized whiteness. In doing so, “different” cultures remain pathologized and systemic inequities remain unproblematized. The solution Benjamin (2017) proposes is a “methodological reversal”, that is, “a critical race approach to the health sciences [that] would require reorienting ourselves—away from a fixation with distrust and towards the problem of institutional trustworthiness” (p. 234). According to Braun (2017), high quality patient care is contingent not only upon scientific knowledge, but requires knowledge of how political and structural mechanisms shape (1) the origins of scientific information; (2) the experiences of minoritized populations within the healthcare system; and (3) clinicians’ beliefs about their own expertise. Health science professionals cannot attain this knowledge without engaging the scholarship of the humanities and social sciences (Braun, 2017). Thus, a CRT approach requires that clinicians relax their preoccupation with traditional quantitative approaches that are entrenched in the status quo and include social theories that are indeed verifiable through both quantitative and qualitative methods. Although largely ignored in the “hard sciences” tradition, social science research is robust and plentiful and necessary for developing scientific methods and clinical approaches that are conducive to social justice. The next section turns to the field of education as a start to incorporating social science perspectives into clinical sciences.

Foundations in Education As is the case in health sciences, traditional frameworks for dealing with race in education employ “culture” in a way that detracts from the system’s generation of the “differences” attributed to communities of color. Multicultural education - which now includes gender, ability, and sexual orientation - is based 89

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on ideals of unity, tolerance, respect, and coexistence. However, multicultural education does not deal with the strain that arises between groups when interests conflict. Instead, interventions developed out of this tradition ultimately lead to assimilation to standards of whiteness (Ladson-Billings & Tate, 1995). In contrast, a CRT lens acknowledges educational structures as inequitable on the basis of race first and foremost, and allows researchers and practitioners to deconstruct notions of merit and objectivity to reveal the white-centered subjectivity on which they are built. CRT was first introduced to the field of education by Ladson-Billings and Tate (1995). They contend that race is undertheorized as compared to class and gender despite the fact that class and gender - separately and taken together - do not explain the vast disparities between Black and white students (see García, 2020). Their theorizing of race draws directly from founding CRT legal scholars - particularly, the concept of whiteness as property. US society is organized around property rights; and property is the basis for “civil rights” - as opposed to natural rights, which are not recognized by law. The United States exists because its founders failed to recognize the natural rights that Natives have to the land, and they claimed ownership based on the absence of formal (written) entitlement, thus creating “civil rights.” White men, as the only property-owning individuals recognized by law, controlled the distribution of property and determined who can be owners of property. One can draw a direct line from slavery (Black people as property) to civil rights battles (protection of property; see Ladson-Billings & Tate, 1995 for a full summary). Following that line through to education, the authors identify curriculum as intellectual property, which varies by school according to its physical property value (see also Anderson, 2016). The distribution of curriculum, then, is uneven due to enduring segregation practices. The conceptualization of curriculum as property explains how enriched (i.e., rich) curriculum is withheld from communities of color on the basis of historical notions of inferiority and worth. This precept is veiled by the fabricated (in)ability demonstrated through poor performance on standardized assessments. However, the connection is evidenced by the ways in which “opportunity to learn” - the supposition that students must have the appropriate materials and environment in order to learn what they are expected to learn - is predicated on the possession of “real” property (e.g., labs, books, personnel training; Ladson-Billings & Tate, 1995, p. 54). Thus, the challenge of achieving equity in education is that white people must come to terms with the loss they will incur in restructuring the system - that is, loss of power and control of distribution. Until power and distribution are shared, the dominant narratives around the achievement gap will perpetuate deficit explanations of difference. Artiles (1998) argues that deficit theories used to explicate cultural differences drive the over-representation of students of color in special education and discount “the tremendous resilience of people of color, which is reflected in various domains such as parent involvement and motivation” (p. 33). Further, the author asserts that the educational system’s obsession with cultural differences as viewed through a deficit lens has created a false dichotomy between deficit on the part of the individual and barriers on the part of the institution. Deficit views persist because the institution fails to acknowledge that it has a cultural perspective. Artiles suggests that the response of educators should be “to conduct more research based on alternative epistemologies and paradigms about human development, learning, and literacy” (p. 34). A significant feature of CRT is the production of counternarrative. Anglo-centric approaches favor universalism as opposed to particularity so that white cultural norms are assumed to be true for all. “The ‘voice’ component of critical race theory,” Ladson-Billings and Tate explain, “provides a way to communicate the experience and realities of the oppressed” (1995, p. 58). The authors argue that without the voices of communities of color, any conclusions we draw about their education and the system that manages it is insufficient. Thus, applying a CRT approach requires validating the knowledge and experi90

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ences of communities of color. To this end, Black feminist education scholar Cynthia Dillard calls for research that “examine[s] more culturally indigenous ways of knowing” such that marginalized “voices are provided legitimization, not of their existence, but as analytic, conceptual, and representational tools that explicate deep meanings” (Dillard, 2000, p. 661). Researchers and practitioners of learning and mastery - including SLPs - must challenge “standards” of performance that are rooted in whiteness and center the competence inherent in the communities that have been barred from contributing to formal streams of knowledge production and dissemination. The next section details how race is encoded into speech-language pathology discourse and utilizes a CRT framework to uncover and challenge the ways in which the field is structured around whiteness as the rule.

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CRT for Speech-Language Pathology Race has not been treated as a significant factor in speech-language pathology, although the field’s jargon is filled with racialized terminology. Instead, race has been conflated with dialect and largely discussed in deficit terms, most notably in discourse surrounding “culturally and linguistically diverse (CLD) populations” and within the difference/disorder paradigm (ASHA, 1983). “Difference” and “diverse,” in this context, are terms that refer to “dialect speakers.” The problem with this language lies in the unstated assumptions that permeate the field as a whole - assumptions that must be explicitly stated and dealt with in order to dismantle the notions of white superiority that underlie the profession’s research and practice. The discussion that follows reveals these unstated assumptions, critiques the way they disenfranchise Black and other communities of color, and offers interventions for subverting them in research, teaching, and clinical practice. Minow (1990) explores the construct of difference in US law - how differences are legally defined and how institutions are regulated to respond to those differences: The “dilemma of difference” is that “[b]uried in the questions about difference are assumptions that difference is linked to stigma or deviance and that sameness is a prerequisite for equality…. If to be equal one must be the same, then to be different is to be unequal or even deviant” (Minow, 1990, p. 50). The author goes on to articulate five unstated assumptions that shape the common understanding of difference: (1) difference is intrinsic to the “other”; (2) the norm does not need to be stated; (3) the observer is neutral; (4) the “other” does not have a relevant perspective; and (5) the status quo is naturally the proper order. The truth that is hidden under these assumptions is that difference is an inherently comparative term. Thus, in order to identify a speaker as having a communication difference, one must have already identified the norm to which the speaker is being compared. In the case of the SLP, the norm that is left unstated is monolingual Mainstream American English (MAE) as spoken by the white middle- and upper-class. This is the demographic that dominates the literature and the curriculum. The fact that MAE is not identified as a dialect in speech-language pathology research and teaching excludes nonmainstream dialects (NMDs) from conversations about typical development. In this manner, NMDs are relegated to an inferior position, which is a particularly dangerous position to occupy in the minds of clinicians who are trained to find disorder in everyday contexts. The status of NMDs in the US can only be appropriately examined through the lens of race. Consider some of the most frequently studied NMDs of English: African American English, Spanish-Influenced English, and Chicano English. The labels given to NMDs are racialized terms (even if they do not map onto formalized racial categories). Each of these terms conjures images of Black and Brown people. Further, the terms conjure ideas about the morality, intelligence, and ability of the people associated 91

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with them. When individuals and organizations act on these ideas, the result is linguistic profiling, which often results in linguistic discrimination (Baugh, 2003). Linguistic discrimination is well-documented in the case of housing and employment discrimination. The work of Black linguist John Baugh (e.g., Baugh, 2003) demonstrates how listeners make assumptions about a speaker’s race based solely on their language, dialect, or accent. Listeners place a higher or lower value on a dialect based on race and class associations. Linguistic profiling in education, in particular, causes Black students and other students of color to “feel a sense of linguistic inferiority and, by extension, a sense of linguistic shame” (Baugh, 2003, p. 166). The practice of linguistic profiling is so ubiquitous, and the consequences of linguistic discrimination are so harmful, that many speakers of NMDs adopt code-switching behaviors to minimize the occurrence of such painful experiences. It is essential to understand that the decision to code-switch to MAE or not - as well as the ability to code-switch to MAE or not - is shaped by dominating whitecentric forces that constrain minoritized individuals’ freedom of communication. NMD speakers may choose to respond to these forces by accommodation (i.e., code-switching) or resistance (i.e., not codeswitching); and a single speaker may deploy either response in various circumstances (Baugh, 2003). This dynamic is a culmination of institutional valuations of language varieties and, in turn, the ways in which US citizens are socialized to think about language and how it should be used. The ways that people think about race and language are socially-informed and often resistant to evidence that contradicts, indeed disproves, popular belief. Linguistics research has a long and robust history that substantiates that all language varieties are independently and equally logical, effective, and creative (e.g., Sankoff, 1986). Yet community members and professionals alike hold on to language ideologies that are both racialized and pathologized (Lippi-Green, 1997). Linguistic anthropologist Jane H. Hill defines language ideology as follows:

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Language ideologies are sets of interested positions about language that represent themselves as forms of common sense, that rationalize and justify the forms and functions of text and talk. ...They sort out language structures and ways of using language as good or bad, correct or incorrect, and link these with persons who are thought to be good or bad, moral or immoral. …The label ‘ideology,’ then, suggests a way of thinking or a perspective saturated with political and economic interest. (Hill, 2008, pp. 33-34) Hill goes on to explain that the dominant language ideology in the United States is the “Monoglot Standard.” The Monoglot Standard assumes that there is one correct, or “standard,” way of speaking, which is given an honorable pedigree to explain its prestige. Other dialects are arbitrarily ranked, and their speakers attributed with moral and social failure for their lack of proficiency in the standard variety. Using both sociolinguistic studies and contemporary examples from the media, Hill illustrates how NMD use, even by people who are known to speak MAE, always has “the potential of stigma…, and the stigma is especially acute when the speaker is African American” (2008, p. 37). The responsibility of SLPs who are oriented towards justice, therefore, is to identify how the Monoglot Standard manifests in their research and practice, and to counter the dominant narrative surrounding NMDs. In this manner, professionals across the discipline can transform the way they talk about language so that their conceptualization of typical language is more inclusive and their diagnostic ability is more accurate. Because it is the task of the SLP to determine the presence or absence of disorder, any critical analysis of the field must include a discussion of disability. Previous sections have discussed the ways in which Black bodies, Black culture, and Black language have been pathologized. This chapter has also shown how the pathologizing of Blackness has led to the over-representation of Black students and 92

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other students of color in special education. The current discussion considers the disparate impact that disability has on Black students and other students of color. Disability alone is a significant factor for discrimination. Despite legislation that prohibits discrimination on the basis of disability, individuals with disabilities graduate from high school and college at lower rates than those without disabilities (APA, 2010). Employers have negative perceptions about the productivity and social skills of people with disabilities (Chan, 2008). While an estimated two thirds of individuals with disabilities want to work, only 20.1% are employed as compared with 68.6% of individuals without disabilities (APA, 2010). Individuals with disabilities who do work make over $10,000 less in median income than those who have no disability. Individuals with disabilities also face barriers to receiving healthcare, including physical access and increased medical costs. Consequently, those with disabilities and their caregivers experience poorer health outcomes (APA, 2010). The educational, employment, and health disparities that result from disability are situated within a racially stratified society where race drives individuals’ experiences of their other identities. Intellectual disability has been used to justify race-based subjugation, so disabled groups have uniquely racialized experiences of their disability (see Annamma, Connor, & Ferri, 2013 for a full discussion of “DisCrit”). Historically, race and disability were intentionally fused to devise rationales for genocide, eugenic sterilization, selective breeding, and anti-miscegenation (Erevelles, 2015). The alleged biological inferiority of disabled individuals was cast as failed whiteness such that “race and disability become clearly interdependent as disabled subjectivities are racialized and racialized subjects are disabled simultaneously” (Erevelles, 2015, p. 147). In order to properly acknowledge the racialized experience of impairment, one must also recognize that contemporary constructions of disability are not purely objective. Standardized assessments (Roberts, 2015), definitions of literacy (Brandt, 1998), and expectations of background knowledge (Blum, 2017) are all products of whiteness and constitute “social impediments to children’s intellectual flourishing” (Roberts, 2015, p. S52). The knowledge inherent in communities of color have not been included in the development of academic standards. As a result, “structural inequalities and external factors can produce forms of intellectual disability,” and “these may affect particular groups disproportionately” (Carlson, 2017, p. 260). As an “invisible disability” that is considered a marker of intelligence (or lack thereof) in the US, speech/language impairment is a category of disability that has profound implications for people of color. In order to theorize the role that race plays in speech-language pathology, a critical analysis must accommodate the compounding influence of language and disability on the experience of racism. In recognition of multiple structures of oppression, critical race scholar Kimberlé Crenshaw formalized intersectionality to account for the compounding impact of oppression on individuals with multiple marginalized identities (e.g., race, sex, class). Crenshaw (1989) explains that the traditional focus on subgroups within minoritized populations that are otherwise privileged (e.g., white women within feminist studies) “marginalizes those who are multiply-burdened and obscures claims that cannot be understood as resulting from discrete sources of discrimination” (p.140). Using the experiences of Black women to illustrate the significance of an intersectional approach, the author continues: If [those concerned with alleviating the ills of racism and sexism]... began with addressing the needs and problems of those who are most disadvantaged and with restructuring and remaking the world where necessary, then others who are singularly disadvantaged would also benefit. In addition, it seems that placing those who currently are marginalized in the center is the most effective way to resist efforts to compartmentalize experiences and undermine potential collective action. (Crenshaw, 1989, p. 167)

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Crenshaw argues that the impact of oppression from various vectors of domination is greater than the sum of its parts. Centering those who live at the intersection of multiple hierarchies of oppression makes way for reforms that are beneficial to everyone. Rather than allowing differences to marginalize those outside of the dominant group, researchers and practitioners can levy differences to build “alliances that can be both more inclusive and effective in the long term” (Roberts & Jesudason, 2013, p. 314). Thus, the experience of Black NMD speakers with speech/language impairment should be of specific concern to SLPs (Figure 1). In doing so, the profession can develop research, pedagogical, and clinical practices that are responsive to the needs and strengths of all communities. Figure 1. An intersectional approach to justice in speech-language pathology recognizes the compounded impact of racism, ableism, and linguistic discrimination on Black speakers of NMDs and languages other than English who have speech/language impairment

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To date, Stanford and Muhammad (2018) represents the only published example of speech-language pathology research that explicitly takes a CRT perspective. Forensic SLP Shameka Stanford collaborated with criminologist Bahiyyah Muhammad to analyze the school-to-confinement pipeline experienced by Black youth with language disorders, emphasizing the intersection of race, class, and disability. Using an interdisciplinary approach that documents how structural racism impacts Black youths’ experience of discipline and disability in low-income schools, the authors demonstrate how “African American youth are disproportionately placed into special education programs that work in conjunction with zero tolerance policies and fuel the school-to-prison pipeline” (Stanford & Muhammad, 2018, p. 713). While the authors do not deal with dialect directly, they acknowledge that harsher punishment for Black youth in schools is a function of their divergence from the white standards that permeate school culture and denigrate those who do not conform. Importantly, the authors offer solutions that are based on restorative justice rather than punitive action. In this manner, the authors adhere to the central purpose and practice of CRT: to reveal, critique, and intervene on oppressive race-based systems (Figure 2).

Figure 2. CRT uses race as a lens by which the profession can reveal, critique and intervene on oppression at the systemic level

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With this framework in mind, the discussion that follows will cover, in turn, some research, teaching, and clinical issues from a critical race perspective. These recommendations are not comprehensive, but provide an infrastructure for the practice of CRT in speech-language pathology so that the field can be more deliberate in its pursuit of justice.

FUTURE RESEARCH DIRECTIONS: PRACTICING CRT

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Implications for Research Research in speech-language pathology sets the tone for how we talk about language, establishes standards for typical development, and delineates parameters for evidence-based practice. Products of research are the foundation for the content taught in programs that prepare aspiring clinicians for clinical practice. Therefore, any efforts to shift linguistic paradigms towards more equitable and inclusive frameworks must involve a race-conscious critique of research activities. Preconceived notions rooted in whiteness about how nonmainstream communities should perform create hegemonic research practices that reproduce stereotypic depictions of the target community. A more accurate presentation of language requires that research inquiries about communities of color be asked differently and the methodologies employed to answer them chosen more carefully. If the goal of clinical research is to illuminate typical linguistic performance in order to determine what is disordered performance, then the methodology employed should be chosen to provide participants with the opportunity to provide their best language output. There can therefore be no standard protocol that is applied to children from all backgrounds. Rather, culturally responsive research methodologies are flexible in order to provide the most accurate description of the linguistic abilities of the target population (see Hyter & Salas-Provance, 2019 for a full discussion). Dillard (2000) states, “what constitutes knowledge depends profoundly on the consensus and ethos of the community in which it is grounded” (p. 662). To conduct responsible research requires the voice of the community - participants, caregivers, community members, teachers, and other professionals in the community. One way to achieve this is through Community-Based Participatory Research (CBPR; also known as Community-Partnered Participatory Research [CPPR]). Simply put, “[r]esearch of this type is ‘with’ community and academic participants rather than ‘for’ community by academic leaders” (Wells & Jones, 2009, p. 321). In order to implement a CBPR framework, researchers must view their research participants as equal partners, incorporating the knowledge of the community into the framing of the research question, the development of methodological protocols, the interpretation of the results, and the dissemination of results to the community (Wells & Jones, 2009). CBPR leads to advocacy for policy changes for greater equity (Cacari-Stone et al., 2014). Examples of CBPR in speech-language pathology include Faircloth and Pfeffer (2008), Gill et al. (2016), and Holt and Asagbra (2020). For those conducting research with mainstream populations, it is important to name the linguistic and cultural characteristics of the participants (Oetting, 2020). Doing so acknowledges that everyone is positioned within a cultural context that shapes their communicative behaviors and expectations, including the researcher. Artiles (1998) summarizes examples of introspective reflections in research and its capacity to prevent deficit interpretations of results: Given the increasing awareness about the importance of the researcher’s perspective, what can we contribute to the deliberations about disproportionate representation if we begin to document our own

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subjective worlds? I anticipate that we would not only have to unveil and justify our assumptions and personal theories about minority students’ educational performance, but we would also have to wrestle with our own beliefs, expectations, distress, and tensions about difference. These practices would force us to see the disproportionate representation debate not as an issue related to whether minority students belong in certain programs, but as a phenomenon in which the discussants’ views are seen as an integral part of the problem. (p. 34) Once researchers acknowledge that they have a perspective, they can acknowledge their position of power regardless of their race. To be a researcher is to have the power to perpetuate or interrupt dominant narratives that uphold white supremacy. Braun (2017) declares, “The academy can enable or it can—and does— obstruct social justice” (p. 256). CRT perspectives in research provide a framework for enabling the work of justice in speech-language pathology.

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Implications for Teaching Pedagogical approaches to teaching language development and disorders should normalize linguistic diversity, underscore dynamic assessment, and de-emphasize standard assessments. Static protocols rely on comparative approaches that perpetuate deficit explanations of differences. Instructors must center the experiences of marginalized groups so that their communication styles are not presented as “other” or simply included as an addendum to the primary content. In this manner, NMDs are not discussed only in the context of finding disorder as in the traditional paradigm. Historically, Black professionals within the field have advocated for professional education in Black English outside of the context of disorder (National Black Association of Speech-Language and Hearing [NBASLH], 1997). This approach has been popularized in recent years as the “disorder within a dialect” paradigm by Oetting, Gregory, and Rivière (2016). Discarding the “dialect/difference vs. disorder” framework reinforces that everyone speaks a dialect and a small percentage of individuals within each dialect has a disorder. Classroom discussions about dialects should explicitly acknowledge the racialized and pathologized language ideologies that are infused into dominant societal narratives so that students’ own biases surrounding linguistic diversity can be addressed. This requires critical self-reflection to situate oneself within the societal hierarchies that shape individuals’ experiences and perceptions (Tervalon & Murray-García, 1998). Privette et al. (2017) provides a summary of student-centered and transformational pedagogical approaches that facilitate the level of reflection necessary to invoke constructive self-critique. Classroom discussions about disparities must move beyond cultural differences, interpersonal skills and cross-cultural interactions that occur in the clinic. Instructors must call out the structures of domination that produce inequality. There are certainly cultural factors pertaining to the client and the clinician that are worth exploring; however, they are not sufficient to mitigate disparities, as disparities are the result of systemic oppression. Metzl and Hansen (2014) explain that students need to be equipped with structural competency - that is, knowledge regarding the financial, legal, educational, and other structures that manufacture racialized disparities and construct the stigma to which minoritized communities are subjected. “Structure” as defined by the authors, “demarcates the oft-invisible diagnostic and bureaucratic frameworks that surround biomedical interactions… [a]nd connotes assumptions embedded in language and attitude that serve as rhetorical social conduits for some groups of persons, and as barriers to others” (Metzl & Hansen, 2014, p. 128). Structural competency includes five core competencies: “1) recognizing the structures that shape clinical interactions; 2) developing an extra-clinical language of structure; 3) 96

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rearticulating ‘cultural’ formulations in structural terms; 4) observing and imagining structural interventions; and 5) developing structural humility” (Metzl & Hansen, 2014, p. 126). This approach requires readings from various disciplines, including those in the humanities and social sciences so that students are well-informed and prepared for effective advocacy specific to the contexts in which they will work. The manifestations of racism in education and healthcare as described in this chapter are the foundation for recognizing how organizational procedures can produce racially discriminatory outcomes in the absence of explicitly racialized language. Therefore, in addition to coursework that addresses systemic racism, clinical instruction should equip students with the legal knowledge and practical tools they need to effectively challenge problematic policies and practices. These practice implications are outlined below.

Implications for Clinical Practice

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Clinicians out in the field are immersed in systems that reify racialized and pathologized language ideologies in their daily functioning. Clinicians need to be prepared to interrupt the enactment of discriminatory practices and policies. In order to build structural competency, professional knowledge must “include the organization of institutions and policies, as well as of neighborhoods and cities, if clinicians are to impact stigma-related health inequalities” (Metzl & Hansen, 2014, p. 127). In order to follow through effective advocacy with antiracist practice, clinicians must arm themselves with a diversity of dynamic assessment and treatment methods, which should be the core of comprehensive speech-language evaluations regardless of the client’s background. While standardized assessments can be informative, they center white-centric norms and fail to capture clients’ full learning abilities. Treatment plans should be co-constructed with clients and caregivers to ensure that goals respect the family’s communication preferences rather than assuming that institutional standards are their desired goal. Traditionally, treatment outcomes are thought to result from individual agency. Moral judgements are imposed upon those who do not “comply” with written goals. This perspective leads to “misdiagnosis, blame, and maltreatment that accompany the experience of poverty and cultural subordination” (Quesada et al., 2011, p. 342). An alternative approach is one that considers “the forces that constrain decision-making, frame choices, and limit life options” (Quesada et al., 2011, p. 342). Medical anthropologists suggest that a “structural vulnerabilities checklist” be developed in collaboration with clinicians across disciplines in order to (1) make social positioning and its effects explicit; (2) provide data for justifying increased allocation of resources to marginalized populations; and (3) enhance quality of care for minoritized clients. Such an analysis of a clinician’s specific context allows the clinician - and the organization - to develop policies with the most vulnerable in mind, which will improve access, quality of care, and treatment outcomes for all clients.

CONCLUSION This chapter summarizes only some of the significant historical moments that infused racism into the foundation of US institutions, within healthcare and education in particular. It is within these systems that SLPs operate. Situating the profession within the larger system helps SLPs understand how racism in the US has shaped their understanding of language and informed their research and practice. The purpose of this chapter has been to reveal, critique, and intervene on the ways that white supremacy has persisted within the profession in subtle but profound ways, and to equip SLPs to do the same within 97

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their specific contexts. A CRT framework - with an intersectional lens in particular - allows professionals across the discipline to make race-informed evaluations of their own beliefs and behaviors and of their professional environment to the end that they will enact proactively inclusive practices and policies that center Black and other communities of color and their racialized experiences of language and disability. CRT operates at variance not only with colorblind approaches, but also in contrast with multicultural frameworks. The words of Ladson-Billings and Tate (1995) capture the intent of this chapter well: We make this observation of the limits of the current multicultural paradigm not to disparage the scholarly efforts and sacrifices of many of its proponents, but to underscore the difficulty (indeed, impossibility) of maintaining the spirit and intent of justice for the oppressed while simultaneously permitting the hegemonic rule of the oppressor. Thus, as critical race theory scholars we unabashedly reject a paradigm that attempts to be everything to everyone and consequently becomes nothing for anyone, allowing the status quo to prevail. (p. 62) CRT rejects “the uncritical and routinized use of race” (Braun, 2017, p. 246). CRT can guide a responsible analysis of race in speech-language pathology that is necessarily intersectional, most prominently with language and disability. The differences SLPs observe (and construct) between racially-defined groups and the way disorders are understood in relation to those differences do not develop outside of social and historical systems of power and domination. Thus, including race in research and practice without a critical analysis of those systems is an irresponsible use of professional power. Our ethical responsibility must rise to meet the urgency that the outcomes of race-based disparities merit.

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ADDITIONAL READING Anderson, C. (2016). White Rage: The unspoken truth of our racial divide. Bloomsbury Publishing. Annamma, S. A., Connor, D., & Ferri, B. (2013). Dis/ability critical race studies (DisCrit): Theorizing at the intersections of race and dis/ability. Race, Ethnicity and Education, 16(1), 1–31. doi:10.1080/13 613324.2012.730511 Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1(8), 139–167. Crenshaw, K., Gotanda, N., Peller, G., & Thomas, K. (Eds.). (1995). Critical Race Theory: The key writings that formed the movement. The New Press.

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KEY TERMS AND DEFINITIONS Code-Switching: A linguistic skill by which speakers of multiple languages or dialects switch between languages or dialects depending on the audience, setting, topic, and communicative intent. Speakers of NMDs are expected to acquire MAE often at the expense of their native dialect. Use of MAE by NMD speakers is posited as a prerequisite to success in various institutions, which are founded upon mainstream (i.e., white) norms. Dialect: Any variation of a language, including the “standard” or “mainstream” variety. Linguistically speaking, dialects of the same language are mutually intelligible; however, the boundaries between languages and dialects can be politically determined. All dialects of English are mutually intelligible. In this chapter, dialect and language variety are used interchangeably. Hegemonic: Related to dominating authority exerted by the socially, economically, and culturally powerful (i.e., mainstream) over subjugated (i.e., nonmainstream) groups. Language: A system of communication—oral, written, or manual—used to transmit ideas from one person to another. The rules that govern a language are socially agreed upon and change over time. Languages are constantly in evolution. Mainstream: Refers to the dominant group in a society whose cultural norms and practices are assumed to be universal and expected to be adopted by other groups in order to fully participate in that society (i.e., assimilation). In the case of the US, the mainstream group is white monolingual Mainstream American English speakers in the upper and middle classes. Minoritized: Describes groups or identities that are viewed as “other.” This term emphasizes the reality that “othered” groups are not necessarily the numerical minority, but minoritized by the dominant group to maintain their social power. Nonmainstream: Describes people, cultures, languages, and dialects that are systematically excluded from accruing social power. It is a sociopolitical position defined by social hierarchies that shape society’s notions of difference and inferiority.

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Chapter 6

A DisCrit-Informed Critique of the Difference vs. Disorder Approach in SpeechLanguage Pathology Betty Yu https://orcid.org/0000-0001-7064-1098 San Francisco State University, USA Laura Epstein San Francisco State University, USA Vivian Tisi San Francisco State University, USA

ABSTRACT

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The disproportionate representation of students of color in special education is among the most longstanding and intractable problems in education. In this chapter, the authors examine the phenomenon of racial disproportionality through the theoretical framework of disability studies and critical race theory (DisCrit). They argue that a DisCrit-informed lens challenges the current framing of racial disproportionality in speech-language pathology as merely resulting from a failure to distinguish between diferences and disorders. Rather, racial disproportionality is a predictable outcome of the institutionalized segregation of students based on perceived deviations from normative standards, a process grounded in the mutually reinforcing mechanisms of systemic ableism and systemic racism.

INTRODUCTION The disproportionate representation of students of color in special education is among the most intractable problems in education (Harry & Klingner, 2014; Morgan et al., 2015; Skiba et al., 2008; Zhang & DOI: 10.4018/978-1-7998-7134-7.ch006

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 A DisCrit-Informed Critique of the Difference vs. Disorder Approach in Speech-Language Pathology

Katsiyannis, 2002). Racial disproportionate representation in special education refers to the phenomenon of students of certain minoritized1 racial backgrounds being identified for particular disabilities at proportionally higher or lower rates relative to students from other populations (U.S. Commission on Civil Rights, 2009; U.S. Department of Education Office for Civil Rights, 2020). It also describes the widespread pattern of students of color being placed in more restrictive educational settings and disciplined more frequently with harsher consequences (de Brey et al., 2019; Fish, 2019; Morgan, 2020; National Council on Disability, 2018). In this chapter, we examine the phenomenon of racial disproportionality through the framework of Disability Studies and Critical Race Theory (DisCrit) (Connor et al., 2016) and argue that the disproportionate representation of marginalized students in special education is not a glitch in the system, but rather a predictable outcome of the institutionalized conflation of the ways in which students are perceived to deviate from normative standards. We assert that disability is disproportionately racialized and race is persistently disabled; thus, in the absence of systemic reforms to dismantle separate and unequal systems of schooling represented by the division of regular and special education, racial disproportionality in special education will persist. We will discuss the relevance of a DisCrit approach for informing and transforming our understanding of and approach to racial disproportionality in the field.

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BACKGROUND Since the U.S. Department of Education’s Office of Civil Rights began conducting biennial surveys of elementary and secondary schools in 1968, the data has shown persistent disproportionate representation of children in special education from minoritized racial/ethnic groups, students living in poverty, and English learners in the special education system, including both over-identification and underidentification (Artiles et al., 2006; Rueda & Windmueller, 2006; Strassfeld, 2017, 2019; U.S. Department of Education Office for Civil Rights, 2020; Zhang & Katsiyannis, 2002). Despite the addition of monitoring, accountability and enforcement provisions in the Individuals with Disabilities Education Act (IDEA) in 2004, as well as the inclusion of new and revised regulations in 2016, disproportionality trends have remained largely unchanged in the history of special education (Albrecht et al., 2012; Artiles et al., 2010; Office of Special Education and Rehabilitative Services, 2016; Skiba et al., 2008; Strassfeld, 2017, 2019). Racial disproportionality in special education has been described as one of the most durable inequalities in American society (Ferri & Connor, 2005; Voulgarides et al., 2017; Zhang et al., 2014), a display of the lasting legacy of racial and educational segregation more than 60 years following the passage of Brown v. Board of Education (1954). Disproportionality by race in the U.S. special education system has manifested in patterned ways that are complex, contradictory and varying by local factors including school ethnic/racial composition, funding, and regional socioeconomic status (Connor et al., 2019; Cruz & Rodl, 2018; Morgan et al., 2015; Shifrer et al., 2011). Nationally, Black and Native American boys are more likely to be over-identified for highly stigmatized disability categories of intellectual disability and emotional disturbance (Bal et al., 2019; Morgan et al., 2015), and under-identified in less stigmatizing and better-resourced disability categories such as learning disabilities, speech/language impairment, attention deficit disorder, and autism spectrum disorder (Center for Disease Control and Prevention, 2018; Oswald & Haworth, 2016; Robinson & Norton, 2019). In contrast, Asian students are consistently under-identified across disability categories (Chhuon & Sullivan, 2013; Sullivan et al., 2020). Disproportionate representation tends to 106

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increase in schools with predominantly white teachers (Fish, 2019). Nationally, almost all students of color, with the exception of East and South Asian students, are under-represented in the area of gifted education (Goings & Ford, 2018). Exceptions to the trends described above can be found in local schools and districts, but the overall patterns are robust and speak to the entangled relationship between race and dis/ability in the U.S. education system.

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RACIAL DISPROPORTIONALITY IN SPEECH-LANGUAGE PATHOLOGY As members of special education teams, speech-language pathologists are also accountable for the inequalities described above and responsible for dismantling the structures that give rise to them. Of particular importance is the need to recognize the positioning of the discipline of speech-language pathology in relationship to race and disability and the significance of those positionings for replicating the institutional biases that contribute to disproportionality. The speech-language pathology field is overwhelmingly (92%) white2 (American Speech Language Hearing Association, 2019, 2020a). According to data from the U.S. Bureau of Labor Statistics in 2013, speech-language pathology was the fourth whitest profession in America. Studies across helping professions show that the over-representation of white practitioners in a professional field is not simply a demographic fact, but also a symptom and contributor to white hegemony (Badwall, 2015; Bonini & Matias, 2021; Spanierman & Smith, 2017). The field of speech-language pathology is, furthermore, strongly rooted in the practices of medicalization and pathologization, as evidenced in the discipline’s nomenclature – speech-language pathology and communication sciences and disorders (Duchan, 2001, 2012; Eagle, 2014). The language of pathology, and the ways of thinking and operating around it, is a culturally powerful discourse, especially when it is bolstered by the prestige of science and the power of institutions with the authority to define, create, enforce, reify and maintain pathologized identities (Tomlinson, 2014, 2017; Valle & Connor, 2010). In special education, as well as the speech-language-hearing sciences, the epistemological and praxeological orientations associated with whiteness, colonialism, and medicalization are found to be mutually reinforcing. They privilege some ways of thinking, knowing, and acting, while marginalizing others (Kalyanpur, 1999; Kalyanpur & Harry, 1999; Pillay & Kathard, 2015), resulting in a lack of overt acknowledgment of the roles of race/racism and disability/ableism in professional practices (Annamma et al., 2017). In contrast to the mandated collection of data in the IDEA, there is scant data on the nature and extent of racial disproportionate representation within the scope of speech-language pathology. The biennial Schools Survey conducted by ASHA (n.d.) tracks a range of information about SLP caseload characteristics (e.g., settings, locations, disability categories), but collects no information on the race, ethnicity, or language backgrounds of the students served. This gap in data collection reflects a telling incongruity between the rhetoric of commitment to addressing the disproportionate representation of minoritized students in the field of speech-language pathology and the actual steps taken towards the problem. Something we do know is that speech/language impairment (S/LI) is the most prevalent disability category assigned to children ages 3-5, and the second-most prevalent for students ages 6-21 (American Speech Language Hearing Association, 2016). Robinson & Norton (2019) conducted one of the few studies examining longitudinal data of students who were assigned the primary disability category of S/LI and found that across a 10-year period, an average of 75% of states showed a disproportionate representation of African American students in the SL/I category, with underrepresentation by 62% of the 107

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states and overrepresentation by 14% of the states. The impact of these disproportionalities is significant. According to Stanford & Muhammad (2018), for example, African American students with unaddressed language and learning disabilities are disproportionally disciplined through suspensions and expulsions, which, in turn, correlate with an overrepresentation of African Americans in the school-to-prison pipeline.

Perspectives on Racial Disproportionality Explanations and Efforts at Redress

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Special Education The causes of racial disproportionality in special education have been explained in many ways (Kulkarni, 2020; Skiba et al., 2008; U.S. Commission on Civil Rights, 2009). The major explanations include both social and structural factors (Cooc & Kiru, 2018). Social explanations focus on the practices and processes involving individual professionals, such as racist practices (Crawford, 2008); individually held cultural/ implicit biases (Godsil et al., 2014); cultural mismatch between students and teachers (Kalyanpur & Harry, 1999); and unsound practices in teaching, referrals, eligibility determination, and student placement (Castro-Villarreal et al., 2016; DeMatthews et al., 2014; Liu et al., 2008; Mandell et al., 2009). The conclusion that problematic practices and processes play a significant role is supported by the fact that disproportionality is found mostly within the high-incidence, psychometrically defined disabilities categories that require professional judgment (e.g., learning disability, emotional disturbance, speech/ language impairment) and much less so in the low-incidence disability categories like hearing or visual impairments (Harry & Klingner, 2014; Sullivan & Bal, 2013). In contrast to social explanations of racial disproportionality, the structural explanations are those involving larger institutional and societal forces, such as poverty (Ryan, 2012), unequal funding (Greene, 2007; Parrish, 2000), systemic racism (Feagin & Barnett, 2004), racial segregation (Beratan, 2008), biased assessment standards (Arias & Friberg, 2017; Edwards, 2006), and environmental injustices (Wehmeyer & Schwartz, 2001). Although most studies emphasized structural inequalities as being at the root of disproportionality, policy recommendations resulting from the studies rarely address systemic issues, but focus instead on addressing social factors (Cooc & Kiru, 2018). The key interventions endorsed by national and state oversight agencies are: a) more stringent monitoring, data collection and reporting requirements on proportionality in school districts (U.S. Government Accountability Office, 2013; 2018); b) improving the referral process used by general education teachers and administrators through the implementation of response to intervention (RtI) and multitier systems of support (MTSS) (Castro-Villarreal et al., 2016); c) and improving evaluation processes and instruments (Artiles & Ortiz, 2002). These efforts have yielded mixed results (Artiles, 2015) and, as stated previously, have not altered the overall trends in racial disproportionate representation in special education over time. (Voulgarides et al., 2017). Speech-Language Pathology The efforts in speech-language pathology similarly focus almost exclusively on improving referral processes and improving evaluation processes and instruments. Specifically, there is a large body of research and practice guidelines in speech-language pathology that is aimed at achieving a more accurate differentiation of children with speech/language differences from those with speech/language disorders. Many highlight the inherent biases of standardized assessments that are based on monolingual, standardized

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English-speaking norms. Studies recommend a wide range of alternative assessment strategies, including: population-specific standardized assessments (Bland-Stewart et al., 2013; Peña et al., 2018); dynamic assessment (Peña, 2001; Peña et al., 2014); response to intervention (Rosa-Lugo et al., 2010); language sampling (Castilla-Earls et al., 2020; Rojas & Iglesias, 2010); ethnographic observation/interviewing (Westby et al., 2003); narrative assessment (Rollins et al., 2000); classroom-based language screening (Hendricks et al., 2019). Due to the lack of data, it remains unknown whether these strategies have positively affected trends in minoritized racial representation as they relate specifically to school-based speech-language pathology; but there is no evidence in the larger educational literature to suggest that they have. A major gap is that research in speech-language pathology largely ignores the structural contributors of racial disproportionality. There is a dearth of research on disproportionate representation of racially minoritized students in speech-language-hearing disability categories as a function of societal forces such as raciolinguistic ideologies, socioeconomic inequities, systemic racism, and academic ableism.

Examining Disproportionality Through the Intersection of Race and Disability

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Critical Race Theory Critical Race Theory (CRT) in education is a tradition of scholarship that critically examines the expression of institutionalized racism by culturally dominant groups in the educational context. It focuses on the issues of racial inequity in schools with an emphasis on race and proceeds from the premise that racism is enmeshed in the fabric of the American education system. Historians described the American public education system as being built on “a system of compulsory ignorance” for racially minoritized children (Weinberg, 1977, p. 11 as cited in Tomlinson, 2017). From anti-literacy laws in the 19th century, separate but (un)equal schooling in the early 1900’s, to the reluctant desegregation of schools in the 1950’s, the American school system was not designed for the equitable education of all children (Orfield & Eaton, 1996). Even today, more than half of American school districts are made up of either over 75 percent white students or over 75 percent students of color (Meatto, 2019). In other words, even though racial segregation in schools was deemed unconstitutional over 65 years ago, segregation persists in practice. From the CRT perspective, a major critique of the current interventions is that they fail to take into account the systemic and cultural bases of the racial disproportionality (Skiba et al., 2008; Voulgarides et al., 2017). Disproportionate representation of students of color in special education needs to be understood as an outgrowth of the ways in which special education is conceptualized, institutionalized, and implemented in relationship to racialized people (for an overview, see Blanchett, 2009; Losen & Orfield, 2002). Meta-analyses of disproportionality research show that race-based inequity holds even after controlling for socioeconomic status, immigration, languages spoken and other sociocultural factors (O’Connor & Fernandez, 2006; Skiba et al., 2005). This finding bolsters an essential reality– that the disproportionate representation of racially minoritized students is, by definition, systemically racist (Bonilla-Silva, 2018; Feagin, 2006). Critical race scholars point to sorting practices in schools, including the inappropriate assignment to special education, as means of maintaining de facto segregation (Blanchett, 2009) and call for systemic reform of legislation, funding, policies that criminalize students (for an overview, see Losen & Orfield, 2002). Systemic changes result in a stronger impact than solutions focused on individual practitioners, but they are also more difficult to bring about.

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DisCrit: Disability Studies and Critical Race Theory DisCrit, short for Disability Studies and Critical Race Theory, draws from both disciplines to offer a unique critical lens to investigate the intersectional positions of race and disability in education (Connor et al., 2016). It emerged in response to the fact that race was often left unexamined or backgrounded in disability scholarship, just as disability was often omitted or minimized in the scholarship of race. The normalization of both racism and ableism are aspects of our educational systems that rely on each other. DisCrit builds on CRT but also critiques a significant limitation in the CRT scholarship as it pertains to issues in special education (Connor et al., 2016). Specifically, it emphasizes that in the fight to unmask and expose racism in its various permutations, race scholarship has often relied on a distinction between race as a social construction and disability as a biological fact (Beratan, 2006, 2008; Erevelles & Minear, 2010; Connor et al., 2016; Reid & Knight, 2006). Annamma et al. (2016) assert that by focusing on how to more effectively distinguish “true” disorders from culturally determined differences, campaigns for racial justice in special education actually contribute to the validation of unjust and ableist segregation practices. Annamma et al. (2016) state that both racism and ableism are normalizing processes that are interconnected and collusive:

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Neither institutional racism alone nor institutional ableism on its own can explain why students of color are more likely to be labeled with dis/abilities and segregated than their white peers with and without dis/abilities; instead, it is the two working together (p. 19). DisCrit scholars argue that the segregation of Black and brown students would be illegal if based upon race, but is allowed because disability is seen as a “real” rather than yet another constructed difference. Beratan (2008) refers to this as a mechanism of transposition in which special education provides a legal and socially-accepted segregation by ability to maintain the effects of the illegal and socially unacceptable segregation by race. DisCrit troubles the assumption that a separate system of education is a necessary or rational approach to disability any more than it would be for any other identity markers. “Simply ‘fixing’ over-representation of students of color is insufficient if by doing so, we still leave segregation based on dis/ability intact – something that DisCrit finds unjustified and problematic” (Annamma et al., 2016, p. 21). Erevelles et al. (2006) argued that special education programs across the country serve millions of students in educational contexts that are both separate and unequal. Students in special education, especially students of color, are less likely to receive access to a rigorous and full curriculum (Petersen, 2015); are less likely to have post-secondary opportunities (Theobald, 2019); are less likely to have positive peer interactions (Rose et al., 2009) ; are more likely to experience social stigmatization (Mueller, 2019), and are more likely to be permanently assigned to special placements that are physically and/or socially segregated (Jones & Hensley, 2012). These patterns point to special education as a problematic system, at the very least, one that is in need of major reform3. Yet, most recommendations for addressing disproportionality approach the problem as if it were an error in sorting due to discriminatory practices, errors in judgment, biased instrumentation, and/or lack of knowledge (Tefera et al., 2020). But these ways of defining the problem do not pose a fundamental challenge to – and in fact may serve to reify – the bright red line between diversity and disability.

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A Focused Review of Critical Inquiries of Disability DisCrit emphasizes that racial disproportionality in special education needs to be understood as a function of the discriminatory constructions of both race and disability, but in the current literature, even among critical scholarship, the discussion of disability is minimized or absent altogether. The backgrounding and dismissal of disability from the scholarship of race is rooted in a long history of the justification of physical and symbolic violence on racially minoritized peoples through the pathologization of their bodies and minds (Craddock, 1999; Herrnstein & Murray, 1996; Roediger & Esch, 2012; Savitt, 2002). Erevelles et al. (2006) argued that critical race theorists, burdened by the debates associated with The Bell Curve (Herrnstein & Murray, 1996) and its assertions of racial intellectual inferiority, have actively attempted to distance themselves from disability (especially intellectual disability). The result, however, is an unfortunate pitting of one marginalized status against another to the benefit of the continued valorization of white and ableist norms. Because critical conversations about disability are often missing from studies of racial disproportionality, we will offer a focused overview of the contributions of disability studies and how they illuminate disproportionality. DisCrit extends and deepens CRT by taking a critical stance to the legitimization of norms that rely on the pathologization of disability (D. J. Connor et al., 2016). It situates the practices of Special Education and other rehabilitation and clinical disciplines (including speech-language pathology) within the medical model (Connor et al., 2008; Danforth & Gabel, 2006; Duchan, 2005; Erevelles, 2000; Slee et al., 2019; Taylor, 2006). The aim of practitioners within a medical approach is to identify a disorder, diagnose its cause and apply interventions to remove the cause or minimize its effects. According to Valle and Connor (2010):

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Viewed through a medical model lens, disability is conceptualized as a pathological condition intrinsic to the individual. Thus, it is a naturalized practice within special education to position the individual student as the unit-of-analysis. For example, under the evaluation procedures set forth by IDEA, a school psychologist administers an individual and “scientifically based” assessment battery to determine if a student meets the criteria for one or more of 13 disability categories (p. 52). The medical approach poses significant limitations when applied to education. A medicalized view of disabled students4 necessarily projects them as being unwell and in need of fixing. It attributes abnormality to the individual rather than as a function of one’s sociocultural positioning within the educational system. Scholars in disability studies in education (DSE) argue that in its current state, the special education system does not function as a liberatory force for the equitable education of all children but as a sorting bureaucracy and an institution for the construction of the so-called “special needs” child (Slee et al., 2019). Disability categories in special education, particularly those in the low-incidence, judgment-based categories (like speech and language impairment), rely on complex technical and administrative mechanisms to be rendered into existence and maintained (Dolmage, 2018; Rapley, 2004; Sleeter, 2010). The history of special education describes the evolution of a system designed to construct the very categories of deficits that it purports to remediate. A historical view also reveals the ways in which disability in education has long been intertwined with racial/class/linguistic statuses in education. The convergence of compulsory education, industrialization, and immigration in the late nineteenth century produced a large number of students who were “troublesome to mainstream classrooms” (Skrtic, 1991; Tomlinson,

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2017). According to Osgood’s (2008) The History of Special Education, in 1897, Boston, the first city in the U.S. to mandate compulsory education, offered special classes for older, non-English-speaking immigrant children, which soon became a “dumping grounds for students struggling both academically and behaviorally” (p. 41-42). By the turn of the century, Boston began establishing more and more segregated settings tailored to specific conditions (e.g., deafness, “mental deficiency,” chronic illness, vision impairments, speech disorders, giftedness, and low English proficiency), giving rise to educational speech specialists (Duchan, 2010) and other specialized professionals. The system of first segregating children who did not fit the modern standardized classroom, then sorting them by ability became a blueprint for special education. By the mid-sixties, the problem had become so widespread that Dunn (1968) wrote in what is now a classic paper, Special Education for the Mildly Retarded: Is Much of it Justifiable?:

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A better education than special class placement is needed for socioculturally deprived children with mild learning problems who have been labeled educable mentally retarded…In the early days, these children were simply excluded from school. Then, as Hollingworth (1923) pointed out, with the advent of compulsory attendance laws, the schools and these children “were forced into a reluctant mutual recognition of each other.” This resulted in the establishment of self contained special schools and classes as a method of transferring these “misfits” out of the regular grades. This practice continues to this day and, unless counterforces are set in motion now, it will probably become even more prevalent in the immediate future due in large measure to increased racial integration and militant teacher organizations (p. 5). In 1973, Jane Mercer questioned the line dividing normal and abnormal students (noting ethnic differences in the two casts) by referring to the process as one that results in the “6-hour” or situationally retarded child. Special education practices became a mechanism to ensure that children remained socially and/or physically segregated in ways that correlated tightly with race, class, language abilities, and other markers of social marginalization. According to Tomlinson (2014), although infused with the spirit and discourses of benevolent humanitarianism, special education provides more problematic labels than any other part of the education system. Many of these labels carry a stigma of inferiority and low status. Since the passage of the Education of All Handicapped Children Act of 1975, the institution of special education (and its modern day counterpart, inclusive education) has only proliferated in the numbers of children served, the numbers of different specialist disciplines involved, and the complexities of the systems of eligibility determination, placement, and service provision (Osgood, 2008; Sleeter, 2010; Tomlinson, 2017). A cadre of related professionals entered to further cement the system – specialized teachers, school psychologists, paraprofessionals, speech-language pathologists, special education administrators, physical therapists, and occupational therapists – each with their own areas of knowledge, professional bodies, and vested interests in the continued expansion of special education (Osgood, 2005; Tomlinson, 2017). One consequence of the technologization of special education is that many mainstream teachers do not feel they possess the knowledge, skills or resources to teach disabled children (Cooc, 2019; Da Fonte & Barton-Arwood, 2017; Symeonidou, 2017). Over time, this has resulted an ironic situation in which the more special education grows in influence, the more regular and special education teachers/students feel alienated from each other, and the louder the call for inclusive education to break down this division (DEC/NAEYC, 2009; UNESCO, 2003; United Nations, 2006). In Inclusive Education Isn’t Dead, It Just Smells Funny, Slee (2018) argues that the contemporary inclusion movement falls short of its promise 112

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because the charge on inclusion work is ceded to experts in special education using the framework of the discipline. He argues that this is a profound contradiction because truly inclusive education cannot be built from the blueprint of special education. The proliferation of specialized instructional categories, services and settings coincided with the development of testing and psychometrics and has a continued influence on determining which children should receive special education (Osgood, 2008; Tomlinson, 2017). Technologization and medicalization of disabilities is a defining feature of both special education and speech-language pathology today (Osgood, 2008; Skiba et al., 2008; Tomlinson, 2017; Yu & Epstein, 2011). According to Duchan (2001, 2005, 2010, 2012), the field of speech-language pathology, as a means of gaining elevated professional status and legitimacy, evolved specifically to pattern itself after the medical field. The progressive medicalization of speech-language pathology is exemplified by the decisions of the American Academy of Speech Correction in 1925 to disassociate from elocutionists and speech teachers to become speech correctionists and pathologists (Duchan, 2010). St. Pierre & St. Pierre (2018) argued that the professional technologies that developed over time to manage disabled people “did not so much discover as produce deviance and disability” (p. 159). The technical language and professional jargon used by specialists are often given more weight than what is communicated by disabled children, their parents or teachers, especially those from minoritized families (Avdi et al., 2000; Harry, 2008; Kalyanpur et al., 2000; Ong-Dean, 2009; Rao, 2000). A contrasting approach to the medical model is the social model of disability which makes a distinction between impairment, a deviation of biological structures or functions from the norm, and disability, a loss of rights as a consequence of those perceived deviations (Abberley, 1987; Anastasiou & Kauffman, 2013; Longmore, 2003; Ware, 2002). Disability is not located primarily in the individual, but rather in the sociocultural environment that limits an individual’s meaningful participation. The presence of an impairment does not necessarily render a person disabled. For example, a Deaf person whose primary language is American Sign Language (ASL) experiences no communication barriers among other ASL signers or within Deaf spaces (Ladd, 2003; Snoddon & Underwood, 2014). Likewise, disabling conditions can exist in the absence of an impairment, as in the case of students not having access to the curriculum in a language that they comprehend (Karathanos, 2009). A shift from a medical model to a social one recasts the emphasis from remediation to accessibility, and repositions disabled persons from recipients of services to the primary agents of their own educational, health and life agendas (Barton, 1992; Boyle et al., 2016; Burchardt, 2004; Campbell, 2009; Fitch, 2002). This approach requires a fundamental shift in the ways in which disability is perceived and responded to in our schools and society. It does not claim that differences in abilities do not exist, or that access to teachers with specialized expertise is not helpful, but simply that biological, neurological, and behavioral differences are subject to arbitrary and racialized societal interpretations of what is normal/ abnormal and judgments of how those differences should be regarded. The tensions between the medical and social approaches in special education and in the speech, language and hearing sciences can be seen, for example, in the divergence between SLP and audiologists’ pursuit of oral/aural rehabilitation versus the Deaf communities’ assertion of the right not to hear (Knight, 2015; Wilson & Atcherson, 2017), or between the practices of remediating/curing autism versus the push for supporting neurodiversity (DeThorne & Searsmith, 2021).

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SOLUTIONS AND RECOMMENDATIONS For nearly 70 years, racial segregation has been masked and hidden in a separate and unequal system of education for children constructed as disabled. The forces that marginalize children based on their disabilities, race/ethnicity, socioeconomic class, language status, gender and other markers of social value are intersectional and mutually constitutive. Both the over-identification and under-identification of racially minoritized students for disability services show race and disability to be interconnected. At times, the statuses are conflated, and at other times, one is used to erase the other. Both are symptomatic of systemic failures that have disproportionately disadvantaged students of color and that are likely to persist in absence of transformational change. It is necessary to move beyond parsing difference from disorder if we are to dismantle the shared racist and ableist norms that give rise to both constructs. Based on these insights, a fundamental transformation in speech-language pathology and education is needed. In particular, we must develop an intersectional understanding of race and disability in order to illuminate and erase the conceptual line between normal and abnormal (Kahane & Savulescu, 2016). This would require a concomitant shift of educational service organization away from focusing on the delivering of services based on disability categories and toward addressing students’ communication needs (Heathfield & Clark, 2004). Communication supports necessary for children to participate meaningfully in their school communities should be accessible without conditions. The bulk of the effort would also shift to removing disabling barriers in the environment, rather than applying interventions to change the individual. The goal is a unified educational system that supports learning and development through inclusion and universal design for learning, rather than fractured systems of specialized personnel applying special educational technologies to “the special needs child.” These may seem like radical reforms from the viewpoint of our current institutional culture, but as professionals in the field, we have the power and responsibility to either uphold the current standard or to dismantle and rebuild. The disproportionate representation of students of color in special education is a symptom of a larger set of systemic inequities that will not be remedied by more refined practices that operate within the same systems. We cannot claim to be antiracist without also acknowledging and challenging the ways in which ableism produces racist outcomes. Knowing that the foundation of our profession is unjust means that we cannot remain neutral. Otherwise, we ourselves become the oppressors.

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FUTURE RESEARCH DIRECTIONS A DisCrit-informed examination of racial disproportionate representation is a relevant framework for research in speech-language pathology because it offers a theoretical lens for us to look deeply and critically at the collusive relationship between racism and ableism. A DisCrit-informed lens challenges the current framing of racial disproportionality in the speech-language pathology field as primarily a failure to distinguish between differences and disorders, because the very language of a difference versus disorders approach masks racism while reifying ableism. There is insufficient recognition of the ways in which speaking and language use are routinely racialized (Baugh, 2003; Lippi-Green, 2012). The very few studies in speech-language pathology that offer this kind of acknowledgment are focused on speakers of African-American English (Evans et al., 2018; Robinson & Norton, 2019). There is a neglect of the racialization of English language learners, who make up the bulk of the students who are disproportionately represented in the category of speech/language impairment. In these ways, discus114

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sions of disproportionality in speech-language pathology neutralizes the significance of race, and fails to notice the ways in which racism is transposed onto ableist systems. From a critical disability’s perspective, methods of discerning differences from disorders do not liberate the speech-language pathologists from serving bureaucratic categories over serving children. They do not challenge the fact that speech-language support services cannot be provided until the application of these tools construct an institutionally-sanctioned disabled child. The distinction does not reflect real differences in children’s needs, but rather reveals the boundaries constructed to protect our disciplinary interests (Tomlinson, 2017). The conflation of difference and disorder is not an aberration given the embedded assumptions about race and ability in our field and in the education system at large, but a natural outgrowth of flawed institutional design and practices that need to be thoroughly investigated and transformed.

AUTHOR POSITIONALITY STATEMENTS The authors wish to acknowledge that their intersectional identities and lived experiences shape the epistemological frames through which we examined the co-constructions of race and disability in speech-language pathology. The first author is a Taiwanese American who immigrated to the U.S. as a child, who learned English at age nine, and who is an educational advocate for disabled family members. These experiences informed her understanding of the ways in which class, race, language and disability shape, afford, and constrain educational opportunities over time. As a white, half-Jewish woman who was raised without religion, the second author’s experience of others’ incorrect assumptions about her identity has taught her about otherness. As a 1.5 generation Chinese-American disabled, Autistic/ ADHDer person raised by non-English speaking family, the third author has personally experienced how the intersection of race and disability impacted their own academic journey as well as observed these inequities experienced by students while serving as a public-school speech-language pathologist throughout various socio-economically, racially, ethnically, and linguistically diverse school districts throughout the state of California.

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Rueda, R., & Windmueller, M. P. (2006). English Language Learners, LD, and Overrepresentation: A Multiple-Level Analysis. Journal of Learning Disabilities, 39(2), 99–107. doi:10.1177/002221940603 90020801 PMID:16583791 Ryan, J. E. (2012). Poverty as disability and the future of special education law. Geological Journal, 101, 1455. Savitt, T. L. (2002). Medicine and slavery: The diseases and health care of blacks in antebellum Virginia (Vol. 82). University of Illinois Press. Shields, C. M., Bishop, R., & Mazawi, A. E. (2005). Pathologizing practices. Lang. Shifrer, D., Muller, C., & Callahan, R. (2011). Disproportionality and learning disabilities: Parsing apart race, socioeconomic status, and language. Journal of Learning Disabilities, 44(3), 246–257. doi:10.1177/0022219410374236 PMID:20587753 Skiba, R. J., Poloni-Staudinger, L., Simmons, A. B., Feggins-Azziz, R., & Chung, C.-G. (2005). Unproven links: Can poverty explain ethnic disporportionality in special education? The Journal of Special Education, 39(3), 130–144. doi:10.1177/00224669050390030101 Skiba, R. J., Simmons, A. B., Ritter, S., Gibb, A. C., Rausch, M. K., Cuadrado, J., & Chung, C.-G. (2008). Achieving equity in special education: History, status, and current challenges. Exceptional Children, 74(3), 264–288. doi:10.1177/001440290807400301 Skrtic, T. M. (1991). Behind special education: A critical analysis of professional culture and school organization. Love Publishing Company Denver. Slee, R. (2018). Inclusive education isn’t dead, it just smells funny. Routledge. doi:10.4324/9780429486869 Slee, R., Corcoran, T., & Best, M. (2019). Disability Studies in Education – Building Platforms to Reclaim Disability and Recognise Disablement. Journal of Disability Studies in Education, 1-11. doi:10.1163/25888803-00101002 Sleeter, C. (2010). Why is there learning disabilities? A critical analysis of the birth of the field in its social context. Disability Studies Quarterly, 30(2), 210–235. doi:10.18061/dsq.v30i2.1261 Snoddon, K., & Underwood, K. (2014). Toward a social relational model of Deaf childhood. Disability & Society, 29(4), 530–542. doi:10.1080/09687599.2013.823081

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Spanierman, L. B., & Smith, L. (2017). Confronting white hegemony: A moral imperative for the helping professions. The Counseling Psychologist, 45(5), 727–736. doi:10.1177/0011000017719550 St. Pierre, J., & St. Pierre, C. (2018). Governing the voice: A critical history of speech-language pathology. Foucault Studies, 24, 151–184. doi:10.22439/fs.v0i24.5530 Stanford, S., & Muhammad, B. (2018). The confluence of language and learning disorders and the schoolto-prison pipeline among minority students of color: A critical race theory. The American University Journal of Gender, Social Policy & the Law, 26(2), 691–718.

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Strassfeld, N. M. (2017). The Future of Idea: Monitoring Disproportionate Representation of Minority Students in Special Education and Intentional Discrimination Claims. Case Western Reserve Law Review, 67, 1121–1151. Strassfeld, N. M. (2019). Education Federalism and Minority Disproportionate Representation Monitoring: Examining IDEA Provisions, Regulations, and Judicial Trends. Journal of Disability Policy Studies, 30(3), 138–147. doi:10.1177/1044207319835185 Sullivan, A. L., & Bal, A. (2013). Disproportionality in Special Education: Effects of Individual and School Variables on Disability Risk. Exceptional Children, 79(4), 475–494. doi:10.1177/001440291307900406 Sullivan, A. L., Kulkarni, T., & Chhuon, V. (2020). Making Visible the Invisible: Multistudy Investigation of Disproportionate Special Education Identification of U.S. Asian American and Pacific Islander Students. Exceptional Children, 86(4), 449–467. doi:10.1177/0014402920905548 Symeonidou, S. (2017). Initial teacher education for inclusion: A review of the literature. Disability & Society, 32(3), 401–422. doi:10.1080/09687599.2017.1298992 Taylor, S. J. (2006). Before it had a name: Exploring the historical roots of disability studies in education. In S. Danforth & S. L. Gabel (Eds.), Vital questions facing disability studies in education. Peter Lang. Tefera, A. A., & Fischman, G. E. (2020). How and Why Context Matters in the Study of Racial Disproportionality in Special Education: Toward a Critical Disability Education Policy Approach. Equity & Excellence in Education, 53(4), 433–448. doi:10.1080/10665684.2020.1791284 Theobald, R., Goldhaber, D., Gratz, T., & Holden, K. (2019). Career and technical education, inclusion, and postsecondary outcomes for students with learning disabilities. Journal of Learning Disabilities, 52(2), 109–119. doi:10.1177/0022219418775121 PMID:29790412 Tomlinson, S. (2014). The politics of race, class and special education. Routledge. doi:10.4324/9781315794785 Tomlinson, S. (2017). A sociology of special and inclusive education: Exploring the manufacture of inability. Routledge. doi:10.4324/9781315646237 UNESCO. (2003). Overcoming exclusion through inclusive approaches in education: A challenge & a vision. Retrieved from https://unesdoc.unesco.org/images/0013/001347/134785e.pdf

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United Nations. (2006). Convention on the rights of persons with disabilities. Retrieved from https:// www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html U.S. Commission on Civil Rights. (2009). Minorities in special education: A briefing before the United States Commission on Civil Rights held in Washington, D.C., December 3, 2007. U.S. Department of Education. (2016). Fact Sheet: Equity in IDEA. Retrieved from https://www.ed.gov/ news/press-releases/fact-sheet-equity-idea U.S. Department of Education Office for Civil Rights. (2020). Civil Rights Data Collection (CRDC). Retrieved from https://www2.ed.gov/about/offices/list/ocr/data.html U.S. Government Accountability Office. (2013). Individuals with disabilities education act: Standards needed to improve identification of racial and ethnic overrepresentation in special education. Author.

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U.S. Government Accountability Office (GAO). (2018, March). K-12 education: Discipline disparities for Black students, boys, and students with disabilities. United States Government Accountability Office. https://www.gao. gov/assets/700/690828.pdf Valle, J. W., & Connor, D. J. (2010). Rethinking disability: A disability studies approach to inclusive practices. McGraw-Hill. Voulgarides, C. K., Fergus, E., & Thorius, K. A. K. (2017). Pursuing Equity: Disproportionality in Special Education and the Reframing of Technical Solutions to Address Systemic Inequities. Review of Research in Education, 41(1), 61–87. doi:10.3102/0091732X16686947 Ware, L. (2002). A moral conversation on disability: Risking the personal in the educational context. Hypatia, 17(3), 143–172. doi:10.1111/j.1527-2001.2002.tb00945.x Wehmeyer, M. L., & Schwartz, M. (2001). Disporportionate representation of males in special education services: Biology, behavior, or bias? Education & Treatment of Children, 24(1), 28–45. Westby, C., Burda, A., & Mehta, Z. (2003). Asking the Right Questions in the Right Ways: Strategies for Ethnographic Interviewing. ASHA Leader, 8(8), 4–17. doi:10.1044/leader.FTR3.08082003.4 Williams, R. L. (1971). abuses and misuses in testing black children. The Counseling Psychologist, 2(3), 62–73. doi:10.1177/001100007100200314 Wilson, J. A., & Atcherson, S. R. (2017). Audism and Its Implications for Audiology. Perspectives of the ASHA Special Interest Groups, 2(8), 18–28. doi:10.1044/persp2.SIG8.18 Yu, B., & Epstein, L. (2011). Facilitating critical reflections about disability among students in speechlanguage pathology. Perspectives on Issues in Higher Education, 14(1), 11–20. doi:10.1044/ihe14.1.11 Zhang, D., & Katsiyannis, A. (2002). Minority Representation in Special Education: A Persistent Challenge. Remedial and Special Education, 23(3), 180–187. doi:10.1177/07419325020230030601 Zhang, D., Katsiyannis, A., Ju, S., & Roberts, E. (2014). Minority representation in special education: 5-year trends. Journal of Child and Family Studies, 23(1), 118–217. doi:10.100710826-012-9698-6

ADDITIONAL READING

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Ben-Moshe, L., Chapman, C., & Carey, A. C. (Eds.). (2014). Disability incarcerated: imprisonment and disability in the United States and Canada. Palgrave Macmillan. doi:10.1057/9781137388476 Blood, G. W., Blood, I., Kreiger, J., O’Connor, S., & Qualls, C. D. (2008). Double Jeopardy for Children Who Stutter. Communication Disorders Quarterly, 30(3), 131–141. doi:10.1177/1525740108325552 Chisholm, N. J. (2020, September 1). To Be BIPOC, Disabled and Fighting for Justice. Colorlines. https://www.colorlines.com/articles/be-bipoc-disabled-and-fighting-justice Harry, B., & Klingner, J. K. (2014). Why are so many minority students in special education?: understanding race & disability in schools. Teachers College Press.

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Kres-Nash, I. (2016, November 10). Racism and Ableism. AAPD. https://www.aapd.com/racism-andableism/ Losen, D. J., & Orfield, G. (2005). Racial inequity in special education. Civil Rights Project at Harvard Univ., Harvard Education Press. Lu, W. (2019, May 24). What It’s Like Being Disabled And Asian In America. HuffPost. https://www. huffpost.com/entry/disability-asian-americans-immigrants-stigma_n_5cd1c2c7e4b0548b7360bf26

KEY TERMS AND DEFINITIONS Ableism: Ableism is the discrimination of and social prejudice against people with disabilities based on the belief that abilities that are culturally defined as typical are superior. Critical Race Theory: A tradition of scholarship that critically examines the expression of institutionalized racism by culturally dominant groups. DisCrit: A shortened term for Disability Studies and Critical Race Theory coined by Annamma et al. (2016) to capture how conceptions of normality are upheld by the interdependency of racism and ableism. Disproportionality: The over-representation and/or under-representation of minoritized students identified for special education, compared to their percentage in the overall population. Epistemology: The study of how a body of belief is structured and justified. Hegemony: Dominance of one group over another through the imposition of norms and ideas. Marginalizing: Relegating a person or a group to insignificance or unimportance. Praxeology: The study of human action or of a particular practice.

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ENDNOTES 1



2



3



4



The term minoritized is used to refer to the process by which one’s experiences and interests are given less attention and cast as marginal to those perceived to be the dominant and the norm. To be minoritized, one does not need to be in the numerical minority; rather, it is unequal power relations that marginalize certain groups socially, economically, and politically (Shields, Bishop, & Mazawi, 2005). We are intentionally breaking with the conventions of the APA and aligning with the orthographic recommendations of the Diversity Style Guide and other social justice organizations by capitalizing Black but not white. https://www.diversitystyleguide.com Some would argue that the necessary reform is already underway in the form of the inclusive education movement. Disability Studies in Education scholars contest this claim, arguing that inclusive education, as it is practiced, and even in its conceptualization, simply expands on existing special education practices, rather than transform them. It is beyond the scope of this chapter to discuss this debate, but readers are referred to (Danforth & Gabel, 2006; Dudley-Marling & Burns, 2014; Fuchs & Fuchs, 1994; Kauffman, Hallahan, Pullen, & Badar, 2018; Slee, 2018) We adopt identity-first language (e.g., “disabled students” over “students with disabilities”) to align with the preferences of many disability advocates to foreground disability and to reframe disability

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as an attribute that is not negative and not in need of grammatical distancing (Brown, 2011; Ferrigon & Tucker, 2019).

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Section 3

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Developing Research and Evidence Oriented Towards Justice

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Chapter 7

Deconstructing the Three Pillars of Evidence-Based Practice to Facilitate Social Justice Work in Speech Language and Hearing Sciences Reem Khamis-Dakwar Adelphi University, USA Melissa Randazzo https://orcid.org/0000-0003-3055-2503 Adelphi University, USA

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ABSTRACT This chapter reviews the limitations of the evidence-based practice (EBP) framework adopted by American Speech Language Hearing Association for the feld of speech, language, and hearing sciences (SLHS) in addressing systemic racism. The authors argue that a shift from a medically-based EBP model to a pluralistic EBP model would better serve the needs of black, indigenous, people of color (BIPOC) with communication impairments in the current sociopolitical landscape. The authors examine the three pillars of EBP through the lens of social justice work. They describe how the current EBP model limits the development of social justice work in SLHS. They describe the need to refne the EBP model by validating the contribution of qualitative research as scientifc evidence, reevaluating the basis of clinical expertise in client-clinician cultural mismatch, and address the importance of integrating policy and culture in consideration of client and family preferences. These transformations are critical in light of the under-representation of BIPOC clinicians in the feld of SLHS profession.

DOI: 10.4018/978-1-7998-7134-7.ch007

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 Deconstructing the Three Pillars of Evidence-Based Practice to Facilitate Social Justice Work

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INTRODUCTION Evidence-Based Practice (EBP) in Speech, Language, and Hearing Sciences (SLHS) refers to a clinical decision making perspective, adopted from evidence-based medicine, which has been endorsed as a primary guiding principle to enhance the quality of clinical services (ASHA, 2004). This three pillar model is described as “…the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…[by] integrating the best available evidence, clinical expertise, and patients’ values and preferences” (Sackett, et al. 1996, as cited in ASHA, 2004, p. 1). In order to meet the demands of insurance companies and government agencies to ensure treatment efficacy and reduce reliance on “intuition” in practice, this three-pillar EBP model was adopted for financial and political reasons (Hazel, et al., 2019). This model sought to address the tendency of certified clinicians to rely on their own opinions in clinical decision-making (ASHA, 2004). Following the adoption of this model of EBP, several critiques came to light. Some of these critiques pointed to the model’s inability to evaluate the effects of therapies, therapists, or some combination of both on treatment outcomes (e.g. Ratner, 2006). Challenges were noted in integrating the scientific evidence with clinical practice (e.g. McCabe & Usher, 2018; Olswang & Prelock, 2015; Plante, 2004). Although there was a focus on evaluating external scientific evidence according to levels of evidence (Dollaghan, 2007), the model did not address the varying quality of work within the same level of evidence (e.g. Nelson & Gilbett, 2020). The focus on the three-pillar model of EBP occurred ten years following an institutionalized emphasis on cultural competence in the academic training of speech language pathologists (SLPs) and audiologists. ASHA’s 1994 national standards for professional certification added a requirement for academic institutions to include culturally and linguistically diverse (CLD) topics in their curriculum. However, more recent events catalyzed larger conversations about racism in the field, along with demands for action from our professional organizations. Following the worldwide and national sociopolitical events of the summer of 2020, including the murders of George Floyd and Brianna Taylor, along with the rise of the Black Lives Matter movement, the field of SLHS was forced to analyze their role in systemic racism and maintaining white supremacy in the field, while addressing the lack of diversity in the profession. The Council on Academic Programs in Communication Sciences and Disorders (CAPCSD, 2020) put out a report on September 9, 2020 announcing the establishment of a Diversity, Equity, and Inclusion Task Force (CAPCSD, 2020). In turn, ASHA began offering free continuing education courses on microaggressions (ASHA, 2020a). With this emphasis on diversity, equity, and inclusion, there is a focus on culturally responsive practices, both in training the next generation of clinicians, and in service to our clients. In culturally responsive practice, clinicians apply their knowledge and skills effectively to integrate the client’s culture, beliefs, and values into service provision (Hyter & Salas-Provance, 2018). To fully engage with culturally responsive practices, clinicians must become knowledgeable of and engaged with social justice work. Social justice work is defined as “scholarship and professional action designed to change societal values, structure, policies, and practices” (Goodman et al., 2014, p.795). Culturally responsive practice is also based on partnership with clients and families and dismantled power relationship between clinician and client (see Bellon-Harn & Garrett, 2008; Hyter & Salas-Provance, 2019 ; Rose, 2013). The main challenge in training healthcare professionals to achieve competency in social justice work is not instilling in them the importance of social justice and diversity, but rather how to apply it to clinical practice (Hage et al., 2020). This chapter will describe and deconstruct the medically-based three pillar framework of EBP in the context of social justice work and culturally-responsive practice. We describe the barriers to authentic 131

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culturally-responsive EBP in the field of SLHS as they apply to both academic and clinical training as well as clinical practice. In reviewing each of the three pillars of evidence based practice (external scientific evidence, clinical expertise, client-family preferences) we outline how each pillar limits social justice in the field of SLHS. We propose a new model of EBP that puts culturally-responsive practice at the core of the clinical process.

BACKGROUND

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The Contradictory Relationship Between the Medically-Based EBP Framework and Culturally Responsive Practice The medically-based EBP model is inadequate in addressing diversity, equity, and inclusion, yet it underlies all professional actions in SLHS from training pre-service clinicians, to research, to clinical applications. The current EBP model is based on a set of medically-based epistemological principles that limit equity in SLHS (Abrahams et al., 2019). Starting in the 1960s, George Engel began critiquing biomedical care, given its outsized emphasis on biological factors at the expense of social and psychological factors. The specific incorporation of social contextual factors in clinical practice and decision-making is referred to as macro practice. Macro practice is characterized by transcending beyond the individual and/or family level to be inclusive of work in society (Hyter & Salas-Provance, 2018). Factors within these domains are referred to as macro level factors. In 1977, Engel proposed the biopsychosocial model to address social context, the patient, and social systems (Farre & Rapley, 2017). While more work is needed to apply the biopsychosocial model in medical research and clinical practice, a “sustained philosophical and political traction is translating in increasing examples across all areas of medicine” (Farre & Rapley, 2017, p.6). Such philosophical change in SLHS has emerged with the adoption of the biopsychosocial model by the World Health Organization’s International Classification of Functioning Disability and Health ([WHO-ICF] WHO, 2001). The ICF framework was originally rooted in the International Classification of Impairments, Disabilities, and Handicaps (Blake & McLoed, 2018; Bruyère, VanLooy, & Peterson, 2005). ICF further recognized the role of environmental factors in health and functioning (Bruyère et al, 2005). For SLHS specifically, the adoption of the ICF framework marked a transition from a focus on handicap to a focus on health and wellness that considers environmental factors (Blake & McLoed, 2018). Across the health professions, the ICF framework evaluates health at both the individual and population levels, while highlighting the social, political, and cultural dimensions of disability (Blake & McLoed, 2018; Bruyère et al, 2005). However, there is still a need for more research on the clinical implications of the ICF framework (Bruyère et al 2005). A review of the literature on the implementation of the ICF framework in SLHS shows that at the early stages, it was used to guide practice for specific populations, for example people who stutter and individuals with alaryngeal speech (Bruyère et al, 2005). Later reviews of the implementation of the ICF framework in SLHS, show it has been implemented across several types of communication impairments including aphasia, head and neck cancer, stuttering, Parkinson’s disease, ataxic dysarthria, dementia, traumatic brain injury, cochlear implants, developmental disabilities, developmental language disorders, speech sound disorders, cleft and lip palate, and acquired hearing impairment (For a review see Blake & McLeod, 2018). In spite of the expanded implementation of the ICF framework in SLHS, its application is still limited in contexts in which exclusion and racism interact with service provision

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in SLHS. Few SLHS professionals address macro level factors in practice with BIPOC clients, while acknowledging that clinical services may be designed for dominant populations (e.g. Westby, 2013). Hence, more work is needed in SLHS to address the integration of social and psychological factors into research, clinical education, and clinical work. To achieve this, SLHS professionals committed to social justice must create a pathway for the ICF framework to be integrated with the current, prevailing three pillar EBP model. Inherent to social justice work is providing culturally responsive practice. Cultural responsiveness guides clinical practice and research in making clinical decisions that are informed by the social, political, and economic realities of those we serve. Once we choose to adopt and implement a culturally responsive pathway as a profession, it would be “unavoidable” to start “ learning about, understanding, thinking about and managing macro level issues” (Hyter & Salas-Provance, 2018, p.173). This culturally responsible pathway should begin during academic and clinical training. Academic programs tend to overlook the diverse backgrounds of SLHS students. If we do not consider the social and cultural backgrounds of students in the profession, we are in effect another system that fails BIPOC students, with cascading repercussions for upholding white supremacy and limiting culturally responsive practice in the field (Radford, 2018). The macro level barriers that fundamentally affect access to SLHS academic programs and services can be eliminated via social justice work and culturally responsive practice, making communication as a human right achievable, rather than unattainable. This embodies the defining characteristics of social justice work as it facilitates clinicians’ awareness of how macro level factors interact with clinical services. Further it works towards changing social policies and practices affecting access and effectiveness of services provided to BIPOC populations, which is a defining feature of social justice work.

Deconstruction of the Three Pillars of EBP To further illustrate the limitations of the current EBP system in promoting social justice in SLHS, we will review the three pillars (scientific evidence, clinical expertise, client preferences) of the medicallybased EBP model. In general, clinical expertise and client preferences have been underrepresented in the examination of professional issues in SLHS, providing us with an open opportunity to describe these pillars through a social justice lens. We will describe how these three pillars impose barriers to promoting social justice work in the field of SLHS. We outline the limitations of these three pillars in facilitating antiracist, socially just, and culturally responsive service delivery.

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1. External Scientific Evidence- levels of evidence minimize qualitative research that would give insight into marginalized groups’ experiences. ASHA (n.d.a) defines the pillar of scientific evidence as, “the best available information gathered from the scientific literature (external evidence) and from data and observations collected on your individual client (internal evidence)”. What is considered best available evidence is based on levels of evidence (ASHA, 2004; Center for Knowledge Translation for Disability and Rehabilitation Research [KTDRR], 2015; OCEBM Levels of Evidence Working Group, 2011). Current evidence ratings do not have a mechanism to evaluate how generalizable research is cross-culturally in spite of its level of rigor. Lack of such a mechanism inherently devalues research that addresses lived experiences and creates the risk of othering culturally and linguistically diverse clients with communication disorders.

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 Deconstructing the Three Pillars of Evidence-Based Practice to Facilitate Social Justice Work

Qualitative and quantitative approaches to systematic inquiry are complementary in holistically addressing both the evidence for specific practices and the socio-political context and patient experiences (Mertens, 2020). Qualitative research designs are optimal to investigate lived experiences within complex social structures (Damico & Ball, 2010), yet are rare in SLHS (Wium & Lowe). At the time of writing this chapter, an examination of the ASHA Evidence Maps under the category of Cultural and Linguistic Diversity shows that only 8% of meta-analysis studies under the external evidence category include qualitative studies. In contrast to testing hypotheses and theories in quantitative research, qualitative research builds through inductive processes to study language and behavior in context. Kozleski (2017) maintains that qualitative research offers “an important contribution to a social justice agenda that can no longer be ignored” (p.25). In the context of SLHS, Damico and Simmons-Mackie (2003) define qualitative research as “… a variety of analytic procedures designed to systematically collect and describe authentic, contextualized social phenomena with the goal of interpretive adequacy” (p. 132). In spite of the rich, descriptive nature and ability to study communication in a naturalistic context, qualitative research designs tend to fall under lower levels of the evidence ratings in medicine (Cesario, et al., 2002). For example, ASHA (2004) presents levels of evidence based on the Scottish Intercollegiate Guideline Network, ranked in descending order according to quality and credibility, with levels I-IV. Listed as most credible are welldesigned meta-analyses of >1 randomized controlled trial (Ia) and well-designed randomized control study (Ib). However, well-designed nonexperimental studies (i.e. correlational and case studies) are listed as level III, only above expert committee report and consensus opinions. Randomized control trials and meta-analyses are prioritized at the top of the level of evidence hierarchy, even though there is growing criticism of their relevance for treatment evidence in fields outside of SLHS (e.g. Sherwood, 2019). Sherwood’s critique notes that conclusions in research are based on which data are included and which data are discarded, rooted in funding and publication bias. This creates a vacuum that values quantifiable data focused on outcomes at the expense of the research process, limits clear definitions of diagnostic categories by basing them solely in quantitative data, and reduces the replicability of studies. These critiques are more essential to consider when creating an evidence base for the specific culturally and linguistically appropriate practices for BIPOC clients. ASHA’s (2004) technical report on EBP outlines five themes for evaluating external evidence: 1) independent confirmation and converging evidence; 2) experimental control; 3) avoidance of subjectivity and bias; 4) effect sizes and confidence intervals; and 5) relevance and feasibility. The first theme of independent confirmation and converging evidence states that the best evidence for answering clinical questions related to efficacy of intervention is meta-analysis studies that synthesize available evidence. This theme does not address the qualitative meta-analysis studies that are prevalent in other fields including sociology, education, the health professions more broadly, and those currently emerging in psychology (e.g. Levitt, 2018). Moreover, this theme does not address the basic limitations of quantitative studies in answering clinically-relevant questions that may be better evaluated using qualitative research designs. For example, small sample sizes would be endemic to studying some culturally and linguistically diverse populations, diminishing the perceived strength of the research. In some cases, smaller more purposeful samples provide better control for understanding language and behavior in a cultural context. Further, the research for culturally and linguistically diverse populations is sparse; thus, the available research to include in systematic reviews and meta-analysis studies is limited (e.g. Kirmayer, 2012). Kirmayer puts it plainly stating that “the absence of evidence for effectiveness due to a lack of studies is not at all the same as evidence of a lack of effectiveness in well-designed trials” (p. 254). Such a focus on 134

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 Deconstructing the Three Pillars of Evidence-Based Practice to Facilitate Social Justice Work

meta-analysis and systematic reviews in light of the sparse research related to social justice and cultural responsiveness limits clinicians’ ability to learn about systematic inequalities in service provision and to create more responsive evidence-based practices (Centeno et al., 2020; Ellis, 2009). The second theme outlined in ASHA’s technical report is experimental control. Experimental control hinges upon its two defining characteristics, independent variable manipulation and random assignment to a control group. This does not take into consideration that qualitative research designs fall under non-experimental studies but have high methodological rigor in their data collection and analysis. For example, a highly-controlled qualitative study can intentionally recruit participants based on specific lived experiences, thus minimizing differences related to the variable of interest. While the ASHA technical report recognizes the potential contributions of single-subject designs, it minimizes the contribution of non-experimental qualitative studies. Qualitative methodology includes control for validity, reliability, and replicability. For example, in qualitative studies providing rich, thick descriptions that contextualize language and/or behavior, triangulation methods strengthen the validity and reliability of the data by utilizing multiple sources of information (Merriam & Tisdell, 2015). The third theme outlined in the ASHA (2004) technical report refers to avoidance of subjectivity and bias. While this theme highlights the significance of investigator bias in data collection and analysis, it refers mainly to quantitative research where investigators can conceal, blind, or mask aspects of the research to minimize the effect of potentially biased expectations for therapeutic outcomes. However, it does not specifically address biases that stem from social and systemic inequities, although ASHA notes that observer bias and expectations have been shown to influence even instrumental measurements. Farrugia and Abou-Arabi (2021) point out that given only 8% of ASHA affiliates identify as a “racial minority”, the majority of the research done in SLHS is by white researchers. This issue is of particular importance, as we tend to research language and communication, which is mediated by social and political factors (Stockman, 2007). Bias in qualitative research has been addressed more directly due to its inductive nature. There is a growing recognition among qualitative researchers of the importance of requiring positionality statements, specifically when the researchers have a shared, narrow background within a society that normalizes systemic racism and inequality. A positionality statement requires the researcher to describe and report their identity and/or social position in relation to the population under study, and further to document how their position influences the analysis of the data. This is also known as reflexivity in the research process. Qualitative researchers can specifically articulate their perspectives, biases, and assumptions and how their values and expectations influence the study as part of the research process (Merriam & Tisdell, 2015). The fourth theme refers to effect sizes and confidence intervals. This theme highlights the importance of reporting statistical significance and the magnitude of the effect. This type of evidence reports only on the effect of treatment from a medical epistemological perspective. For EBP to be in harmony with cultural responsiveness, this theme needs to address the perspectives of individuals receiving the therapy while addressing social, economic, and political factors. This would be possible by integrating qualitative research or mixed methods design. Mixed methods research employs both rigorous quantitative methods integrated with the authentic and contextual understanding of cultural influences afforded by qualitative methods (Wium and Lowe, 2008). Work in implementation science acknowledges that closing the research to practice gap requires integration of both quantitative and qualitative methodologies for clinically efficacious practices to be successfully implemented (Olswang & Prelock, 2015). The last theme from the ASHA technical report refers to relevance and feasibility. Here relevance is described in terms of how closely the research participants represent the patients seen in clinical 135

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practice. BIPOC participants are underrepresented in research across medicine, education, and health professions (Stanley et al., 2020). Feasibility is described in how readily the methods can be applied to clinical practice in the real world. This theme cannot be examined without addressing issue of diversity, equity, and inclusion. For example, ASHA Evidence Maps suggest that patients should be tested for COVID-19 prior to seeking audiological services. This might be less feasible for BIPOC patients due to the documented discrimination in accessing COVID-19 testing. Additionally, ASHA’s Evidence Maps related to COVID-19 recommend the provision of telemedicine for screenings and service delivery (Adhikari, et al., 2020). Once again, such recommendations may not be feasible for many BIPOC clients due to disparities in digital access and collective mistrust in and awareness of telehealth (Weber et al., 2020). Thus, the current approach to evaluating external scientific evidence in regards to BIPOC clients lacks crucially applicable information to guide the practices of speech-language pathologists and audiologists in the field. Qualitative research has informed EBP in nursing and sociology as well as in educational settings (e.g. Kozleski, 2017; Levitt, 2018) where 53% of ASHA members and non-member certificate holders work (ASHA, 2019). Qualitative research answers educational questions related to practice and policy, cultural knowledge and social inequity, implementation of response to intervention (RTI), and university partnerships (e.g. Kozleski, 2017). Similar directions can be pursued by the SLHS professional community to address questions related racism in CSD, the evolving nature of interprofessional practice (IPP), and effectiveness of intervention in culturally and linguistically diverse populations. Approaches that are in actuality the best research designs to investigate lived experiences of marginalized individuals, systemic social policies, cultural responsiveness, and social justice are minimally regarded. By equally evaluating qualitative and quantitative studies in EBP, or pursuing mixed method studies that facilitate implementation science, relevant answers for clinical questions will be found. This enhances the value of qualitative research, which more specifically addresses the concerns of culturally and linguistically diverse clients. Moreover, this will include social structures and policies as part of the EBP decision-making framework in the model itself. The current framework fails BIPOC clients by having a system that guides clinicians to consider evidence relevant to working with them as less valuable for clinical decision-making. This overlooks clinicians’ need to understand where and how their clients live, their experiences with institutional and societal oppression and exclusion, and how all this information interacts with service delivery.

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2. Clinical expertise- As defined may be interpreted as a subjective measure and vulnerable to implicit bias. ASHA (n.d.a) defines clinical expertise/expert opinion as, “The knowledge, judgment, and critical reasoning acquired through your training and professional experiences”. However, accumulated experience and knowledge does not necessarily lead to expertise (Magnavita & Lilienfeld, 2016). Rather, it results “from extracting the relevant information from experience and applying it in the appropriate situation” (McKnight & Sechrest, 2003 as cited in Magnavita & Lilienfeld, 2016, p.25). Douglas, et al. (2019) maintain that most discussions related to EBP focus on external scientific evidence, thus limiting discussion related to clinical expertise, in spite of it being equally critical for the implementation of EBP. Both the client-clinician relationship and clinician’s knowledge contribute to treatment outcomes (Ebert & Kohnert, 2010). Douglas et al. (2019) state that so far, we do not have a theory of clinical expertise

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in the field. The operational theory that we do have is based on Kamhi’s (1995) work examining the development of clinical expertise in speech-language pathologists. Almost 30 years ago, Kamhi (1995) described the development of clinical expertise during one’s clinical career as confidence in one’s knowledge base, problem solving skills, and interpersonal skills and attitudes. Part of the expertise associated with one’s professional attitude includes the knowledge and professional norms imparted by educational and accrediting institutions (Kamhi, 1994). It is acknowledged that the field of CSD is predominantly white and female, and thus not representative of the diverse populations served by SLHS professionals (ASHA, 2019). The mismatch between the lived experiences of the clinicians and BIPOC clients leaves clinical decision-making vulnerable to implicit bias. Implicit biases are unconsciously held biases derived from negative stereotypes about certain groups. These implicit biases diverge from explicit, or overt bias, likely due to the desire to have a positive selfpresentation in society (Nosek et al., 2007). Often implicit bias occurs subconsciously and may even diverge from one’s consciously held personal beliefs (Chapman et al., 2013). In Kamhi’s framework of clinical expertise, problem-solving skills are related to experience with assessment, diagnosis, intervention, and counseling. By definition, expertise develops with experience. For clinicians with limited experience outside of their own communities, there may be a tendency to overgeneralize practices across clients in the development of these problem-solving skills. Interpersonal skills and attitudes are mediated by immersion in racist ideas through systemic racism in our institutions (Kendi, 2019) and thus are vulnerable to implicit bias in assessing and treating individuals from outside one’s own community. In 2002, the Institute of Medicine published a report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, highlighting how bias, prejudice, and stereotyping negatively impact the quality of healthcare received by BIPOC patients. Following the Institute of Medicine’s report concluding that implicit biases held by healthcare workers contributes to healthcare disparities, significant research has been done in medicine and healthcare to understand the causes and outcomes of this phenomenon (Dehon et al., 2016; Smedley et al., 2002; Zescott et al., 2016). Implicit bias in healthcare is found to contribute to health disparities, even when controlling for socioeconomic status, level of education, and access to resources (Zescott et al., 2016). Overall, ethnic and racial minorities report greater dissatisfaction with healthcare providers (Collins et al, 2002; Zescott et al., 2016). The amount of implicit bias is related to quality of clinical relationships (Blair et al., 2013). Implicit bias negatively affects the health and level of care received by all non-white patients, most starkly for black patients compared to Latino and Asian patients (Agency for Healthcare Research and Quality, 2016; Blair et al., 2013; Maina et al., 2017). Implicit bias in clinical decision-making has been predominantly examined experimentally by finding associations between provider implicit bias, as measured by the Harvard Implicit Assessment Test (Greenwald et al., 1998), and responses to vignettes of realistic patients (FitzGerald and Hurst, 2017). Some findings include physicians not providing pediatric black patients narcotic medication for post-surgical pain and black patients being less likely to receive electrocardiographs and chest x-rays when presenting with signs of acute coronary syndrome (Dehon et al., 2017; Green et al., 2007; Musey et al., 2016; Pezzin et al., 2007; Sabin et al., 2008; Sabin et al., 2012). The role of implicit bias in clinical decision-making has not been directly examined in SLHS. In their narrative review of implicit bias in healthcare, Zescott and colleagues (2016) outlined two paths by which implicit bias contributes to health disparities. In the first path, judgments and decisions about patient care directly lead to disparities in health, perhaps due to unequal disbursement of treatment and medication. In the second path, provider implicit bias degrades communication and trust with patients, which leads to decreased patient engagement and adherence to treatment recommendations. One idea 137

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that has underlined the preponderance of implicit bias in medicine is the heuristic process of emergency room professionals making snap judgments about patients. In the intensity of the emergency setting there is limited time to react, thus providers are more vulnerable to resorting to implicit stereotypes and prejudices even if they conflict with their consciously-held beliefs. Most settings in SLHS are not as pressurized as an emergency room. However, culture underlies all social-communicative interactions. Therefore, the way a communication disorder is conceptualized and interpreted may be mediated by culture and community norms (Hyter & Salas-Provance, 2018). Hence, by nature of working with individuals with communication impairments, speech and hearing professionals may be more vulnerable to communication breakdowns as described in Zescott and colleagues’ second path. This may be evident in the inclusion of culturally-alienating artifacts and culturally-incompatible changes to routines and activities of daily living as part of intervention with BIPOC clients. Another element under the pillar of clinical expertise is expert opinion. Expert opinion, usually through consensus policy statements from organizations like ASHA, have the same limitations as external scientific evidence, as these statements are in part based on the interpretation and implementation of the current evidence. Further, given the demographics of the field of SLHS, stakeholders and panel experts are not likely representative of the BIPOC communities to which these consensus statements are applied. The obstacles for individual clinicians to apply social justice work in clinical practice is rooted in the systemic racism that extends to institutions of higher education and accrediting organizations. While an emphasis on cultural competency in SLHS has increased awareness of diversity and has improved some practices regarding assessment and treatment of culturally and linguistically diverse clients, professional development and training has not challenged clinicians to go beyond the first step of recognizing differences. More research is needed to examine how clinicians’ implicit bias impacts client outcomes in SLHS. Studies regarding implicit bias in the field should reexamine its effect across all aspects of the profession: scientific research, academic and clinical training, assessment, diagnosis, treatment, counseling, and implementation of evidence. Reconceptualizing clinical expertise less as one’s individual experience and more as practice-based evidence may reduce some inherent bias in clinical decision-making (Dollaghan, 2007; Lof, 2011; Sackett et al., 1996). Practice-based evidence broadly refers to internal evidence from clinical practice, for example tracking patient data to inform clinical decisions. This internal evidence may also be derived from family and caregiver reports of the usefulness and effectiveness of treatment. Placing higher value on not only patient data but also family report may put treatment plateaus or gains in a more informative and culturally appropriate context. One way to address the limitations of clinical expertise is to institute an antiracist curriculum that includes implicit bias and systemic racism as part of the standards to be addressed by academic programs and continuing education. Given the underrepresentation of minorities in SLHS and academia in general, the knowledge base as an extension of the academic programs may perpetuate the mainstream white cultural bias both in core content and professional norms imparted during clinical training. Gonzalez and colleagues (2018) discuss how the hidden curriculum in medical training (e.g. institutional culture, interpersonal encounters, and student learning outside the formal curriculum setting) affect implicit bias training. In a qualitative study examining medical faculty’s obstacles in instituting implicit bias modules, they found that instructor racial background and professional identity, institutional values, and student perceptions as obstacles to facilitating implicit bias instruction. Sukhera and Watling (2018) outlined a six-point framework for integrating implicit bias training into education in the health professions to ultimately reduce the negative influences of bias on patient outcomes. These points include creating a 138

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safe and nonthreatening learning context that respects confidentiality and promotes personal responsibility; increasing scientific knowledge about implicit bias, particularly in the domains of psychology and neurobiology; teaching how implicit bias influences provider behavior and patient outcomes; increasing one’s awareness of their own biases, including taking the Harvard Implicit Association Test; making conscious efforts to overcome implicit bias including employing metacognitive strategies, self-regulation, and self-monitoring; and enhancing awareness about how implicit bias influences others, including developing social perspective taking, empathy, and treating patients as collaborators. In summary, clinical expertise is seldom defined and addressed in discussions of EBP (Douglas et al., 2019). Due to this lack of explicit dialog regarding how clinical expertise develops and how it interfaces with clinical decision-making, it remains vulnerable to subjectivity and bias. According to Magnavita & Lilienfeld (2016), clinical decision-making may be approached rationally or emotionally. Although bias may be evident in both approaches to clinical decision-making, many professionals “fall prey to the ease of use and the overconfidence of thinking fast, and therein is the problem” (Magnavita & Lilienfeld, 2016, p. 34). Thus, the emotional route may be activated in uncertain situations, for example when working in communities outside of one’s own comfort zone. Thus, clinical decisions must be informed by internal evidence from clinical practice and self-awareness of implicit bias. Given the underrepresentation of BIPOC clinicians in SLHS, this implicit bias may exert undue influence on the implementation of EBP. This may be directly addressed by emphasizing social justice and antiracism in all levels of training, from pre-service education to continuing education requirements.

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3. Client-family preferences overlooks larger policies and structures that need to be addressed in evidence based decision when serving BIPOC clients. ASHA (n.d.a) defines client-family preferences as, “The unique set of personal and cultural circumstances, values, priorities, and expectations identified by your client and their caregivers”. This is a more expanded description of what is meant by client’s values and preferences when compared to the definition of this construct in ASHA’s (2004) report of the Joint Coordinating Committee on EvidenceBased Practice that referred to it as “e.g. preferences, concerns, expectations” (p.3). As with the pillar of clinical expertise, client and family preferences is minimally discussed within the field of SLHS. Examination of ASHA Evidence Maps across topics and categories consistently shows the client preferences category to have the least available literature. This likely intersects with our previous discussion of the underestimation of qualitative research in SLHS. Guidance by ASHA for working with culturally and linguistically diverse clients focuses on the individual clinician. The ASHA Practice Portal (ASHA, n.d.c) includes several tools for self-assessment of cultural competence. The available tools are presented in the form of checklists, focusing on the clinician’s own awareness of several parameters of cultural and linguistic diversity (e.g. differences in child rearing practices, language difference versus language disorder, etc.) However, there is no mention of the role of white privilege in perpetuating power structures that uphold institutional policies that disadvantage BIPOC clients in their daily lives. Nor is there acknowledgement of the importance of addressing implicit bias in the way clinicians may interact, react, and conduct themselves when engaging with individuals from culturally and linguistically diverse populations. In many instances, these checklists may serve to perpetuate generalizations and stereotypes of culturally and linguistically diverse clients (i.e. understanding that the use of foreign accent or limited English proficiency is not a reflection of the ability to effectively communicate in a non-native language). Recognizing the presence of a foreign ac139

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cent does not facilitate clinicians’ recognition of the underlying premise of white supremacy in seeking accent reduction services. Rather this recognition should facilitate culturally responsive practices that empower clients who are fluent in languages other than the language of power. Further, the clinician should recognize their role as a listener in communicative interactions and advocate for clients’ access to information in their native language (Yu, 2020). These checklists in themselves provide a superficial acknowledgment of cultural differences but no real guidance on how to navigate those differences in a culturally responsive manner. In effect, this guidance may do more harm by othering BIPOC clients and reinforcing white clinicians’ supremacy and epistemological perspective that tokenizes linguistic and cultural differences. One common thread within definitions of client and family preferences is the focus on the individual micro level in the process of evidence based clinical decision-making. Hyter & Salas-Provance (2018) maintain that culturally responsive practice cannot occur without understanding macro level issues. Such an approach necessitates reimagining research in SLHS and the evidence needed to guide our practice. Our service of BIPOC clients is not in silos but within their communities and the policies that impact their access and lived experiences (Hyter & Salas-Provance, 2018). Hence, the pathway to social justice work in SLHS starts with the growth of culturally responsive research, which in turn informs EBP. To achieve this, the current conceptualization of client and family preferences needs to be reevaluated. Focus must be shifted from the narrow scope of the individual to the individual as part of their community. One way to implement such a holistic approach would be to have an EBP framework that is informed by micro, meso, and macro levels factors, as well as the connections between these levels (for a review see Wylie, et al., 2013; Hyter & Salas-Provance, 2018). Such approach is argued to best to bring social change and innovation (e.g. Wylie et al, 2013; Hyter & Salas-Provance, 2018; van Wijk, et al., 2019). Current EBP guidelines conceptualizes “client and family preferences” as micro level factors. Micro level factors are factors that are within the individual. However, meso and macro level forces are an integral part of evidence based clinical decisions that are culturally responsive and socially just. Meso level variables refer to external variables that are close to the individual and families’ local practices and policies. These meso level factors acknowledge how communities influence the individual and families’ perceptions and choices. Such variables may include male-female or adult-child interactions in specific communities. Macro level variables refer to external variables that are distant from the individual and families such as organizational guidelines, institutional policies, global practices and policies, economics, and state violence (Wylie, et al., 2013; Hyter & Salas-Provance, 2018). Further consideration of meso and macro level variables afford clinicians the understanding of the anthropological, psychological, and social forces that serve as barriers or facilitators to activities and participation for culturally and linguistically diverse clients. If the evidence guiding our clinical practice is narrowly focused only on one dimension of these professional interactions, then it is limiting the extent of evidence based decisions (e.g. Kozleski 2017). Hence, there is a need to transform the EBP model in SLHS to address equity and agency in its design. This can be achieved through an expansion of the client and family preferences pillar to be inclusive of understanding systemic and institutional practices, as well as local policies and practices. By doing so, a more comprehensive understanding of individual and family priorities will be achieved. This is critical because BIPOC individuals are less represented in clinical research in SLHS. Most SLHS research examines communication disorders in the context of monolingual speakers from middle-class white backgrounds. For example, Oetting (2020) argues that the failure to refer to General American English

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as a dialect elevates it to higher status than other dialects such that it is considered a norm, and descriptions of other dialects must be meticulously described as deviating from that norm. Narrow, mainstream perspectives impart power relationships, which have the potential to alienate and harm BIPOC clients (for a general review of such debates in psychiatry see Gone, 2015). Thus, meso and macro level factors must be considered in culturally responsive practice. For example, clinicians must consider the impact of race, ethnicity, and culture on the lived experiences of BIPOC clients. Further consideration should examine how this reflects BIPOC clients’ engagement with mainstreamed, whitedominant, standardized educational and clinical practices. This is critical because, based on the demographics of the field, services are usually provided by white clinicians from outside these communities. By addressing meso and macro level factors as part of EBP for client and family preferences, clinicians will become aware of the exclusionary experiences endured by BIPOC patients when introduced to mainstreamed practices. Such an understanding would facilitate clinicians’ efforts to empower families to share their preferences in clinical decision-making. Further, this forces the clinician to acknowledge the potential power differences in client-clinician relationships and the potential alienating effects the mainstreamed therapeutic process may impart to the client. Clinicians need better tools to implement culturally responsive practice when addressing the pillar of client and family preferences. Developing culturally responsive practices at the meso and macro levels requires clinicians to acknowledge how the mainstreamed practices they adhere to influence their interactions with BIPOC clients and families and how such practices uphold systems of oppression. Operationalizing this shift in addressing client and family preferences calls upon our previous discussion of prioritizing qualitative research that describes lived experiences of BIPOC clients and encourages clinicians’ introspection about their own biases.

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SOLUTIONS AND RECOMMENDATIONS SLHS need a model of EBP that takes into account cultural responsiveness. Figure 1 shows a reconstructed EBP model that is integrated with culturally responsive practice through all three pillars. It considers the client’s cultural perspectives, beliefs, and values as central rather than adjacent to the application of EBP. The traditional three pillars of external scientific evidence, clinical expertise, and client-family preferences remain as integral components of the model; however, the foundations of these pillars are rooted in social justice work and anti-racism. External scientific evidence calls upon the practitioners and researchers to further consider the lived experiences of BIPOC clients, equally evaluating qualitative research rooted in the clients’ communities along with quantitative studies. In conducting research on marginalized groups, researchers apply positionality statements to monitor potential bias in the research design and interpretation of data. Given the demographics of the field, clinicians must actively acknowledge their implicit bias when considering their clinical expertise. Adoption of anti-racist curricula in our academic institutions and continuing education courses will equip the next generation of clinicians, and those currently practicing, with the tools to recognize and rectify the effects of bias and privilege in the services they provide. Finally, client-family preferences will transcend the stereotypes and generalizations typically made about racial, ethnic, and religious groups. By considering micro, meso, and macro level factors, culturally-responsive practice will be achieved by empowering clients and their families to participate in clinical decision-making.

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Figure 1.

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FUTURE RESEARCH Cultural competence was introduced as part of the Council on Academic Accreditation (CAA) in Audiology and Speech-language Pathology review for accreditation decisions in 1985. At that time ASHA encouraged educational programs to include multicultural issues but their inclusion was not required for accreditation. Later in 1994, accredited programs were required to include topics about cultural and linguistic diversity in their curriculum (Stockman, Boult, Robinson, 2004). That change has been reauthorized since 1994 and no new changes to the standard have been instituted. Still, multiculturalism, which is typically misrepresented in the field as power-neutral, is a relatively a new concept and newer in its application for SLHS academic programs. Hence, there is sparse research on best practices for teaching multiculturalism (Radford & Hoepner, 2018). Most academic programs implement an infusion model. In an infusion model, programs offer content dedicated to multicultural/multilingual issues within different courses offered within the curriculum (i.e. teaching bilingual phonological development in the pediatric speech sound disorders course), but without a course dedicated to the theoretical background and models of cultural competence and/or cultural responsiveness in the curriculum. The infusion model would be more effective if it included as its focus the theoretical grounding of multiculturalism/multilingualism, which can be reinforced through specific courses with infused content. However, research shows that this combined model, which is found to be the best pedagogical approach to facilitate the development of cultural competence, is not prevalent in academic SLHS programs (Stockman, Boult, & Robinson, 2008). Power structures are imparted through academic training, which promotes a specific way to conceptualize observations of the world (See Abrahams, Kathard, Harty, & Pillay, 2019). The overall

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whiteness of the field of SLHS is reinforced by systemic racism in the institutions of higher education (Alexander, 2020e), as well as the systemic racism prevailing in the educational and healthcare settings where SLHS professionals work (Agency for Healthcare Research and Quality, 2016). Hence, more discussion is needed about how power disadvantages students, scholars, clinicians, individuals, families and communities. More importantly, we are mandated to start the dialogue that avoids othering BIPOC members of our community, including clinicians and clients. One way to change the status quo is to take a systemic approach that addresses the challenges related to diversity, equity, and inclusion from both micro and macro levels of practice, as well as the interactions between them. In doing so, we elevate those in our professional community who were subjected to exclusionary practices to a place of strength leading the change in the field (Radford, 2018). This in part can be attained through a transformation of EBP to be inclusive and comprehensive, integrating culturally responsive practice as central to the framework. Without reform of the EBP paradigm, there will continue to be a barrier to social justice work for research and clinical practice in SLHS.

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CONCLUSION This chapter examined how the current conceptualization of the medically based three-pillar EBP model limits the development of culturally responsive practice and social justice work in SLHS. Adoption of social justice work into EBP requires the incorporation of qualitative external evidence, reduction of implicit bias in clinical expertise, and a shift from recognizing cultural differences at a micro level to engagement in advocacy and dismantling inequity at a macro level. Only by understanding the sociocultural factors that intersect with EBP can we remove barriers to culturally responsive practice. The need for social justice work in the discipline has increased in the current sociopolitical climate. An EBP paradigm that is closely intertwined with culturally responsive practice will facilitate advances in social justice work in SLHS by providing mechanisms for the implementation of the types of research, clinical perspectives, and community-based relationships that put BIPOC clients and their families at the forefront. BIPOC students and professionals in SLHS report feelings of isolation, alienation, limited support in higher education, and difficulty to fitting in to the field. (Fuse & Bergen, 2018; Ginsberg, 2018). If this is how the individuals who are part of the profession serving populations with communication disabilities feel, we must consider the potential feelings of alienation and resistance to services experienced by BIPOC clients and their families. Due to the lack of diversity in SLHS, there is a risk of othering non-white clients and communities if white researchers produce all of the science (Farrugia & Abou-Arabi, 2021). Advocacy and grassroots-level community involvement are needed to build relationships and enlist community stake-holders in the research efforts. Farrugia and Abou-Arabi (2021) describe this as “research with, not about”. Social justice work is needed at all levels from access to higher education, to visibility in science, to culturally responsive practices in the field to recruit more diverse researchers and clinicians to produce the research that informs new, pluralistic models of EBP. Engel’s (1977) call to integrate the biopsychosocial framework into the biomedical model makes the standard of care more humanistic and scientifically sound. We argue that a similar transformation is needed in the field of SLHS. We believe that broadening the underlying principles of EBP to transcend beyond biomedical evidence is a way to improve the quality of patient-centered care, and increase diversity, equity, and inclusion in research. However, transitioning to that model of care and a transformative change at a large scale will only be possible when the EBP framework is reconstructed with a commitment to social

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justice work. This commitment can be operationalized by addressing bias in clinical recommendations and expertise, equalizing taxonomies for evaluating the level of rigor for both quantitative or qualitative research, and empowering clinicians and clients to advocate for social justice. Innovation is dependent upon bringing new ideas along with an expansion of depth and breadth in our academic education, clinical training, research, and practice. SLHS has been stuck at the first step of recognizing differences as cultural competence, with limited progress towards implementation of culturally responsive practices. This chapter provides a critical analysis of the currently used EBP framework from a social justice lens and offers a pathway for facilitating EBP that is driven by social justice work.

REFERENCES Abrahams, K., Kathard, H., Harty, M., & Pillay, M. (2019). Inequity and the Professionalisation of Speech-Language Pathology. Professions and Professionalism, 9(3). Advance online publication. doi:10.7577/pp.3285 Academic Affairs Board. (2016). PhD programs in Communication Sciences and Disorders: Innovative models and practices. Available from https://www.asha.org/siteassets/uploadedFiles/2016-PhDPrograms-in-CSD-Report.pdf Adhikari, S., Pantaleo, N. P., Feldman, J. M., Ogedegbe, O., Thorpe, L., & Troxel, A. B. (2020). Assessment of community-level disparities in coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas. JAMA Network Open, 3(7), e2016938–e2016938. doi:10.1001/jamanetworkopen.2020.16938 PMID:32721027 Alexander, B. (2020). Academia next: The futures of higher education. John Hopkins University Press. American Speech-Language and Hearing Association. (2019). The 2019 member and affiliate profile. Retrieved from https://www.asha.org/uploadedFiles/2019-Member-Counts.pdf American Speech-Language and Hearing Association. (n.d.a). Evidence based practice. Retrieved from https://www.asha.org/research/ebp/evidence-based-practice/ American Speech-Language and Hearing Association. (n.d.b). Evidence maps: cultural and linguistic diversity. Retrieved from https://www2.asha.org/EvidenceMapLanding.aspx?id=8589945970&recenta rticles=false&year=undefined&tab=evTab

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American Speech-Language and Hearing Association. (n.d.c) Cultural Competence. Retrieved from https://www.asha.org/practice-portal/professional-issues/cultural-competence/ American Speech-Language-Hearing Association. (2004). Evidence-Based Practice in Communication Disorders: An Introduction [Technical Report]. Available from https://www.asha.org/policy/TR200400001/ American Speech Language Hearing Association. (2020a). Addressing Systemic Racism and Institutional Inequities in CSD. Retrieved from: https://www.asha.org/about/diversity-equity-inclusion/ American Speech Language Hearing Association. (2020b). Profile of ASHA members and affiliates, year-end 2019. Retrieved from www.asha.org

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Sherwood, V. R. (2019). Does evidence-based treatment exist in the mental health disciplines? Journal of Theoretical and Philosophical Psychology, 39(4), 239–253. Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. National Academy Press. Stanley, L. R., Swaim, R. C., Kaholokula, J. K. A., Kelly, K. J., Belcourt, A., & Allen, J. (2020). The imperative for research to promote health equity in indigenous communities. Prevention Science, 21(1), 13–21. Stockman, I. (2007). Social–political influences on research practices: Examining language acquisition by African American children. Sociolinguistic variation: Theory, method, and applications, 297-317.

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Stockman, I. J., Boult, J., & Robinson, G. (2004). Multicultural issues in academic and clinical education: A cultural mosaic. ASHA Leader, 9, 6–22. Stockman, I. J. Boult, J. & Robinson, G. C. (2008). Multicultural/multilingual instruction in educational programs: A survey of perceived faculty practices and outcomes. Academic Press. Sukhera, J., & Watling, C. (2018). A framework for integrating implicit bias recognition into health professions education. Academic Medicine, 93(1), 35–40. Thompson, D. (2013, November 6). The 33 Whitest Jobs in America. The Atlantic. US Department of Health and Human Services, Agency for Healthcare Research and Quality. (2016). 2015 national healthcare quality and disparities report and 5th anniversary update on the national quality strategy. Rockville, MD: Agency for Healthcare Research and Quality. van Wijk, J., Zietsma, C., Dorado, S., de Bakker, F. G. A., & Martí, I. (2019). Social innovation: Integrating micro, meso, and macro level insights from institutional theory. Business & Society, 58(5), 887–918. Weber, E., Miller, S. J., Astha, V., Janevic, T., & Benn, E. (2020). Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic. Journal of the American Medical Informatics Association, 27(12), 1949–1954. Westby, C. (2013). Implementing recommendations of the World Report on Disability for indigenous populations. International Journal of Speech-Language Pathology, 15(1), 96–100. Wium, A.-M., & Louw, B. (2018). Mixed-methods research: A tutorial for speech-language therapists and audiologists in South Africa. The South African Journal of Communication Disorders, 65(1). https:// doi.org/10.4102/sajcd.v65i1.573 World Health Organization. (2001). International classification of function, disability and health. World Health Organization. Worthington, C. (2018). Assessing School-Age Children with Language Disorders. Invited webinar – American Speech-Language-Hearing Association, Rockville, MD.

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Wylie, K., McAllister, L., Davidson, B., & Marshall, J. (2013). Changing practice: Implications of the World Report on Disabilities for responding to communication disability in under-served populations. International Journal of Speech-Language Pathology, 15(1), 1–13. Yu, B. (2020). Does Accent Modification Do More Harm than Good? Invited presentation at the Asian Pacific Islander Speech-Language-Hearing Caucus (via Zoom) https://www.apislhc.com/api-speakerseries/ Zestcott, C. A., Blair, I. V., & Stone, J. (2016). Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations, 19(4), 528–542. Zipoli, R. P., & Kennedy, M. (2005). Evidence-Based Practice among Speech-Language Pathologists: Attitudes, utilization, and barriers. American Journal of Speech-Language Pathology, 4, 208–220.

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ADDITIONAL READING Farre, A., & Rapley, T. (2017). The new old (and old new) medical model: Four decades navigating the biomedical and psychosocial understanding of health and illness. Health Care, 5, 88–97. Hyter, Y. D., & Salas-Provance, M. B. (2018). Culturally responsive practices in speech, language, and hearing sciences. Plural Publishing. Kozleski, E. B. (2017). The uses of qualitative research: Powerful methods to inform evidence-based practice in education. Research and Practice for Persons with Severe Disabilities, 42(1), 19–32. doi:10.1177/1540796916683710 Magnavita, J. J., & Lilienfeld, S. O. (2016). Clinical expertise and decision making: An overview of bias in clinical practice. In J. J. Magnavita (Ed.), Clinical Decision Making in Metal Health Practice. American Psychological Association. doi:10.1037/14711-002 Malherbe, N., & Dlamini, S. (2020). Troubling history and diversity: Disciplinary decadence in community psychology. Community Psychology in Global Perspective, 6(2), 144–157.

KEY TERMS AND DEFINITIONS

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Client/Family Preferences: Clinical decisions that acknowledge individual interests of clients and social norms. Clinical Expertise: Clinical knowledge and decision-making skills developed through self-reflection, experience, and lifelong learning. Evidence-Based Practice (EBP): Clinical decisions that are based on the integration of best available scientific evidence, clinical expertise, and client preferences. External Scientific Evidence: Evidence published in the form peer-reviewed research or consensus statements from stakeholders. Qualitative Research: Systematic research approaches that are based on nonnumeric data collection and analysis procedures. Qualitative research is typically based on inductive reasoning and conducted in the natural environment of the population under study. Social Justice Work: Professional engagement that dismantles any form of inequity between groups of people. Systemic Racism: Racial inequities embedded within policies, procedures, and rules across different organizations that are normalized by society.

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Chapter 8

Research Methodology to Examine Disparities in Communication Disorders in Underrepresented and Vulnerable Populations Molly Jacobs East Carolina University, USA Charles Ellis East Carolina University, USA

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ABSTRACT The existence of disparities in health has gained national attention. While disparities in communication disorders undoubtedly exist, little research has documented these disparities. Disparities may occur across categories such as race/ethnicity, age, sex/gender, geographic, and socioeconomic status. In order to heighten awareness of existing disparities in the feld of communication sciences and disorders (CSD), this chapter focuses on designing and conducting research to identify and explain disparities among population subgroups. The chapter consists of seven sections: 1) Challenges in Defning Variables for Measuring Health Disparities, 2) Other Data Considerations, 3) Thinking Beyond the Traditionally Measured Sociodemographic Variables, 4) Causal Pathways Between Social Determinants and Health Outcomes, 5) Research Designs, 6) Research Frameworks, and 7) Theories of Contextual Factors. The goal of this chapter is to ofer information that assist CSD researchers in systematically identifying, analyzing, and addressing health disparities in CSD.

DOI: 10.4018/978-1-7998-7134-7.ch008

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 Research Methodology to Examine Disparities in Communication Disorders

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INTRODUCTION Many Americans do not reap the benefits of good health despite the United States (US) being a world leader in advances in healthcare and the provision of state-of-the-art care for most medical conditions. There are many individuals who are more “vulnerable” to disease and disability results in worse clinical and health-related outcomes. These individuals operationally defined as “vulnerable populations” live in disadvantaged communities that typically report worse health-related outcomes than other communities (Shivayogi, 2013). A range of sociodemographic factors have been identified as critical to understanding the make-up of vulnerable population and these include race/ethnicity, economic disadvantage, residence (rural vs urban) sex/gender identity and incarceration. Individuals with these sociodemographic characteristics are most likely to experience negative health-related outcomes. Therefore, these among other factors should be carefully considered when studying clinical outcomes that are at risk of the influences of health disparities in CSD. Consequently, the aforementioned populations suffer from health disparities or an “avoidable difference in health or in important influences on health that can be shaped by policies; it is a difference in which a disadvantaged social group or groups (such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination in the past) systematically experience worse health or greater health risks than the most advantaged social groups (Braveman, 2006, p.180). Therefore, disparities research involves elucidating mechanisms that contribute to observed outcomes, understanding the interactions among these mechanisms, and explaining how these mechanisms differentially impact various population subgroups. Research methodology examining disparities in underrepresented and marginalized populations involves significant definitional and methodological challenges. Proper research requires adherence to several key conceptual and definitional issues. It is important to note that disparities are not simply differences. The term disparity may connote a difference that is inequitable, unjust, or unacceptable (Krieger, 2005; Whitehead, 1992). Characterization of a difference as unjust requires a detailed understanding of the nature and etiology of the difference and is likely to involve multiple criteria such as avoidability, mutability, and detriment to groups that are disadvantaged in terms of opportunities and access to resources (Braveman and Gruskin, 2003). The term “health disparities” is, however, widely used to describe differences in health status without necessarily implying the presence of injustice (Thomson et al. 2006). Health disparities have been reported in CSD. Studies have shown health disparities in the areas of aphasia (Ellis, Hardy, Lindrooth, et al., 2016; Hardy, Lindrooth, et al., 2018; Rogalaski, Rademaker, & Weintraub, 2007; Sharma, Briley, Wright, et al., 2019; Wallentin, 2018), dysphagia (Bussell & GonzalezFernandez, 2011), mild cognitive impairment/cognitive decline (Lee, Richardson, Black, Shore, et al., 2012; Weuve, Barnes, Mendes de Leon, et al., 2018) and hearing healthcare (Nieman, Marrone, Szanton, et al., 2016). Consequently, health disparities are not new to the field yet the study of the contribution of health disparities to clinical outcomes has been limited. A key goal of this chapter is to provide CSD researchers with the necessary definitions, concepts, frameworks and research design approaches to address the many factors that contribute to health disparities while also preserving the core elements of the stellar research that currently exists in the field.

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BACKGROUND

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Challenges in Defining Variables for Measuring Health Disparities As noted above careful consideration must be given to a range of sociodemographic and clinical characteristics of individuals with conditions that are studied in CSD. The measurement of disparities can be captured utilizing a range of data and approaches. Yet, one must understand that existing data that can be utilized to measure inequalities in health status, health care access and quality, and health outcomes for certain racial and ethnic minority groups are subject to several limitations. Much of the available data is based on large groupings by race and ethnicity. Broad categories serve to mask substantial variation within some groups. Members of the same racial-ethnic group from different countries and areas of origin show different patterns of health and disease. Understanding and addressing disparities in marginalized and vulnerable populations will clearly require looking at subgroups within large racial-ethnic categories, despite the difficulty in obtaining adequate data. Disparities and Clinical Outcomes: One striking finding about health disparities is their occurrence across a wide range of clinical health outcomes with differing etiologic risk factors. Over the past decade, a growing body of clinical evidence has shown that social determinants of health are as important to patient outcomes as their genetics. Social determinants have a major impact on health outcomes—especially for the most vulnerable populations. While the measurement of clinical outcomes is generally straight forward in the majority of disciplines, the difficulty arises when researchers attempt to measure the role that social determinants play in clinical outcomes. The social determinants of health that affect clinical outcomes are defined as those conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (Gurewich, et al. 2020). Known determinants of clinical outcomes, such as genetic vulnerabilities, access to and the quality of health care, physical environment, social environment, health-related behaviors, and exposure to stress, should be considered in the investigation of the causes of disparities (Bulatao and Anderson, 2004; Singer and Ryff, 2001). In other words, the impact of these determinants does not occur singularly or in an isolationist scenario. Individuals live, work and produce their individual health in dynamic, multi-faceted environments. The following are key considerations for the measurement of commonly reported disparities that have the potential to impact CSD outcomes. Measuring Race/Ethnicity: While issues of measuring race and ethnicity might appear to be concrete, variation in the clinical definition, self-classification mechanism and evaluation rubric can lead to large conceptual and methodological differences. Race and ethnicity are constantly evolving concepts, deceptively easy to measure and used ubiquitously in scholarly literature (Winker, 2004). A current dictionary definition of race is “a family, tribe, people, or nation belonging to the same common stock, or a class or kind of people unified by shared interests, habits, or characteristics” (Merriam-Webster & Credo, 2003). For 154 years, the US government has defined race for its census takers, and for many years census takers then defined it for US residents. Medical definitions of race have lagged behind and precise definitions rarely appear in biomedical literature. Given that the connotations and definitions of race and ethnicity are constantly evolving, the use of the terms and concepts of race and ethnicity can have a deterministic impact on study findings. Study results that associate characteristics and outcomes with race, often defined by an investigator as skin color, are largely a function of other less easily measured variables. While physical attributes can be a convenient explanation, studies should adhere to more didactic, exact measures of race. 153

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 Research Methodology to Examine Disparities in Communication Disorders

Measuring Socioeconomic Disparities: Many health and communication outcomes vary with socioeconomic status—though again, the patterns of disparity vary depending on the measures used and variables studied. Social and economic factors, such as income, education, employment, community safety, and social supports affect the ability to make healthy choices, afford medical care and housing, manage stress, and act. Despite the importance of these factors, researchers, and public health agencies often fail to collect empirical data on income, education, and occupation or contain different levels of inconsistent methods of measurement for these characteristics. Studies that do measure socioeconomic status often do so in an incomplete, inconsistent, or ill-defined manner. Measuring Urban/Rural Disparities: People living in rural areas seem to have worse health outcomes than people living in metropolitan areas, but this pattern does not hold across all racial and ethnic groups (Committee on the Future of Rural Health Care, 2005; NCHS, 2004). For some indicators, suburban counties show better health status than either rural areas or urban centers, thus suggesting the need for finer differentiations than simply urban and rural (Eberhardt and Pamuk, 2004). In addition to determining differences by the degree of urban or rural locale, health status differs by geographic region (Hartley, 2004). It is unclear whether this is explained by the fact that some areas of the country are more rural than others, by regional differences in socioeconomic levels, or by other relevant differences in living conditions in various parts of the country. One of the primary issues with measuring rural and urban status is the myriad of ways that “rural” is defined across agencies, disciplines and geographic regions. The prevalence or degree of disparities observed can vary largely with the ways these terms are defined. Measuring Sociodemographic Disparities: Characteristics such as minority racial/ethnic status, low socioeconomic position, and rural residence frequently coexist within populations, reflecting exposures and vulnerabilities that may interact to produce health disparities. Education and income are nonrandomly distributed across racial and ethnic groups. Both African Americans and Hispanics are overrepresented in lower categories of socioeconomic status. For some health outcomes, the differences between racial/ ethnic minorities and whites become nonsignificant, once income is controlled. For others the gap diminishes with higher income, though a difference remains at each income level. These differences can manifest in health disparities across groups based on the way socioeconomic status is measured, the level on which socioeconomic status is aggregated, and the level of granularity of the socioeconomic indicators (Williams, 1999). For example, at each level of income, African Americans and Hispanics have lower net worth and live in poorer neighborhoods than whites suggesting that higher education confers fewer health benefits on minorities and women than majority males (Williams and Jackson, 2005; Farmer and Ferraro, 2005). The intrinsic entanglement of racial and ethnic health disparities with socioeconomic factors and vice versa makes the study of either independently improbable (Kawachi et al., 2005; Lillie-Blanton and LaVeist, 1996). Measuring Biological Factors: Recent scientific advances have resulted in unprecedented opportunities to explore the biological determinants of health outcomes at a variety of different levels of measurement. New technologies allow for rapid measurement and collection of vast amounts of biological data, and new techniques involving bioinformatics and biomathematics provide new tools to analyze these data. These advances provide an opportunity to measure pathophysiologic processes at the community, individual or cellular and molecular levels, making it possible to understand how differences in genetic variation and metabolic processes contribute to health disparities. Measuring Health Care Access and Quality: Health care deficiencies involve both poor accesses to care and poor quality of care. Disparities in access and quality also impact the poor and, although not well studied, likely affect those in rural locations, and residents of disadvantaged neighborhoods (Smedley et 154

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 Research Methodology to Examine Disparities in Communication Disorders

al., 2003). Access to care is a concept that has been extensively studied and for which reliable measures exist. However quality measures are less concrete. Oftentimes, instruments, surveys or other secondary outcomes must be used to account for quality. Clear description of these tools and their relationship to the concept of health care quality is necessary to substantiate and validate findings. Measuring the Physical Environment: Physical locations can vary with respect to exposures to toxins, pathogens, and carcinogens. The built, or manmade, environment may present differential risks from chemical substances, such as lead paint, crowding, and noise. The built environment can also constrain exercise, reduce access to healthy foods, facilitate risky behaviors, and discourage health-promoting activities. Clearly outlining and adhering accepted physical environments is necessary for proper analysis. Measuring the Social Environment: At the individual level, the social environment is described by factors such as social connectedness and social support. These factors may impact or benefit health in diverse ways: providing the ability to mobilize resources when needed to deal with problems and threats, buffering the effects of stress exposure, and facilitating access to information from others about health issues (Carducci, et al. 2019). At the aggregate level, lower morbidity and mortality are evident in communities with greater social capital, which may be measured by the resources available to individuals and groups within communities as a result of their social network of connections. Social capital can be measured by indicators such as levels of interpersonal trust, norms of reciprocity, and patterns of social engagement. A related concept to social capital is collective efficacy, which refers to the ability of community residents to undertake collective action for mutual benefit. Collective efficacy and social capital have been shown to contribute to health even when the socioeconomic status of a neighborhood is controlled for—although greater social capital and collective efficacy are generally associated with more advantaged communities so socioeconomic issues should also be considered in these contexts (Shantz & Elliott, 2021). Measuring Behavioral Factors: Health behaviors and lifestyle attributes contribute significantly to morbidity and mortality. Both health-promoting and risky behaviors may be rooted in cultural norms and be influenced by family socialization early in life. Given that behavioral patterns are often formed during childhood or adolescence, but impact health outcomes decades later, measurement becomes difficulty due to the difficulty of recalling the point of behavioral adoption or the subjective nature of behavioral attributes. Behaviors are difficulty to measure given the myriad of outside influences such as education, experience and environment. Behaviors that impair or support good health may also be facilitated or discouraged by environmental factor such as the influence of the built environment on patterns of physical activity. Measuring Stress: Growing evidence highlights the negative impact of stress on both children and adults across the lifespan. Commonly referred to as “allostatic load”, chronic exposure to social and environmental stressors and the resulting behavioral and biological responses, often results in biological “wear-and-tear” that puts individuals at risk for a range of diseases and conditions (O’Connor, et al. 2021). Studies documenting greater stress exposure for groups disadvantaged by race, ethnicity, or socioeconomic status suggest that differential stress exposure may be an important conduit for the impact of social disadvantage on health. Various measurements are used for stress and include perceived discrimination, neighborhood stress, daily stress, family stress, acculturative stress, environmental stress, and maternal stress. The concept of allostatic load was developed to describe the physiologic damage caused by exposure to chronic stress and measure the cumulative—received through multiple biological pathways—effects of stress on a range of health outcomes (McEwen, 1998; McEwen and Stellar, 1993). Examples include observations that stress can induce pro-inflammatory responses and that lower 155

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income and educational achievement contribute to higher blood pressure and unfavorable cholesterol profiles (Broyles et al 2012; Kaplan & Keil 1993). Furthermore, some evidence suggests that social and environmental stressors can impact the hypothalamic-pituitary-adrenal axis, sympathetic nervous system, and immune, cardiovascular, and metabolic systems (McEwen & Gianaros 2010; Seeman et al 2010). Measuring Discrimination: In addition to the indirect health effects of discrimination, direct health impacts manifest through associated community exposure, increased barriers to quality health care and institutional racism. Some research also suggests that the experience of as well as the response to discrimination have health consequences (Williams, 1999). While research has increased the understanding of how discrimination can impact the health of African Americans, little is known about its impacts on other groups (Seeman, 2004). Difficulties avail in both the measurement of discrimination and the role of discrimination on health outcomes. Researchers have debated the validity of audit studies that attempt to collect individualized evidence of discrimination. Calculation of measures of discrimination is often unreliable, subjective and difficult to interpret. An estimate of discrimination among a randomly selected group does not measure the impact of discrimination, but rather the opinions of those surveyed. Rather, researchers suggest that discrimination should be measured by looking at (1) the average difference in the treatment of disadvantaged racial groups and whites or (2) the actual experience of the average member of a disadvantaged racial group, as opposed to examining the average experience of members of disadvantaged racial groups in a random sample of firms (i.e., the focus should be on the average across the population of applicants rather than the population of firms) (Dupree, et al. 2021). Both of these proposed approaches to measuring discrimination are valid, but each has limitations. Careful consideration of these issues should be stated and evaluated.

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Other Data Considerations Significant and persistent differences in disease burden, mortality, life expectancy, and health outcomes between people of differing race, ethnicity, socioeconomic status, and area of residence have been well documented (Eberhardt and Pamuk, 2004; Hartley, 2004). These disparities are often the result of a complex system of factors and conditions and can only be appropriately assessed with a clear understanding of methodological issues. These methodological issues may include but not be limited to age variation within and between demographic cohorts, cause-specific mortality trends between demographic cohorts, misclassification/misidentification of socio-demographic variation, and intra-cohort variation. Outlined below are several factors that should be considered in studies in CSD that include diverse populations. Race/Ethnicity Identification and Misclassification/Misidentification: It has been well established that research in CSD is frequently absent of race/ethnicity data (Ellis, 2009). At the same time, there is concern with the misclassification and misidentification of the race/ethnicity of individuals included in outcomes data. Many disparities in disease burden for American Indians/Native Alaskans have been largely unrecognized because of errors in national data that disproportionately affect this group (Rhoades, 2005). Furthermore, race and ethnicity misclassification in national vital event data can result in discrepancies of reported outcomes between racial group rates and between different data sources (Lee et al., 1998; Howard et al., 1999). Therefore, research that does not account for race and ethnicity misclassification is at risk of grossly underestimating racial and ethnic group rates and subsequently inaccurately determining the existence or magnitude of health disparities (Rhoades, 2005). Age Variation in the Chronic Diseases that Cause Communication Disorders: Age adjustment, a weighted average of age-specific rates, can be used to compare rates of health events for populations or

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groups that differ in age structure. Many racial/ethnic populations vary considerably in age structure. For example, the median age for whites being older than that of all other major racial/ethnic groups. Average lifespans are longer in whites and age of onset of disease frequently occurs at a much younger age in racial-ethnic minorities. Concurrently, chronic disease duration is frequently longer among racial-ethnic minorities (Haas, & Rohlfsen, 2010). It is unclear how these collective factors contribute to adult onset communication disorders and study designs rarely account for these baseline differences in analyses. More importantly, adequate adjustments for age related issues must occur particularly when studying disparities in health outcomes in adults. In the absence of such adjustments, age-specific data may reveal different outcome patterns that reflect baseline differences in age rather than disease driven differences. Mortality Variation in the Chronic Diseases that Cause Communication Disorders: Both the all-cause and cause-specific death rates can differ widely across demographic groups. African Americans, for example, have a 30 percent higher death rate than that of whites while the age-specific mortality rates suggest that the all-cause mortality of African Americans is actually about 75 percent higher than that of whites after age 45 (Cunningham, et al. 2017). The all-cause age-adjusted mortality data for Hispanics indicate that this population has a lower death rate than that of whites, but a more complex pattern emerges with age-specific data. Because mortality rates and average lifespans vary greatly across racialethnic groups, age of disease/condition onset and study enrollment dates should be carefully considered during data interpretation. Intra-Cohort Variation: Data that incorporates large groupings by race, ethnicity, or other demographic identifier often fails to distinguish substantial differences in health status within some racial groups. While these differences may reflect within-group and between-group variations due to biological and genetic factors, as well as differences in social and environmental conditions, it can often be difficult to determine the underlying cause or causes. Since the study of disparities is the study of the multiple, complex, and sometimes subtle relationships among genetic susceptibility, individual behavior, social environment, physical surroundings, disease prevention, and treatment interventions, any or a combination of these factors can lead to the observed variation in outcomes.

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Thinking Beyond the Traditionally Measured Sociodemographic Variables Mounting evidence suggests that many social and socioeconomic factors impact health outcomes both directly—such as the contribution of substandard housing to low cognitive function and stunted physical development in exposed children—as well as through complex pathways often involving biopsychosocial processes—such as the social acceptability of risky behaviors such as violence and alcohol use (Miller et al. 2009). The impact on health outcomes can be seen relatively rapidly or manifest much later in life. (Lidsky & Schneider 2003; Afeiche et al. 2012; Bingenheimer, Brennan, & Earls 2005; Pollack et al 2005). For example, while neighborhood socioeconomic disadvantage and higher concentration of convenience/fast food stores have been linked to higher levels of tobacco use in the short-run, lower availability of fresh produce and consumption of high levels of saturated fats can lead to poorer nutrition and less physical activity—the health consequences of the chronic diseases related to these conditions will not appear for decades (Chuang et al. 2005; Gordon-Larsen et al. 2006; Cummins & Macintyre 2006). Research has shown also an association between duration of childhood poverty and adult cognitive function, mortality and educational attainment as well as socioeconomic disadvantage greater direct physical challenges to health status. Adjusting for depression, anxiety, and other negative

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emotional states, however, has not completely explained the effects of social factors on health (Evans & Schamberg 2009; Cutler et al 2011; Matthews et al., 2010). Some studies suggest that socioeconomic and other social factors impact the epigenetic processes that regulate whether genes are expressed or suppressed (Wolffe & Matzke 1999; Tung, et al 2012). Social status, educational attainment, occupational class, work schedules, perceived stress, and intimate partner violence have all been linked with changes in the DNA-protein complexes capping the ends of chromosomes that protect against damage—known as telomeres Surtees et al 2012; Steptoe et al 2011; Cherkas et al 2006; Parks et al 2011; Parks et al 2009; Epel et al 2004; Humphreys et al 2012; Price et al 2013; Aubert & Lansdorp 2008). Associations between social processes and physiology are further complicated by the effects of timing, such as when and for how long a experience, stress or hardship is experienced (Singer & Ryff 1999; Rahkonen, Lahelma & Huuhka 1997). In general, the immediate and cumulative effects of socioeconomic and related social stressors can manifest in a variety of adverse health outcomes with both short- and long-run implications. Despite considerable evidence indicating important effects of social factors on health, not every individual exposed to socioeconomic or other adversity develops poor health outcomes. Protective social factors, such as social support, self-esteem, and self-efficacy, may mitigate the deleterious effects of adverse social conditions (Matthews, Gallo & Taylor 2010; Seeman et al 2010; Gallo et al 2009; Franzini, Ribble & Keddie 2001). Furthermore, these adverse circumstances may have less impact on the health of individuals in settings in which basic needs—food, housing, education, healthcare—are met by the state or family partly because the insecurity about meeting basic needs is alleviated (Anand & Ravallion 1993). While income may have less health impact where there is less social stigma associated with having limited means, genetics may also play a role in vulnerability or resilience to socioeconomic adversity (Cole et al. 2011). A growing number of disciplines—including psychology, neurology, immunology, education, child development, demography, economics, sociology, and epidemiology—have begun to examine the interplay of social/socioeconomic factors, mediating factors, and health outcomes. Evidence has clearly demonstrated that relationships between these factors and health are complex, dynamic, and interactive; involving multiple mechanisms that may only manifest decades after exposure. Not only is it necessary to properly define these mechanistic components when evaluating social determinants of health, but it is also important that research within these critical areas be translatable in order to vulnerable and marginalized populations.

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The Causal Pathways Between Social Determinants and Health Outcomes The complex causal pathways and long time periods through which the social determinants impact health outcomes can create barriers to conceptual research (Gallo et al 2009; Braveman et al 2011; Hertzman 1999; Kuh et al 2002; Lawlor et al 2005; Melchior et al 2007; Turrell et al 2007). Complexity arises because both upstream factors—income, wealth and education—and downstream factors—genetics—interact with each other and with other unobserved factors resulting numerous multifactorial pathways (Philippe & Mansi 1998). As these factors interact, each juncture presents an opportunity for confounding and interactions. Nevertheless, it may be possible to study small pieces of the causal web with randomized experiments or other applicable research design, making incremental contributions to understanding the overall pathways (Braveman et al 2011).

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While the causal pathways between social determinants and health outcomes are often complex, four theories have been proposed to explain inequities in health and its relation to social and socioeconomic factors. 1) The materialist/ structuralist theory proposes that inadequacy in individual income levels leads to a lack of resources to cope with stressors of life and thus produces ill health (Goldberg et al., 2003; Frohlich et al., 2001; Macintyre, 1997). 2) The psycho-social model proposes that discrimination based on one’s place in the social hierarchy causes stressors of various kinds which lead to a neuroendocrine response that produces disease (Karasek, 1996; Siegrist & Marmot, 2004; Evans & Stoddart, 2003; Goldberg et al., 2003). 3) The social production of health model is based on the premise that capitalist priorities for accumulating wealth, power, prestige and material assets are achieved at the cost of the disadvantaged. 4) The eco-social theory brings together psycho-social and social production of health models and looks at how social and physical environments interact with biology and how individuals ‘embody’ aspects of the contexts in which they live and work (Goldberg et al., 2003; Krieger, 2001). It builds on the ‘collective lifestyles’ approach that lifestyle choices are influenced by life chances defined by the environment in which people live (Frohlich, 2001; Cockerham, 1997). While these theories provide general frameworks for the mechanism of influence between social factors and health, no theory exists that addresses the underlying certainty about cause and effect between these elements. Instead, these aforementioned theories rely on mostly associational or probabilistic types of explanations (Link & Phelan, 2005; Mechanic et al., 2005). A more generalized research framework could consider that health outcomes result from social causes, biological causes and the interaction between the two. Researchers should consider both social and biological processes and the interaction between them. The social determination of health and corresponding disparities result from differential contextual stimuli and their respective interactive chains differ according to social position, country of residence, and the surrounding political climate. Genetics, immunity, nutritional status, resilience, and ability to cope serve as mediating factors in the causal pathways connecting social factors/social determinants to ultimate outcomes (Hurrelmann & Richter, 2019). In CSD, the randomized controlled trial (RCT) often provides the best way of identifying existing disparities in clinical outcomes and possibly the mechanisms of the cause and those factors that ameliorate the cause (Chalmers, 1998). However, as with all clinical disciplines, the challenge remains conjoining the social and the biological and developing plausible explanatory models. While researchers have been able to identify some of the necessary and the sufficient conditions involved in the causation, the nature, circumstances, and operational mechanisms behind the social determinants of health are not always clear. Because of these difficulties and the theoretical differences in explanations, research has been slow to progress in identify the inequities in outcomes and the best mechanism to integrate equity into clinical practice (Oxman et al., 2006). In addition to the uncertainty regarding population inequities and the pathways between the social determinants and clinical outcomes, these inequities often emerge over decades or generations. Few studies are able to follow participants for more than a few years. The long-time lag between independent and dependent variables represents a scientific challenge. Understanding the effects of social factors on the health of certain population requires information across multiple sectors (e.g., as education, planning, housing, labor, and health) and multiple programs within a given sector. However, cross-sectoral collaborations face multiple barriers, including differing priorities, funding streams, and timelines across agencies (Arcaya & Briggs 2007).

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In order to identify disparities in clinical communication and health outcomes, improve research findings and determine effective ways to address the social determinants of health, accurate and appropriate measurement of social factors is requisite in all of the following areas: Descriptive studies. Ongoing descriptive research is needed to monitor changes over time both in the distributions of key upstream social factors across groups defined by race/ethnicity, geography, and gender, and in their associations with health outcomes in specific populations. Longitudinal studies. Longitudinal studies with comprehensive information on both social factors and health outcomes collected repeatedly over a long period of time are needed to assess health consequences over the life course. These longitudinal studies would facilitate the examination of children’s trajectories of health and social advantage across the life course as well as in adulthood. Linking sources of knowledge. Documenting and quantifying how social factors influence health outcomes and how to influences intervene over the life course requires accounting for a variety of characteristics and contexts. The most efficient means to characterize this type of system would be linking a series of distinct studies examining specific segments of the pathway. Once the links in the causal chain are documented, an incremental approach could be applied to study the effectiveness of interventions both across and within population subsets. While not a novel approach, the knowledge gained from connecting a segmented series of studies could provide considerable insight on various levels.

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Research Designs Despite the importance and pervasive nature of the social determinants in determining health outcomes, research has made little progress in exploring the mechanisms through with these social factors operate or identifying the causality within these pathways. To proliferate findings in these necessary areas of research, CSD researchers must produce findings that not only have a meaningful impact on the lives and health vulnerable populations, but that also are translatable into the context of day-to-day practice for all individuals. Generating this type of research requires CSD investigators to assume alternative approaches to research such as that embodied in health services research (HSR). HSR is a multidisciplinary field that examines the “use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services” (Institute of Medicine, 1995). HSR requires the engagement of multiple stakeholders, including “individuals, families, organizations, institutions, communities, and populations” throughout the research process (Institute of Medicine, 1995; Lohr & Steinwachs, 2002). Because of the complexities of conducting research in a noncontrolled, socio-politicoeconomically diverse health care landscape, HSR embodies effective collaboration across multiple subdisciplines including health economics, epidemiology, biostatistics, sociology, dissemination and implementation science, and quality improvement (QI) sciences. HSR directly studies the context of health care delivery aiming to engage stakeholders through partnerships to identify appropriate and relevant questions, actively engage in the research process or disseminate/implement findings. HSR uses multiple, flexible methods and study designs. While not a comprehensive review, aspects of HSR study design and data are described below. HSR Study Design: HRS studies seek to understand and address the multiple and complex factors of health outcomes and healthcare delivery. For example, a mixed-methods research study could utilize both population-based quantitative methods to describe phenomena (Kroll, Neri, & Miller, 2005). They could also employ pragmatic trials—those conducted in real-world settings—to evaluate internal and external validity, fidelity, and local adaptations of interventions, and the effects of these interventions

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within real-life settings and populations (Ford & Norrie, 2016). Finally, cost-effectiveness studies, which seek to compare the outcomes of treatments relative to their costs, are quite common in HSR (Jamison et al., 2006). HSR Data: HSR data can range from data collected at the population level to that collected at the hospital/clinic level to qualitative data collected from individuals. Data can vary in size, scope, and depth. It can contain information on certain conditions, diagnoses, procedures, care, or perceptions of these categories. Population Level Data: HSR often employs large, population-level databases containing information on thousands of people with diverse backgrounds such as the National Health Interview Survey (NHIS)—an annual households survey of 100,000 individuals about their health and health behaviors, health care, and sociodemographic characteristics publicly available through the National Center for Health Statistics (U.S. Department of Health and Human Services, 2017). Despite the large amount of information contained in the NHIS and other surveys, information should be assessed with caution. Respondents may provide inaccurate information for reasons including recall bias, stigma, shame, or telescoping. While claims databases, such as Medicare and Medicaid records containing information about healthcare utilization, are not subject to the same individuals-level bias, these databases contain no patient-level identifiable information and often pose a large fee for use. These and other similar data sources can provide insight into the determinants of clinical outcomes, but no single data source contains all the information on the provider, patient, facility, cost, household, childhood environment, etc. necessary to properly assess the complex association between social determinants and observed communication outcomes. Furthermore, little standardization exists within or between data sources or at different levels of data collection. While federal agencies have made efforts to incorporate a standard sequence of questions regarding certain disability into all federal surveys, none of the six questions chosen to identify disabilities specifically identifies persons with speech, language, and voice disabilities (existing questions identify physical, cognitive, visual, deaf or hard-of-hearing, self-care, and independent living disabilities; Office of the Assistant Secretary for Planning and Evaluation, 2011). The lack of comprehensive CSD identifiers not only limits the research that can be done involving persons with communication disorders (CD) but is also leads to the underrepresentation of CSD populations in HSR studies. These data limitations have made it difficult determine the current breadth and scope of communication disorders. For example, a one-time sponsored supplement to the NHIS provided the first national estimates of adults living with speech, language, and voice disorders (10% of the population; Morris, Meier, Griffin, Branda, & Phelan, 2015). Unfortunately, this supplement was only administered once, and 80 percent of those reporting disorders admitted that they have never been diagnosed with their disorder—evidence of patient misspecification or inability to access health care services. Organization Level Data: Electronic health records (EHRs) can be used both retrospectively and prospectively as a source of patient-level health care data at the organizational level (Morris & Kho, 2014). Although a promising source of data, EHRs have present considerable limitations. First, the data are still often “messy” and fraught with errors. Extensive coding and data verification is required to translate EHRs into usable data. Second, much of the needed information is contained in free-text fields composed of various languages and terms. Free-text fields often require significant data mining and natural language processing to become useful for research purposes. Furthermore, they are dependent on providers appropriately documenting procedures, diagnoses, and so forth. Patients are likely to have

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multiple health care providers documenting within one medical record, frequently using inconsistent language. Finally, measures of interest may not be collected or may only capture certain groups of people. In-Depth Qualitative Data: Qualitative research involves collecting data through interviews, focus groups, observations, or reviews of existing documents (Creswell, 1998). While data from qualitative research are not generalizable at the population level, it provides an understanding of the outcomes and interventions and important contextual information to stakeholders regarding efficacy and efficiency (Shortell, 1999). While the penultimate goal—informing evidence-based practice and reducing health disparities—of research is clear, the translation of CSD research to often results in “research waste” which is attributable to multiple factors such as inadequate training, limited time and resources, and lack of incentives for change or staff engagement (Moher et al., 2016; Glasgow, Lichtenstein, & Marcus, 2003). However, much of this waste could be reduced through use of the appropriate framework to guide the data generating process. Formats ensure that intervention or data gathering research gathers the evidence needed identify disparities, address vulnerable populations and effect health equity. The use of a framework is widely recognized as a critical factor in bridging the gap between research and clinical practice (Meyers, Durlak, & Wandersman, 2012). Since HRS exists at this intersection of policy, practice and patient outcomes, researchers have increasingly turned to health services research frameworks to focus the research process and ensure generation of evidence capable of identifying disparities, gathering appropriate data, identifying appropriate outcomes, and evaluating a variety of social and economic determinants (Breton and De Leeuw, 2011; Smith and Katikireddi, 2013; Baum et al., 2018; Graham, et al. 2018; Horner, et al. 2013).

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Research Frameworks Frameworks act as a guide for conducting impactful research by helping to ensure that all the appropriate and essential factors are considered from conception to results (Lurie & Mason, 2007). Frameworks support the research process by simplifying a complex process by providing structure and guidance; identifying and including stakeholders; explaining reasons for outcomes; generating transferable lessons; and identifying the mechanisms driving or inhibiting change (Bradford, et al. 2019). Three common frameworks which have been used are the Multiple Streams Framework, Advocacy Coalition Framework and Punctuated Equilibrium. The Multiple Streams Framework suggests that health changes manifest from three streams via the emergence of windows of opportunity between entities (Herweg et al., 2015). The three streams include problems, policy and politics. The use of these three streams is seen as a prerequisite for successful problem solving and problem brokering to improve health outcomes through legislative agenda and policy actions. For example, instituting a new public health screening process requires consideration of public health policies, individual health needs and legal compliance. The second framework, the Advocacy Coalition Framework focuses attention on how health care entities form coalitions based on shared beliefs in order to bring about change (Sabatier and Jenkins-Smith, 1993). For example, people engage in politics to turn their beliefs into policy by establishing coalitions of individuals with similar beliefs. An example would be related to vaccine requirements for school entrance which requires cooperation among parent-teacher organizations, school boards and public health experts. Finally, Punctuated Equilibrium suggests that systems operate through patterns of gridlock and inertia and that, while shifts are difficult, sudden points of influence can occur (Baumgartner and Jones, 1991). An example related to tighter gun control prompted by the devastation of school shootings.

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Using established frameworks helps identify those significant social determinants that align with measurable short-term impacts over longer-term outcomes (Embrett and Randall, 2014). This approach allows for consideration of a wide range of drivers of both the barriers and the enablers that can contribute to advancing action for addressing the social determinants of health (Embret and Randall, 2014; Baum and Friel, 2017). While one single framework may not fit each study, a combination of frameworks can easily be utilized to best illuminate the complexities research into the social determinants of and inequities in vulnerable populations (Cairney, 2007; Harris et al., 2018).

FUTURE RESEARCH DIRECTIONS

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Theories of Contextual Factors Used in Consideration of Assessment While knowledge of the pathways and biological mechanisms connecting social determinants with the health outcomes of vulnerable populations has increased during the past 25 years, mounting evidence supports causal relationships between many social—including socioeconomic—factors and many communication outcomes, not only through direct relationships but also through more complex pathways often involving biopsychosocial processes (Ackerson & Viswanath, 2009). In addition to the biological components associated with the etiology, incidence, and evolution of communication disorders, social and environmental issues constitute an important and often overlooked component. Understanding the scope and extent to which such social determinants impact health disparities remains a primary research agenda within the field of CSD. Communication and other health outcomes result from complicated processes involving interactions between environmental factors, personal characteristics, and biology. However, the nature of these multifactorial causal pathways presents many challenges for researchers seeking to identify health inequalities. For example, researchers should carefully consider measurement of spatially defined environments and focus on use of agent-based models to better capture how relations between individuals affect populationlevel patterns of health (Cooper, et al. 2006; Galea, et al. 2009). Studies involving disparities in communication disorders hinge on theories regarding the relevant social factors and the ways in which they may operate. Theories governing how group-level or contextual factors interact with communication outcomes dictate the types of multilevel analyses required. Theories generally involve multiple levels of analysis incorporating ecological or aggregate variables in models of individual level outcomes. While it is generally acceptable to include individual and ecological level measures in the same analysis, models can assume various levels of complexity. The simplest method, often called contextual analysis, is an extension of conventional model (See Figure I) in which both individual level and ecologic predictors are included (Von Korff et al. 1992). As noted in Figure 1, individual health determinants do not dictate health outcomes independently. In fact, health outcomes are determined by the multiple confounding factors such as social structure, health behaviors and workplace environment of all which behave intersectionally with health outcomes and with one another. A limitation of contextual analysis is the likely violation of the assumption that error terms are random, independent and uncorrelated with any other variable causing the estimated confidence intervals to be wider than they should be (Rothman & Greenland 1998). In order to overcome the statistical shortcomings of contextual analysis, newer statistical techniques such multi-level models, random-effects models and hierarchical regression models have been developed to allow for the consequences of within-group

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clustering, so that both individual-level and aggregate-level variables may be included and appropriately analyzed (Austin et al. 2001).

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Figure 1.

The primary components of these estimation models can be classified into four broad groups: social determinants, health care system, behavioral, and health outcomes. The interrelated nature of these elements implies various causal pathways must be used in the analyses of social determinants as they relate to health inequalities. The need to incorporate social determinants in the model is emphasized by the population health approach which recognizes that “an individual’s risk of illness cannot be considered in isolation from the disease risk of the population to which she belongs” (Berkman & Kawachi 2000) and that “the causes of individual variation and the causes of variation between populations and time periods may be distinct” (Schwartz & Carpenter 1999; Rose, 1994). While clinicians often disregard social determinants since they are considered to be unmodifiable, outside the scope of CSD or not in alignment with local or jurisdictional policies or political directions, inclusion of social determinants in health outcome models helps to build a better bridge between CSD and the field of public health in the real world (Schwartz & Carpenter 1999). Analytic strategies appropriate for the complex causal pathways conceptualized between communication disorders and social determinants include multilevel modelling, path analysis and structural equation modelling, combining qualitative and quantitative research methods, and collaborative research (Lancaster, Hope & Camarata, 2014; Levine et al., 2005; Loehlin 1992). However, this is far from an inclusive list. Many of these techniques are rarely employed in CSD research. Instead, much of the research into the social determinants of communication outcomes consists of collecting social data about individuals, such as their social class, educational status, income, lifestyle, attitudes to health care and disease, etc. and relating the variables to health outcomes using various forms of multiple regression analysis. However, multiple regression is highly problematic when applied to these models. Multiple regression elucidates the relative strength of the association between each variable and communication

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outcomes in order to predict risk factors and ascertain causal links between the individual risk factors and outcomes. Even though multiple regression analysis allows for the prediction of risk factors and the demonstration of direct causal pathways, it does not explore the complex causal processes. If the pathways between the various social factors are not teased out, such factors exist as isolated features without a clear relationship to the other factors or outcome in the model. Although a simplified depiction, FIGURE I illustrates the inadequate conventional model compared to the complex pathways that more closely resemble the relationships. Causal models of complex phenomena are difficult to study empirically (Gentzel, et al. 2019). There is a danger that what is studied is limited by the research methods and analytic tools available, and that the tradition of quantitative research methods and multivariate statistical analysis in CSD research dictates that these methods are used whether they are appropriate or not (Krumholz, et al. 2006). Integrating a complex theoretical model into research methods, analytic approaches and statistical models, in ways that understand and reflect the underlying complexity of the social and biological processes being investigated, requires the development of new research methods and analytic tools. Before more appropriate statistical models can be employed, the types and structure of the available data must be considered. First, data collected in CSD is often clustered or hierarchical, e.g. individuals in a cohort, children in a family, communities are located in a geographical region, etc. Observations within a group are often more similar than would be predicted, hence the assumption of independent observations necessary for multiple regression analysis is compromised (Hays, et al. 2005). Secondly, it has been shown that multiple regression analysis can give misleading results when analyzing sequentially causal relationships (Hays, et al. 2005). It cannot estimate factors in a sequential order and assumes that all factors have direct effects. Thus, distal and proximal causal factors are treated as being equally distant to the outcome thus underestimating or omitting the effect of these factors (Weitkunat & Wildner 2002). Thirdly, controlling confounding variables in order to predict statistical effects of single factors precludes the study of the complex forces involved in the preservation or breakdown of health or communication function. Other statistical analytical techniques, e.g. multilevel modelling (MM), path analysis and structural equation modelling (SEM), are able to overcome some of these problems (Hays, et al. 2005; Duncan, et al. 1998). MM (Temme, et al. 2008), also known as hierarchical linear modelling (O’Connell & McCoach 2004), provides a framework within which to analyze data which are hierarchical or clustered. The interactions between variables within a level and between levels can be modelled, avoiding the need to aggregate data to a higher level (resulting in loss of statistical power), or disaggregate data to the base level (leading to inflated estimates of significance). MM is capable of demonstrating where and how effects at different levels occur (Duncan, et al. 1998). It is also useful when data are sparse (for example, a minority group only comprises a small percentage of the population) (Weston & Gore, 2006). However, MM is not capable of modelling mediating pathways or latent variables and provides little indication of the overall fit of the model (Hayes & Preacher, 2010). Some of the limitations of MM are the strengths of SEM. SEM and the related technique of path analysis are used to test the plausibility of a complex causal pathways. The temporal ordering between various antecedent variables and an outcome are modelled, and the relative size of each of the pathways between the various antecedent variables and the outcome are assessed. The essential difference between path analysis and SEM is that the former only explores relationships among manifested or observed variables, whereas SEM, in combining path analysis and confirmatory factor analysis, explores relationships among latent variables as well (Lei & Wu, 2007). SEM is able to model measurement error 165

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of the predictor variables and provide an estimate of the overall model fit (Weston & Gore, 2006; Lei & Wu, 2007). Figure II shows a SEM plausible analysis incorporating appropriate antecedent variables and mediators. More specifically, the model includes factors that directly and indirectly impact health both in a contemporaneous and historical context. For example, government policy impacts education directly and in turn impacts health behaviors and subsequently health outcomes indirectly. When compared to multiple regression techniques, path analysis and SEM have several advantages. First, variables are analyzed simultaneously in the sequence of their operating order, allowing factors to have direct and indirect influences on the outcome. Second, theoretically important variables can be are retained (Heck, 2001). Third, the model has many possible extensions allowing for additional factor exploration. Finally, SEM allows for the inclusion of latent variables thereby reducing the likelihood of regression dilution (Temme, et al. 2008; Hays, et al. 2005; Heck 2001)

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Figure 2.

While preferable to traditional techniques, these models are not without their limitations. Like all statistical models, SEM and path analysis are only as good as the hypothesized framework, which is inevitably more simplistic than real life processes (Newton & Bower, 2005). Unlike MM, SEM and path analysis still involve reducing complex social phenomena to individual attributes in the analysis process. Additionally, all the variables used in SEM and path analysis, particularly the outcome measures, should be continuous and normally distributed. While dichotomous variables are acceptable in practical application if they are exogenous, researchers often find it necessary to create different SEMs for dichotomous classification such as male and female to overcome the problem of the dichotomous variable of sex. Programs vary both in their flexibility of models that can be fitted and the range of data types that can be accommodated (Heck, 2001).

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CONCLUSIONS Identifying and understanding outcome disparities in health and specifically communication disorders is an important first step toward improving health equity and reducing disparities among marginalized populations. While addressing the causes of health disparities can be challenging, identification of health inequities and the populations where they exist is an important step in the establishment of population health. Oftentimes health disparities and the factors underlying them may exist at different organizational levels (e.g., individual, family, neighborhood), establishing a complete conceptualization that acknowledges each of the underlying associations enables research to appropriately frame the analysis. The processes that generate the disparities may include complex, dynamic relationships that traditional statistical models represent poorly. These complexities often require the integration of various analytic methods and designs, multilevel approaches, and complex systems modeling techniques to advance disparities research and identify approaches to mitigate them.

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Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012). The quality implementation framework: A synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50(3-4), 462–480. doi:10.100710464-012-9522-x PMID:22644083 Miller, G. E., Chen, E., Fok, A. K., Walker, H., Lim, A., Nicholls, E. F., Cole, S., Kobor, M. S., & Singer, B. H. (2009). Low early-life social class leaves a biological residue manifested by decreased glucocorticoid and increased proinflammatory signaling. Proceedings of the National Academy of Sciences of the United States of America, 106(34), 14716–14721. doi:10.1073/pnas.0902971106 PMID:19617551 Moher, D., Glasziou, P., Chalmers, I., Nasser, M., Bossuyt, P., Korevaar, D. A., Graham, I. D., Ravaud, P., & Boutron, I. (2016). Increasing value and reducing waste in biomedical research: Who’s listening? Lancet, 387(10027), 1573–1586. doi:10.1016/S0140-6736(15)00307-4 PMID:26423180

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Seeman, T., Epel, E., Gruenewald, T., Karlamangla, A., & McEwen, B. S. (2010). Socio-economic differentials in peripheral biology: Cumulative allostatic load. Annals of the New York Academy of Sciences, 1186(1), 223–239. doi:10.1111/j.1749-6632.2009.05341.x PMID:20201875 Sharma, S., Briley, P. A., Wright, H. H., Perry, J. A., Fang, X., & Ellis, C. (2019). Gender differences in aphasia outcomes: Evidence from the AphasiaBank. International Journal of Language & Communication Disorders, 54(5), 806–813. doi:10.1111/1460-6984.12486 PMID:31257676 Shivayogi, P. (2013). Vulnerable population and methods for their safeguard. Perspectives in Clinical Research, 4(1), 53–57. doi:10.4103/2229-3485.106389 PMID:23533983 Shortell, S. M. (1999). The emergence of qualitative methods in health services research. Health Services Research, 34(5 Pt 2), 1083–1090. PMID:10591274

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Tung, J., Barreiro, L. B., Johnson, Z. P., Hansen, K. D., Michopoulos, V., Toufexis, D., Michelini, K., Wilson, M. E., & Gilad, Y. (2012). Social environment is associated with gene regulatory variation in the rhesus macaque immune system. Proceedings of the National Academy of Sciences of the United States of America, 109(17), 6490-6495. 10.1073/pnas.1202734109 Turrell, G., Lynch, J. W., Leite, C., Raghunathan, T., & Kaplan, G. A. (2007). Socioeconomic disadvantage in childhood and across the life course and all-cause mortality and physical function in adulthood: Evidence from the Alameda County Study. Journal of Epidemiology and Community Health, 61(8), 723–730. doi:10.1136/jech.2006.050609 PMID:17630374 U.S. Department of Health and Human Services. (2012). 2012 National Health Interview Survey (NHIS) Public Use Data File and Documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2012/srvydesc.pdf

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Von Korff, M., Koepsell, T., Curry, S., & Diehr, P. (1992). Multi-level analysis in epidemiologic research on health behaviors and outcomes. American Journal of Epidemiology, 135(10), 1077–1082. doi:10.1093/ oxfordjournals.aje.a116207 PMID:1632420 Wallentin, M. (2018). Sex differences in post-stroke aphasia rates are caused by age. A meta-analysis and database query. PLoS One, 13(12), e0209571. doi:10.1371/journal.pone.0209571 PMID:30571747 Weitkunat, R., & Wildner, M. (2002). Exploratory causal modeling in epidemiology: Are all factors created equal? Journal of Clinical Epidemiology, 55(5), 436–444. doi:10.1016/S0895-4356(01)00507-8 PMID:12007545 Weston, R., & Gore, P. A. Jr. (2006). A brief guide to structural equation modeling. The Counseling Psychologist, 34(5), 719–751. doi:10.1177/0011000006286345 Weuve, J., Barnes, L. L., Mendes de Leon, C. F., Rajan, K. B., Beck, T., Aggarwal, N. T., Hebert, L. E., Bennett, D. A., Wilson, R. S., & Evans, D. A. (2018). Cognitive Aging in Black and White Americans: Cognition, Cognitive Decline, and Incidence of Alzheimer Disease Dementia. Epidemiology (Cambridge, Mass.), 29(1), 151–159. doi:10.1097/EDE.0000000000000747 PMID:28863046 Whitehead M. (1992). The concepts and principles of equity and health. International Journal of Health Services: Planning, Administration, Evaluation, 22(3), 429–445. doi:10.2190/986L-LHQ6-2VTE-YRRN Williams, D. R. (1999). Race, socioeconomic status, and health. The added effects of racism and discrimination. Annals of the New York Academy of Sciences, 896(1), 173–188. doi:10.1111/j.1749-6632.1999. tb08114.x PMID:10681897 Williams, D. R., & Jackson, P. B. (2005). Social sources of racial disparities in health. Health Affairs, 24(2), 325–334. doi:10.1377/hlthaff.24.2.325 PMID:15757915 Winker, M. A. (2004). Measuring race and ethnicity: Why and how? Journal of the American Medical Association, 292(13), 1612–1614. doi:10.1001/jama.292.13.1612 PMID:15467065 Wolffe, A. P., & Matzke, M. A. (1999). Epigenetics: Regulation through repression. Science, 286(5439), 481–486. doi:10.1126cience.286.5439.481 PMID:10521337

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ADDITIONAL READING Baum, F., & Friel, S. (2017). Politics, policies and processes: A multidisciplinary and multimethods research programme on policies on the social determinants of health inequity in Australia. BMJ Open, 7(12), e017772. doi:10.1136/bmjopen-2017-017772 PMID:29273655 Berkman, L., & Kawachi, I. (Eds.). (2000). Social epidemiology. Oxford University Press. Bulatao, R. A., & Anderson, N. B. (Eds.). (2004). Understanding racial differences in health in late life: A research agenda. The National Academies Press.

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Guise, J. M., Chang, C., Butler, M., Viswanathan, M., & Tugwell, P. (2017). AHRQ series on complex intervention systematic reviews—paper 1: An introduction to a series of articles that provide guidance and tools for reviews of complex interventions. Journal of Clinical Epidemiology, 90, 6–10. doi:10.1016/j. jclinepi.2017.06.011 PMID:28720511 Jeffries, N., Zaslavsky, A. M., Diez Roux, A. V., Creswell, J. W., Palmer, R. C., Gregorich, S. E., Reschovsky, J. D., Graubard, B. I., Choi, K., Pfeiffer, R. M., Zhang, X., & Breen, N. (2019). Methodological approaches to understanding causes of health disparities. American Journal of Public Health, 109(S1), S28–S33. doi:10.2105/AJPH.2018.304843 PMID:30699015 Lohr, K. N., & Steinwachs, D. M. (2002). Health services research: An evolving definition of the field. Health Services Research, 37(1), 7–9. PMID:11949927 Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012). The quality implementation framework: A synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50(3–4), 462–480. doi:10.100710464-012-9522-x PMID:22644083 Williams, D. R., & Jackson, P. B. (2005). Social sources of racial disparities in health. Health Affairs, 24(2), 325–334. doi:10.1377/hlthaff.24.2.325 PMID:15757915 Winker, M. A. (2004). Measuring race and ethnicity: Why and how? Journal of the American Medical Association, 292(13), 1612–1614. doi:10.1001/jama.292.13.1612 PMID:15467065

KEY TERMS AND DEFINITIONS

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Health Disparities: Higher burden of illness, injury, disability experienced by one group of individuals relative to another. Race/Ethnicity: The self-identified race and ethnic group of individuals. Research: Systematic work designed to increase knowledge. Social Environment: The physical and social setting in which individuals live. Socioeconomic Status: The measure of an individual’s economic and social position in relationship to others. Study Design: The methods and procedures used to collect and analyze data on variables specific to a research question. Vulnerable Populations: Population groups that are at greater risk for poorer health, less healthcare access and who experience disparities in life expectancy.

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Chapter 9

An Unequal Partnership: Communication Sciences and Disorders, Black Children, and the Black Speech Community Brandi L. Newkirk-Turner Jackson State University, USA Lekeitha R. Morris Lamar University, USA

ABSTRACT

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This chapter addresses what Rickford referred to as an unequal partnership between researchers and the researched. In this chapter, Rickford’s assertion of an unequal partnership within the feld of sociolinguistics is extended to the feld of communication sciences and disorders (CSD). A summary of the CSD literature on the Black speech community identifes shortcomings, leading the authors to argue that more can be done to equalize the partnership between CSD researchers and the Black speech community. The authors make the case for the establishment of service-in-return as a general principle of CSD research – especially when the researched community is a minority, marginalized, or underserved community. Ideas of ways that researchers can give back to the researched communities are provided. The authors also suggest ways that researchers can foster a sense of civic responsibility in student researchers in order to usher in a new generation of researchers who are more committed than past generations to equalizing the partnership between researchers and researched communities.

Ms. Helen introduced me to the students by saying: Remember I told you all about Ms. Baker-Bell? She’s here from Michigan State University and will be working with us for a few months on a project about language. She’s not like those other people—you know the ones that I’m talking about. They come watch us and then we never see them again. Ms. Baker-Bell is not like that; she’s good! The “other DOI: 10.4018/978-1-7998-7134-7.ch009

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 An Unequal Partnership

people” that Ms. Helen was referring to are the “hit it and quit it” researchers that enter into schools and classrooms, collect data, and bounce. -Linguistic Justice April Baker-Bell (2020, p. 93).

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INTRODUCTION This chapter provides us with the opportunity to discuss and provide suggestions for how to remedy the unequal partnership between researchers in communication sciences and disorders and the Black speech community with a specific focus on Black children. This has been a growing concern for the two authors since the time that we were doctoral students in the early 2000s. At that time, we discovered Rickford’s 1997 article, Unequal Partnership: Sociolinguistics and the African-American Speech Community. As doctoral students working in a research lab that focused on Black children’s language, we awakened to racial disparities in the research literature and research culture in our field. We were becoming aware that White scholars were studying Black children and their families with seemingly no regard or concern for them. With our very own eyes and ears we were witnessing the “hit it and quit it” phenomena. We were also feeling convicted that for most of our years as doctoral students, we spent our time in a research lab studying Black children’s language but had very few opportunities to interact with Black children and their families as part of our work. In a sense, we felt isolated and cut off from the population that we studied and feared that we were becoming complicit in perpetuating an unequal partnership within our own community. A little less than 20 years later as we write this article, we are isolated for a different reason -- the COVID-19 pandemic, a world health crisis that in our country, is disproportionately affecting Black Americans and keeping people socially distant. While the pandemic is still raging, Black Americans are in the center of another pandemic (i.e., a pandemic within a pandemic; Sanders, 2020) -- racial injustice and violence, most notably marked by the killings of George Floyd, Ahmaud Arbery, and Breonna Taylor in 2020. At the same time that Black Americans are experiencing a pandemic within a pandemic, they are watching White Americans go undetected and unpunished for unimaginable actions associated with the capital “insurrection” (Mogelson, 2021). This being what many have considered to be the ultimate signs of White privilege and the racial injustice in our society (Glanton, 2021; Inskeep, 2021). So, we write this chapter at a time when Black Americans are in the midst of an unprecedented health crisis, physical and mental harm, and racially unjust treatment. It is within this current context that we find the courage and boldness to write about the seeming exploitation of Black children in research in our field, Communication Sciences and Disorders (CSD). This chapter, inspired by Rickford (1997) will address what he referred to as an unequal partnership between researchers and the participants and what Baker-Bell (2020) contemporarily refers to in the introductory quote as “hit it and quit it” research. In this chapter, we extend Rickford’s assertion of an unequal partnership within the field of sociolinguistics to the field of CSD. To build our argument, we begin by discussing some key events in the history of research on African American English (AAE) in the field of CSD. In doing this, we discuss how child speakers of AAE, have gone from invisible to deficient to different to an unequal partner in the narratives of their communication behaviors. A summary of the CSD literature on AAE will identify shortcomings of the existing literature and more broadly in the field, leading us to argue that the Black speech community has been underserved and that more can be done 181

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in the CSD field to equalize the partnership between researchers and the Black speech community. We make the case for the establishment of service-in-return as a general principle of CSD research – especially when the researched community is a minoritized, marginalized or underserved community. We provide ideas of ways that researchers can give back to the researched communities through activities that relate to CSD and through activities that do not. We also suggest ways that researchers can foster a sense of civic responsibility in student researchers in order to usher in a new generation of researchers who are more committed than past generations to equalizing the partnership between researchers and researched communities.

BACKGROUND

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A Brief Overview of Research on Black Children in CSD Research on Black children’s speech and language began in the mid 1960s when the empirical works of linguists such as Stewart (1964), Shuy (1965) and Labov (1966) established the rule-governed nature of Black children’s language. Prior to their work, the prevailing thoughts about Black children’s language was influenced by deficit theory. Deficit theory assumed that Black children were incapable of learning language like other children due to an inadequate linguistic model provided by parents deemed to have intellectual deficiencies (Bereiter & Englemann, 1966; Deutsch, 1964). During the next two decades, important research on Black children’s language by Black scholars such as Ida J. Stockman, Fay Vaughn-Cooke, Patricia Cole, Lorraine Cole, Ceil Kovac, Harry Seymour, Margaret Steffenson, and Orlando Taylor was conducted and published. These scholars’ studies were revolutionary in that they deviated from the status quo and challenged the unfounded claim that deficit theorists advanced in the 1960s. Importantly, these scholars introduced new research paradigms to the field that would guide the study of Black children’s language in the subsequent decades. Despite these advances, many White scholars in the field continued to struggle with how to think about Black children’s language. Unsure of how to conceptualize Black children’s language, some White scholars made decisions to exclude the speech and language data of Black children from their research studies in CSD because of the perceived noise (Stockman, 2007) that their language introduced in the data. This practice of excluding Black children in research on speech and language disorders rendered Black children essentially invisible in the literature (Seymour, 1992). The early practice of exclusion has certainly limited what is currently available in the literature about Black children’s speech and language but the last several decades have seen numerous studies published, adding to our body of knowledge. Stockman (2010) reported that between 1970 and 2008, Language Speech, and Hearing Services in Schools (LSHSS) alone published more than 110 papers with titles focused on Black language and cultural issues inclusive of AAE. Her paper summarized developments in language acquisition, assessment, and intervention issues. More recently, Horton, Johnson and Koonce (2018) conducted a cross-disciplinary review of 289 articles published in the last 40 years that focused on Black children’s language. Included in their review were 53 articles published in American SpeechLanguage Hearing Association (ASHA) journals. Their analyses revealed that published research has four major focus areas: language development, awareness/policy, instruction/AAE/reading interference, and assessment. Aside from published research articles such as those included in the studies of Stockman

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(2010) and Horton, Johnson, and Koonce (2018), numerous books, videos, doctoral dissertations, master theses, and presentations have also had a focus on Black children’s speech and language. CSD has learned much from linguistic studies about the Black speech community and their useful descriptive, theoretical, and methodological approaches to language acquisition. Work in CSD on the communication of Black speakers has been used to demonstrate the structured variability and rule-governed nature of AAE, to improve our understanding of the relationship between language and various sociolinguistic constructs, to test theories of language acquisition and development, to develop dialect-neutral assessment tools, and to test new approaches to instruction and intervention. There have been personal career gains from studies of the Black speech community too. Indeed, research agendas focused on the Black speech community has fueled the careers of many CSD scholars over the years -- certainly those who are Black but increasingly, those who are not Black as well.

Shortcomings of CSD Research on Black Children In his article, Unequal Partnerships: Sociolinguistics and the African American Speech Community, Rickford (1997) argued that in comparison to the contributions of the Black speech community to fields that study language, considerably less has been given in return to the Black speech community. Rickford highlighted three areas in which there is an unequal partnership between the field of sociolinguistics and the Black speech community: the lack of induction of African Americans into linguistics; the inaccurate presentation of AAE in the literature; and the lack of sustained involvement with communities after their research involvement. In the next section, we discuss three areas. The issues that we have identified and will discuss differ slightly from Rickford’s and include: the lack of induction of African Americans into CSD, the cyclical nature of research on issues related to Black children, and the lack of sustained involvement with the Black speech community after their research involvement. We will provide an extended discussion of the lack of researchers’ sustained involvement with the Black speech community after the completion of the participants’ research involvement.

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The Lack of Induction of Black People into CSD The CSD field has been described as one of the whitest fields in the United States (Thompson, 2013). In the most recent year (2019-2020), approximately 31% of CSDs undergraduate students were from an ethnic/racial minority background. In that same year, just 23.3% of SLP graduate students and 18.6 of AuD students were from an ethnic/racial minority background. The representation of people from ethnic/racial minority backgrounds drops even more at the professional level where only about 8% of CSD professionals are from a non-white background (ASHA, n.d.). These percentages reflect problems in at least three areas. The first is a problem attracting and recruiting students of color into CSD fields. Students are often attracted to fields in which they can see themselves represented so fields like CSD that lack diversity have a hard time attracting diverse students (Rodriguez, 2016). The second problem is learning environments that reflect and cater to a homogeneous student population (Dewsberry & Brame, 2019). There is increasing evidence emerging that the learning environments in CSD programs are not always nurturing and inviting to non-white students (Ginsberg, 2018a; Ginsberg, 2018b;Yeager et al., 2014). Instead they have been reported to be lonely, isolating, and breeding grounds for micro-aggressions. Studies in the literature have documented that the educational experiences of Black students in CSD programs tend to include social isolation, uncomfortable interac183

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tions with faculty and staff members, microaggressions, and overt racism (Ginsberg, 2018a; Ginsberg, 2018b). The third issue is a pipeline problem. As the data show, between undergraduate programs to induction into the profession, a large percentage of non-white students leave the chosen field of study and do not go on to enter the profession as a speech-language pathologist or audiologist (ASHA, 2020). The same is true of the pipeline to the professoriate and doctoral-level academic positions for non-white people. According to ASHA’s most recent profile of ASHA Members (2019), approximately 85% of ASHA members that have a Ph.D. and work at colleges or universities are White. Less than 6% are Black or African American (ASHA, 2019). These three issues converge to result in a field of study that is among the whitest in America on all levels of schooling (undergraduate and graduate), in professional practice, and in the academy.

Cyclical Nature of Research on Issues Related to Black Children’s Speech and Language As previously discussed, CSD research on Black children began to gain momentum in the late 1970s and since that time, hundreds of articles have been published. In a span of 50 years, it is reasonable for a field of study to make significant gains in the knowledge base. Certainly, the CSD field has made notable progress in the study of Black children as comprehensively noted by Stockman (2010) and Horton et al. (2018). These articles and others have also identified gaps in the literature, which include research on the developmental path of AAE, intervention, adolescents’ language, and written language performance (Horton et al., 2018; Newkirk-Turner & Green, 2021; Stockman, 2010). Arguably, these gaps remain largely unaddressed. In fact, recent critical analyses of research on Black children have led scholars to describe the body of work in the CSD field as cyclical or zig-zag in nature (See Green, 2017 as an example). Horton et al. (2018) reiterated this point by describing the research literature on child AAE in CSD as reflecting a zig-zag pattern (e.g., here, there, back again). They noted that “we seem to be revisiting paradigms and frameworks that have not really been successful in making an impact” (p. 65). While work that is cyclical or repetitive in nature can be useful to corroborate or replicate the findings of previous studies, it cannot move the field of study forward to advance new knowledge, innovate, or discover what is not yet known (Green, 2017). When a field finds itself in this type of pattern of work, its impact in theory and practice will be minimal.

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The Lack of Sustained Researcher Involvement with Communities After Research Returning to the opening excerpt from Baker-Bell (2020), Ms. Helen’s comments to her students help us to see how our research participants may come to view researchers. Ms. Helen and her students had grown accustomed to researchers who were not fully committed to the research partnership. They were accustomed to researchers who came in, collected their data, and “bounced” (left). Our own experiences as doctoral students lead us to know that Ms. Helen’s students’ experience with researchers is not an anomaly. It is not uncommon for researchers to visit schools and classrooms, collect their data, and move on to the next school to do the same thing in an effort to meet their timelines and deadlines. Based on our experiences and those of others, we suspect that the researchers that Ms. Helen’s students were skeptical about are more common than not in the CSD field. Our assertion of an unequal partnership between the Black speech community and CSD is not limited to our own experiences. The events of 2020 – the pandemic within a pandemic – clearly revealed the 184

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unequal partnership between the CSD field and the Black speech community. After the George Floyd murder, in response to increased advocacy, activism, and demands for justice, many professional organizations and companies followed the public interest and issued statements denouncing racism. ASHA was one of the professional organizations that issued a statement about racism at the end of May 2020 following the murder of George Floyd. The organization’s message was widely interpreted to be one that did not clearly or explicitly denounce systemic racism and injustice or harm towards Black Americans. In response to the overwhelming and sharp rejection of the statement by the membership, the ASHA CEO sent out an email on behalf of the organization that in part, said: Our statement fell short; it was not clear or strong enough, and for that we apologize. We missed the mark, and we let you down. We have heard from many members about the pain this message has caused, and we want to do better. We will do better, to support members and those they serve, and to commit individually and collectively, to build bridges, and to speak out against systemic and institutional racism (A. Pietranton, personal communication, June 2, 2020). This email, which was followed by a revised statement, put into words the unequal partnership that the CSD field has had with Black people, including the Black speech community, which has been the backbone of a great portion of CSD research concerned with language diversity. Despite the contributions of the Black speech community to the CSD field, ASHA has -- in its own words -- “missed the mark” (Pietranton, 2020). Therefore, our assertion of an unequal partnership is not merely a hunch. It is supported by ASHA’s words, our experiences and the experiences of others, statistics that show the lack of significant induction of Black people into the field, the cyclical nature of research, and a “hit it and quit it” approach to research. In the section that follows we focus specifically on the “hit it and quit it” research approach or the lack of sustained involvement with communities after research. We argue for the establishment of service-in-return as a general principle of CSD research – especially when the researched community is Black or a minoritized, marginalized or underserved community.

FUTURE RESEARCH DIRECTIONS

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Equalizing the Partnership by Adopting a Principle of Service-In-Return Data on the Black speech community has been valuable to the theoretical and applied research advances that we have made in the field of CSD over the last 50 years. To move towards filling some of the gaps identified by Stockman (2010), Horton et al. (2018) and Newkirk-Turner and Green (2021), we need the data of the Black speech community, especially children, so our work with this speech community should not stop. We should continue to include the data of the Black speech community in our studies, but our work must be guided by a different framework and different rules of engagement. The framework that we are proposing aligns with Labov’s “principle of the debt incurred.” Labov argued that “an investigator who has obtained linguistic data from members of a speech community has an obligation to use the knowledge based on that data for the benefit of the community, when it has need of it” (1982, p. 173). Rickford (1997) expounded on this principle by suggesting that researchers should require themselves and their students one hour of community service and applied work for every hour of recorded speech or language data collected, or every hour spent on transcribing, coding, or analyzing for theoretical and 185

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descriptive purposes. We agree with this suggestion and here, we frame this idea as service-in-return as a general principle of conducting research with Black, minoritized, marginalized, and underserved communities. This principle involves the researcher’s responsibility of creating a reciprocal relationship, building true partnerships between communities and researchers, and fostering a sense of civic responsibility in students who engage in research. The primary reason for advocating for a service-in-return principle of conducting research is that we have a professional responsibility and owe it to the people whose data have fueled our theories, research, and careers. We agree with Labov (1982) that after our data are collected, we have an obligation to use our knowledge and skills to benefit the speech community that participated in our work. Fortunately, there is increasing value being placed on partnerships between higher education and surrounding communities. Regional accrediting bodies for higher education institutions are showing greater recognition of the benefits of community engagement and have begun to include this as part of their evaluation of an institutions’ quality (Weerts & Sandmann, 2010). Community engagement has been linked to satisfaction with college and an increased likelihood of graduation (Yamauchi et al., 2016). Service to the community also increases a university’s visibility in that community, allowing institutions to have more impact in becoming an agent of change in the areas in which they are located (Driscoll et al., 1996). Positive university-community relationships are more likely to form when members of the university have demonstrated sustained interest and engagement in that community. Moreover, the interactions between the university and the community may also be an opportunity to recruit and help students make contacts with potential employers. These noted benefits have led to institutions becoming more committed to its internal constituents engaging with communities external to the university (Hatcher & Bringle, 1997). Researchers can play a critical role in facilitating stronger community engagement at their universities. Adopting a service-in-return principle will help foster trust between the university and its researchers and the Black speech community. When authentic partnerships are established, the Black speech community will be more likely to participate and trust that the research will not be exploitative in nature. True partnerships will help research participants trust the intentions of the researchers and feel more confident that their involvement will positively impact their community. A concerted effort by researchers is needed to create a more balanced relationship between researchers and the communities that they research and to ensure that the CSD field is providing service-in-return for the data that are collected. Following Rickford (1997), to do this, we propose two categories of service that can be provided in return for the data we receive from speech communities: service that draws on our expertise as professionals and service that has no direct relation to the profession but can be useful to the community.

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Service That Draws on Our Expertise as CSD Professionals First, activities that draw on our expertise and involvement as CSD professionals allow us to give back in ways that have the potential to improve the outcomes or experiences of Black children and families. In this section we provide suggestions in six areas: 1) creating service-learning courses, 2) recruiting and retaining Black students in the field, 3) providing teacher trainings in language and literacy enrichment strategies, 4) collaborating with teachers in the classroom or co-teaching, 5) educating teachers about AAE and 6) conducting speech, language, hearing screenings.

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Create Service-Learning Courses

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Researchers can be more intentional about adopting a service-in-return principle in their research programs by transitioning their traditional courses to service-learning courses in their departments. Service-learning is a rigorous, reciprocal, reflective pedagogical technique that fosters student engagement, improves retention, strengthens civic responsibility, and promotes critical thinking by coupling student learning outcomes with identified needs of the community (Procario-Foley & Van Cleave, 2016; Strait et al., 2015). Additionally, service-learning allows students to learn from each other through reflection in real life experiences as opposed to contrived scenarios. It also has been shown to increase student motivation which impacts student learning positively (Bryant & Hunton, 2000). A growing body of literature recognizes service-learning as an effective strategy to promote stronger analytical skills in students while also helping them learn empathy, facilitate racial awareness and sensitivity, and solidarity with marginalized communities (Van Cleave, 2013; Van Cleave & Cartwright, 2017). Service-learning has also been shown to help reinforce professional ethics such as social responsibility, personal integrity, and respect for individuals (Veyvoda et al., 2020). Strait et al. (2015) describes four different types of service projects for service-learning which include direct service, indirect service, community-engaged research, and advocacy and public awareness. Direct service-learning is perhaps the most rewarding and involves working face to face with individuals and organizations to address a community need that directly affects the population. Students get instantaneous feedback which then they can reflect on as part of the curriculum. As the title suggests, indirect service-learning projects seek to help community members indirectly. In these opportunities, students work to improve the life for the community as whole without targeting individuals for assistance. Similar to indirect, community-engaged research does not require students to engage directly with the population an organization serves, but rather students use research design and data collection to answer a question raised by the community partner that is related to learning outcomes of the course. Although research is being done, the purpose of the research is generated by the community members or organization. Students are engaged in investigating and creating a solution to the problem and may also present their findings to an organization that can carry on the work they have started to benefit the community. Finally, students may engage in service learning through advocacy and public awareness campaigns in which they take a stand to solve a known problem or increase public awareness. This type of service learning promotes policy or legislative change and the focus is on articulating solutions clearly and convincingly. Table 1 provides definitions and examples of activities that may be integrated into the curriculum as servicelearning opportunities as a way for CSD researchers to add a service-in-return component to their courses.

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Table 1. Types of service-learning, definitions, and examples (Strait et al., 2015). Name

Direct Indirect Community engaged research Advocacy and public awareness

Definition

Examples

Working directly with individuals and organizations to address a community need Working indirectly with individuals and organizations to address a community need Collecting, analyzing, and/or implementing qualitative and quantitative data to address a community need Planning, conducting, and/or creating awareness initiatives and events to address a community need

Speech, language, hearing screenings in the community; tutoring; serving meals to the homeless; helping parents complete job applications; spending time with older adults in local nursing homes Getting involved in building or renovation projects; working in soup kitchens; litter pick up at a local park; creating promotional materials for local organization; creating community garden; providing on-site children’s activities for local health fair Analyzing an organization’s survey results to evaluate the effectiveness of their program; compiling facts about the organization’s history; creating an assessment tool to poll community opinions about a specific issue Legislation day at the state capitol; writing letters to local politicians; workshops with community leaders; on campus forum that addresses systemic inequities facing members of the Black speech community

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Recruit, Retain, and Support Black Students in the Field Data from ASHA (2020) Thirty-one percent of CSD undergraduates are from an ethnic/racial minority background; approximately 4% of students offered admission to speech-language pathology programs were African American and only three percent of certified speech-language pathologists identify as Black. These data suggest that there are fewer Black students in our graduate programs than in the undergraduate programs and even fewer are certified speech-language pathologists. Several researchers have described strategies related to recruitment, admissions, advising, retention, mentoring, and anti-racist pedagogy that can be used to increase the number of Black students and in turn, yield more Black CSD professionals (Lilienfield, 2017; Nadal et al., 2014; Newkirk-Turner et al., 2017; Wilbur et al., 2020). Purposeful and effortful recruitment and retention activities will raise awareness of the field among Black students, while increasing the number of those inducted into CSD. To introduce more people to the field, researchers can participate in career days at schools in the community, allow students to shadow them and attend their classes, guest lecture in high school classes on topics related to communication, or attend career fairs. To support the admission and retention of students who are in CSD programs, researchers can assist students with personal statements by proof-reading and giving feedback, accompany students on graduate school visits, connect students to tutors or peer support groups, serve as a mentor or connect students to potential mentors. To better support the success of Black students in CSD programs, researchers can connect students to outside resources, teach students new study strategies, provide a quiet place for studying, serve as an accountability partner, send weekly inspirational messages, or do other things that show support of the student and the researcher’s desire for them to be successful. Another way for researchers to show support for students is to value their ideas and create academic spaces and

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opportunities for students to explore questions, write about and present those ideas to their peers or to the wider scholarly community. These acts of service show that the researcher believes in and is committed to cultivating the students’ growth as a professional. Provide Teacher and Parent Trainings in Language and Literacy CSD researchers play a significant role in language and literacy development. Given our knowledge in language and literacy, CSD researchers can facilitate training and professional development programs for educators to increase the emergent and later literacy skills of children who are vulnerable for academic failure. Teacher training workshops and individual coaching can be provided throughout the academic year and can focus on topics including developmental and academic milestones and ways to facilitate children’s language and literacy development in the classroom. Through a sustained relationship with teachers, the CSD researcher can monitor for additional needs and then work collaboratively with the teacher to address them. In similar ways, CSD researchers can conduct trainings with parents in groups or in individual settings. Morris (2010) found that Black caregivers increased their use of facilitative language and literary behaviors following a training program so there is evidence that these types of activities benefit members of the Black speech community. Researchers can partner with Head Start or other preschool programs to participate in their family literacy night or writing a monthly newsletter for parents regarding tips for facilitating language and literacy. The authors also recommend that CSD researchers consider attending a school’s open house or meet-the-teacher event to provide parent education materials and tips on facilitating language and literacy development. CSD researchers are encouraged to collaborate with faith-based organizations, local health departments, and pediatrician offices to provide workshops and educational pamphlets for the lobby and waiting areas regarding language and literacy development (Cousins et al., 2008; Hankerson et al., 2018). Collaborate with Teachers in the Classroom or Co-Teach As a way of giving back, CSD researchers can collaborate with teachers in the classroom to provide explicit instruction to the students in the areas of language and literacy. A co-teaching model can be used or the researcher can be assigned to work with smaller groups of children who need additional support. By engaging and being present in the classroom, the CSD researcher can model strategies that facilitate language and literacy development and be available to support the teacher. There are several models for co-teaching approaches in the literature. See Justice and Kaderavek (2004) and Nelson and VanMeter (2006) for examples.

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Educate Teachers About African American English Research suggests that teachers’ perceptions and expectations of children have a direct influence on educational outcomes and it has been documented that teachers have misconceptions about the Black speech community and AAE (Hudley & Mallinson, 2011; Newkirk-Turner et al., 2013; Smitherman, 1997; Wheeler, 2008). For example, teachers and pre-service teachers who have negative views of AAE have been shown to be more likely to give lower ratings on reading and writing assignments of students who speak AAE and have lower academic expectations for them (Gupta, 2010; Newkirk-Turner et al., 2013). Because very few teachers report having academic training or continuing education on AAE (Diehm & Hendricks, 2021), CSD researchers can play a role in educating teachers about AAE and debunking myths

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about it. We can use our expertise explicitly to teach educators about the rule-governed nature of AAE and its status as a legitimate system of communication. Fogel and Ehri (2006) found that by increasing teachers’ knowledge of the complexity of AAE, teachers increased their positive attitudes toward AAE. Another way that researchers can support teachers of Black children is to help stock classroom libraries with books and materials that include Black characters, have positive representations of Black culture, and appropriately represent Black speech. By doing these things, CSD researchers can help to create more accepting classrooms and learning environments for Black children. Additionally, CSD researchers can develop and advocate for resources and training in culturally responsive and relevant teaching to empower students intellectually, socially, emotionally, and politically (Ladson-Billings, 2009). Conduct Speech and Language Screenings Limited access to health care services decreases the likelihood that Black students with language and/or learning disorders will receive the early intervention services they need (Morgan, et al. 2015). Professionals in CSD can be instrumental in helping to ensure that these children are identified early by performing free hearing, speech, and language screenings in the local community at preschools, churches, and homeless shelters. The results of the screening can be shared with the parents along with educational materials regarding speech and language developmental milestones, facilitative techniques, and suggestions about activities that promote optimal development. The CSD researcher can also be available to go over the materials and provide the parents with an opportunity to ask questions. For children who show signs of a communication disorder, the researcher can provide resources for additional testing and services.

Activities that Have Little or No Direct Relation to Communication Sciences and Disorders

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Provide Community Service Across CSD departments, there are more than 340 National Student Speech Language Hearing Association chapters (NSSHLA, 2001). Researchers can work with these student organizations to plan community service events that will directly benefit research participants in the Black speech community. For example, the organization can partner with local restaurants to arrange for proceeds on a given day to be donated to an organization that supports children or families in the Black speech community (e.g., community centers, summer programs, vacation Bible schools). Students can also initiate a book drive for the school in which the researcher collects data or gather items for garage sales and donate the funds to organizations that work to support the Black speech community. Students can also volunteer in classrooms and after-school programs to work directly with children. In addition to giving back to the Black speech community, these experiences can foster a sense of pride, personal growth, and increased cultural awareness for researchers and students. Become a Financial and Informational Resource Helping to meet financial or resource needs is another way to give back. For example, researchers can sponsor field trips for kids who are unable to attend because of limited resources, can sponsor classroom parties, or can create a scholarship fund at the school, church or a recreational or educational center. Researchers can use their skills in writing and math to join initiatives that help members of the commu-

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nity complete job applications, to proof-read scholarship essays, or to complete financial aid documents. Researchers can use their expertise to share information about communication and cognitive wellness and health. For example, in the current pandemic, researchers can participate in webinars to share information about preventing the spread of the virus among students with communication and learning challenges. Another idea is that researchers can connect community members to resources and support offered by the university (e.g., informational webinars, give-aways, free leisure courses). In sum, CSD researchers have many ways in which they can implement a service-in-return principle in their research programs. The in-field activities that are more closely aligned with our professional scope of practice have obvious benefits, however the latter are just as relevant and impactful. A benefit of the out-of-field activities is that they may have more immediate impacts on the community. Both types of activities, though, provide viable ways that researchers can adopt a service-in-return component to their research programs and cultivate a sense of civic responsibility in their student researchers.

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CONCLUSION Our chapter began with our own personal experiences that led us to think more deeply about our responsibilities as researchers. Our convictions have prompted us to seek out a better path for ourselves and other researchers. We believe that researchers adopting a general principle of service-in-return will foster a stronger connection and investment in the Black speech community. Since becoming independent researchers with our own labs, we both have adopted the service-in-return principle in our work. The first author has maintained a six-year partnership with a local preschool in which the researcher and students provide weekly classroom-based language and literacy enrichment sessions as well as conduct speech and language screenings. Similarly, the second author has maintained ongoing partnerships with libraries, schools, and homeless shelters to work with mothers, individually and in small groups, to support their children’s development in language and literacy. In these experiences, we worked with partners in the community to identify needs and we collaborated with them to address those needs. For example, the services provided in the homeless shelter came about after a community member identified a need. Importantly, in the activities that we are describing, no research data have come from them. The primary goal of the experiences was not to collect data; it was to give back -- or pour into -- a community that has added to our work. Another important goal is to make sure that members of the Black speech community know that there are researchers who are truly vested in the Black speech community and the well-being of its community members. In doing this, we have established service-in-return as a key principle of our work. Importantly, we have become an example of CSD researchers who are committed to being a fountain rather than a drain; never to be described by the kids or the community as the “other people,” but as the researchers who continued to show up even when there were no data to be collected.

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Mogelson, L. (2021, January 15). Among the Insurrectionists. The New Yorker. https://www.newyorker. com/magazine/2021/01/25/among-the-insurrectionists Morgan, P. L., Farkas, G., Hillemeier, M. M., Mattison, R., Maczuga, S., & Cook, M. (2015). Minorities are disproportionately underrepresented in special education: Longitudinal evidence across five disability conditions. Education Research, 44(5), 278–292. doi:10.3102/0013189X15591157 PMID:27445414 Morris, L. R. (2010). Behaviors and beliefs of African American caregivers as related to their children’s language-literacy development (Unpublished doctoral dissertation). Louisiana State University, Baton Rouge, LA. Nadal, K. L., Wong, Y., Griffin, K. E., Davidoff, K., & Striken, J. (2014). The adverse impact of racial microaggressions on college students’ self-esteem. Journal of College Student Development, 55(5), 461–474. doi:10.1353/csd.2014.0051

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National Student Speech Language Hearing Association. (2021). Chapters. https://www.nsslha.org/ chapters/ Nelson, N. W., & Van Meter, A. M. (2006). The writing lab approach for building language, literacy, and communication abilities. In R. J. McCauley & M. E. Fey (Eds.), Treatment of language disorders in children (pp. 383–422). Paul H. Brookes Publishing. Newkirk-Turner, B. L., & Green, L. (2021). Language use and development in third person singular contexts: Assessment implications. Language, Speech, and Hearing Services in Schools, 52(1), 16–30. doi:10.1044/2020_LSHSS-19-00109 PMID:33464987 Newkirk-Turner, B. L., Williams, M. C., Harris, T., & McDaniels, P. E. W. (2013). Pre-service teachers’ attitudes toward students’ use of African American English. The Researcher: An Interdisciplinary Journal, 26, 41–57. Procario-Foley, C., & Van Cleave, T. J. (2016). Curricular infusion of service-learning. In M. A. Levy & B. Polnariev (Eds.), Academic and student affairs in collaboration: Creating a culture of student success (pp. 65–80). Taylor & Francis. Rickford, J. R. (1997). Unequal partnership: Sociolinguistics and the African American speech Community. Language in Society, 26(2), 161–197. doi:10.1017/S0047404500020893 Sanders, S. (2020, August 5). Addressing racism in communication sciences and disorders: Inclusive [Video]. Facebook. https://www.facebook.com/Teaching-and-Learning-in-Communication-SciencesDisorders-945262528903275 Seymour, H. N. (1992). The invisible children: A reply to Lahey’s perspective. Journal of Speech, Language, and Hearing Research: JSLHR, 35(3), 640–641. doi:10.1044/jshr.3503.640 Shuy, R. W. (1965). Social dialects and language learning. National Council of Teachers of English. Smitherman, G. (1977). Talkin and testifyin: The language of Black America. Houghton Mifflin. Stewart, W. A. (1964). Nonstandard speech and the teaching of English. Center for Applied Linguistics.

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Stockman, I. J. (2007). Social–political influences on research practices: Examining language acquisition by African American children. Sociolinguistic variation: Theory, method, and applications, 297-317. doi:10.1017/CBO9780511619496.016 Stockman, I. J. (2010). A review of developmental and applied research language research: From a deficit to a difference perspective on dialect differences. Language, Speech, and Hearing Services in Schools, 41, 23–38. doi:10.1044/0161-1461(2009/08-0086) PMID:20051577 Strait, J., Turk, J., & Nordyke, K. J. (2015). Pedagogy of civic engagement, high-impact practices, and service-learning. In J. Strait & K. J. Nordyke (Eds.), eService-Learning: Creating experiential learning and civic engagement through online and hybrid courses (pp. 7–19). Stylus Publishing. Weerts, D. J., & Sandmann, L. R. (2010). Community engagement and boundary-spanning roles at research universities. The Journal of Higher Education, 81(6), 702–727. doi:10.1080/00221546.2010.11779075 Wheeler, R. S. (2008). Becoming adept at code-switching. Educational Leadership, 65(7), 54–58.

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Wilbur, K., Snyder, C., Essary, A. C., Reddy, S., Will, K. K., & Saxon, M. (2020). Developing Workforce diversity in the health professions: A social justice perspective. Health Profession Education, 6(2), 222–229. doi:10.1016/j.hpe.2020.01.002 Yamauchi, L. A., Taira, K., & Trevorrow, T. (2016). Effective instruction for engaging culturally diverse students in higher education. International Journal on Teaching and Learning in Higher Education, 28(3), 460–470.

ADDITIONAL READING Baker-Bell, A. (2020). Linguistic Justice. Routledge. doi:10.4324/9781315147383 Ellis, C., & Jacobs, M. (2021). The complexity of health disparities: More than just Black-White Differences. Perspectives of the ASHA Special Interest Groups, 6(1), 112–121. doi:10.1044/2020_PERSP-20-00199 Green, L. J. (2011). Language and the African American child. Cambridge University Press. Hankerson, S. H., Wells, K., Sullivan, M. A., Johnson, J., Smith, L., Crayton, L., Miller-Sethi, F., Brooks, C., Rule, A., Ahmad-Llewellyn, J., Rhem, D., Porter, X., Croskey, R., Simpson, E., Butler, C., Roberts, S., James, A., & Jones, L. (2018). Partnering with African American Churches to Create a Community Coalition for Mental Health. Ethnicity & Disease, 28(Suppl 2), 467–474. doi:10.18865/ed.28.S2.467 PMID:30202200 Horton, R., Johnson, V., & Koonce, N. (2018). From Here to There and Back Again: Forty Years of Research on African American Children’s Language. Perspectives of the ASHA Special Interest Groups, 3(14), 57–70. doi:10.1044/persp3.SIG14.57 Meikle, P. A. (2020). The right to breathe: A sociological commentary on racialized injustice, borders and violence. Equality, Diversity and Inclusion, 39(7), 793–801. doi:10.1108/EDI-06-2020-0152 Rickford, J. R. (1997). Unequal partnership: Sociolinguistics and the African American speech Community. Language in Society, 26(2), 161–197. doi:10.1017/S0047404500020893

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Stockman, I. J. (2007). Social–political influences on research practices: Examining language acquisition by African American children. Sociolinguistic variation: Theory, method, and applications, 297-317. doi:10.1017/CBO9780511619496.016 Stockman, I. J. (2010). A review of developmental and applied research language research: From a deficit to a difference perspective on dialect differences. Language, Speech, and Hearing Services in Schools, 41, 23–38. doi:10.1044/0161-1461(2009/08-0086) PMID:20051577 Strait, J., Turk, J., & Nordyke, K. J. (2015). Pedagogy of civic engagement, high-impact practices, and service-learning. In J. Strait & K. J. Nordyke (Eds.), eService-Learning: Creating experiential learning and civic engagement through online and hybrid courses (pp. 7–19). Stylus Publishing.

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KEY TERMS AND DEFINITIONS

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African American English: A system of syntactic, semantic, pragmatic, phonological, morphological, and lexical patterns that are intertwined with patterns of general English (Green, 2011). Bounce: Slang for to leave or to exit. Communication Sciences and Disorders (CSD): A field of study that leads to careers as an audiologist, speech-language pathologist, or speech, language, and hearing scientist. Hit It and Quit It Phenomena: 1) to collect data from the Black speech community and disconnect from them soon after; 2) the act of researchers collecting data within the Black speech community with no intentions or commitment to give back to the Black speech community in a meaningful way. Service Learning: An approach to education in which learning objectives are combined with community service in order to provide experiential learning while meeting societal needs. Service-in-Return: To give back to the speech community in a meaningful way for the data the community has provided to the researcher. Unequal Partnership: A partnership that that unbalanced or unequal between researchers and research participants or participants’ communities.

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Section 4

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Curriculum, Training, and Practice Oriented Towards Justice

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Chapter 10

An Ethics-of-Care Approach to Developing Students’ Antiracist Practice in SLP Curricula: The Cross-CulturalCommunication Project Johanna Boult Louisiana State University Health, Shreveport, USA Jennifer E. Whited University of Louisiana, Monroe, USA Tamara M. Easley DC Therapy Solutions; Travel and Give, USA

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ABSTRACT There is a necessity for students to learn about multicultural multilingual (MM) content in speechlanguage-pathology curricula. One reason for doing so is personal motivation: an awareness of and commitment to developing competence in working with diverse clients. Awareness can grow given specifc instructional experiences in the form of special projects that aim to build cross-cultural relationships with the goal of fostering empathy and compassion. This chapter provides a tutorial explaining one such instructional experience: the cross-cultural communication (CCC) project. Central to the project are face-to-face meetings and refective journaling on topics including counteracting stereotypes and planning for culturally responsive service provision. Activities have antiracist intentions guided by the moral obligation to care for fellow human beings (as per ethics of care [EoC] theory). This chapter provides (1) theoretical underpinnings of the project, (2) procedures for its completion, and (3) description of a modifcation of the project for a language disorders course.

DOI: 10.4018/978-1-7998-7134-7.ch010

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 An Ethics-of-Care Approach to Developing Students’ Antiracist Practice in SLP Curricula

“The arc of the moral universe is long, but it bends toward justice.” —attributed to Rev. Martin Luther King, Jr.

INTRODUCTION Instructors of university Speech-Language Pathology (SLP) courses have several reasons for teaching students to become more culturally competent clinicians (Stockman et al., 2004, 2008). First, there are legal and professional mandates (e.g., Individuals with Disabilities Education Act (IDEA); also see Appendix A) that oblige speech-language pathologists (SLPs) to develop cultural competence. Furthermore, there is also a practical necessity to do so considering the increasing diversity of the United States (US) population and the resulting diversity of clientele. Finally, instructors may embrace a personal motivation to do so based on awareness of and commitment to the importance of cultural competence. Although awareness may begin as mere acknowledgement, it can grow to deeper levels of awareness given specific awareness instruction. The Ethics of Care (EoC) theory (Gilligan, 1982; Tronto, 1998, 2013) is useful in explaining awareness development. It holds that central to any conception of morality is the building of relationships with other people in order to foster empathy and compassion. When used within multicultural multilingual (MM) education, EoC can serve an important role in the teaching of antiracist practices. One project, the Cross-Cultural Communication (CCC) project, rooted in EoC theory, is described in detail in this chapter as a tutorial to guide instructors in its implementation. The CCC project can be used as part of a comprehensive plan for integrally infusing MM content into dedicated MM courses. A modified version of the CCC project (the CCC-Nondedicated (CCC-ND) can be used as an additional experience to meet the goal of integral infusion of MM content.

BACKGROUND

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Professional Mandates Several American Speech-Language-Hearing Association (ASHA) policies mandate aspects of service provision to clients from MM backgrounds. These policies guide clinical service and are used by course instructors in the academic preparation of students. Among the ASHA policy documents mentioning MM service provision are: the code of ethics, position papers, and certification and accreditation standards to which students and accredited academic programs are held. For representative examples of these documents, see Appendix A. Each of these policies was generated following one of the most dynamic sociopolitical shifts in US history, the US Civil Rights movement of the 1960s.

The Civil Rights Movement as a Backdrop to ASHA MM Policy Development During the Civil Rights era, existing systemic racism in the social institutions of the US was contested through several legal decisions. Before this, however, the Plessy v. Ferguson (1896) decision held that “separate but equal” public services were legal under federal law. The case was brought to the Supreme Court when an African American man (James Plessy) refused to sit in a “Blacks-only” train car. After the passage of Plessy, and for the next 50 years, Jim-Crow segregation was official, common practice in 199

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the south. However, the Brown v. Board of Education (1954) decision determined that separate but equal was, in fact, not equal when Oliver Brown, a resident of Topeka, KS, attempted to enroll his daughter in a segregated, Whites-only school. Even with the passage of Brown, it was not until The Civil Rights Act (1964) was tied to federal funding of public institutions that the administrations of many southern schools felt the pressure to desegregate. And even then, many southern schools held out and remained segregated until well into the 1970s (Wilkerson, 2011). It was on the heels of this broader sociopolitical movement that ASHA’s membership began to follow suit; first through the development of the Position Statement on Social Dialects (ASHA, 1983), and most recently in the condemnation of racism offered in the Response to Racism Position Statement (ASHA, 2020). It is only by situating ASHA’s history in this broader context can we understand the reason why ASHA’s policy documents are valuable to us, its membership (Horton-Ikard et al., 2009; Taylor, 1986). This collection of policies serves as an antiracist guidepost for us to follow in pursuing a common goal of social justice.

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The Current Sociopolitical Climate as a Backdrop to Highlight the Importance of Diversity Training Historical context is all the more vital considering the current socio-political landscape to be navigated. First, although the Jim-Crow segregation of the Southern states has been officially abolished, de facto segregation of social institutions (e.g., schools, housing, businesses, places of worship, etc.) remains alive and well (Bankston & Caldas, 1996), and systemic and institutional racism persists in both overt and covert forms (Henricks, 2015; West, 2017). Furthermore, although legal and professional policy advancements with a goal of social justice were made, some policymakers continue to actively promote policies decidedly counter to the antiracist policies that originated in the Civil Rights era. For example, federal policy over the past four years has reversed many of the gains made during the Civil Rights era, rolling back laws guaranteed to ensure equal voting rights (Huseman & Waldman, 2017) and racial equity in housing (Reina et al., 2020). Furthermore, when a half million people gathered in over 550 U.S. cities to protest the disproportionate killing of Black citizens at the hands of police officers and to affirm that “Black Lives Matter” (Buchanan et al., 2020), the Trump administration responded by disaffirming the name of the Black Lives Matter (BLM) movement as a “symbol of hate” (Liptak & Holmes, 2020). In September 2020, two weeks prior to initiating the writing of this chapter proposal, direct opposition to antiracist policy advancement occurred when Russell Vought, the director of The Executive Office of the President of the United States’ Office of Management and Budget, issued a memo announcing a halt to the funding of diversity education within federally funded programs (United States, 2020). This memo referred to diversity education as “divisive, un-American propaganda training sessions.” In less than two weeks, this new policy began directly affecting the way that institutions with federal employees conduct scholarly research and teach students (Asimov, 2020). NOTE: During publication of this chapter the NIH (2021) seems to have reversed its position and implemented UNITE an initiative designed specifically to identify and address structural racism in the scientific community. With recent shifts in policy vacillating between antiracism and its counterpart (i.e., “anti-antiracism”), it is important for well-meaning individuals to examine their biases. Even those with antiracist intentions may harbor covert biases; unexamined biases that impact the manner in which those from different backgrounds interact with one another. These anti-antiracist policy developments indicate that it is 200

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more vital than ever that SLP course instructors infuse MM awareness education into their classes to ensure graduate students are better motivated to collaborate with, advocate for, interact with, and provide clinical services to clients from an increasingly diverse US population. Instructors of speech-language pathology courses are responsible for ensuring that speech-language pathology professionals graduate from university programs with the basic knowledge and skills to begin the journey to act as culturally competent clinicians. Furthermore, fostering students’ increased cultural awareness can increase motivation to learn about MM and set the foundation for knowledge and skill development. Providing students with cultural awareness projects can result in: development of self-awareness, examination of personal biases, and an expansion of world views (Horton-Ikard et al., 2009).

The Contextualization of MM SLP Pedagogy MM SLP pedagogy is situated in its historical sociopolitical context (Stockman et al., 2008).

A Focus on MM Inclusive of and Beyond Solely Race Although it has focused on disenfranchised racial/ethnic groups that motivated the US Civil Rights Movement, it has been extended to include those marginalized according to additional social variables such as: disability status, SES, sexual orientation, gender identity, etc. (Banks, 1989; 1994). A curriculum which is myopic in its definition of MM will not adequately prepare SLP students to work with the full diversity of clients to which they will be exposed within practicum and in their future careers. Although the focus of MM instruction may be readjusting to acknowledge the current sociopolitical importance of race and ethnicity, this contemporary lens by no means erases the importance of intersectionality, the multiple dimensions across which people identify, oppress others and afford privilege.

Pedogogical Focus: Decontextualization vs Social Action Furthermore, pedagogical goals of MM education have existed on one of two ends of a continuum: from a decontextualized orientation (focusing on learning facts about different cultural groups without acknowledgement of a particular worldview) to a social- action orientation (in which self-critique is used to increase self-awareness with a larger goal of taking social action to redress power imbalances and work toward social justice). On which end of the continuum an instructor will be oriented, depends on the choice of the instructor. Depending on the choice of curricular goals, a corresponding delivery model will need to be chosen.

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Service Delivery Models: Options and Theoretical Underpinnings There are two main types of models for delivery of MM content that have been described in the literature: delivery through an MMI-dedicated course or delivery through infusion of MM content throughout the curriculum. Reflecting on curricular goals, those with a decontextualized orientation may mesh well with an infusion-only model. However, those with a social-action approach would likely not be able to meet the objectives entailed by such an approach with an infusion-only delivery model. Instead, a socialaction approach would require a combination of both a dedicated course and infusion of MM content throughout the curriculum. This combined model (of an MM course + infusion in MM non-dedicated 201

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courses) has been termed integral infusion; integral in that the infusion of MM content is done with intentionality and mindfulness as with any concept integral to the study of human communication. Take language development, for example. It would be short-sighted to simply infuse language development throughout the graduate-level SLP curriculum without a dedicated course, whereas a dedicated language development course plus infusion throughout the curriculum is the typical model in this realm. As is the norm that language development content is integrally infused, so it should be with MM course content.

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A Need for an Updated MM Pedagogy Over the past twenty years, research has highlighted the need for a specific pedagogy to guide the infusion of MM into SLP coursework (Horton-Ikard et al., 2009, 2010; Stewart & Gonzalez, 2002; Stockman, et al., 2004, 2008; Hyter, 2014). Investigation of pedagogical practices began with surveys of program directors’ and course instructors’ curricular coverage of MM (Stewart & Gonzales, 2002; Stockman et al., 2004, 2008). These early studies found variability in instructor preparation and a lack of a cohesive theory to guide MM teaching. As a result, some called for a paradigm shift toward an “integral infusion” of MM by means of: (a) offering not only a specific MM course, but also; (b) having non-dedicated SLP courses, which include MM content as inextricably relevant (Stockman, et al., 2004, 2008). Others have proposed frameworks that foreground theory (specifically Critical Theories such as the Critical Race Theory and Critical Social Theory) as guides for both micro-level clinical service provision to clients from MM backgrounds, and macro-level service to a global society through addressing educational and healthcare inequity and making changes to public policy (Hyter, 2014). Others have provided tutorials designed to provide practical guidance for course instructors for course development and implementation of an MM course (Horton-Ikard, et al. 2009). Horton-Ikard et al. (2009) distinguishes three dimensions of competency: awareness, knowledge, and skills. In order to develop these dimensions of cultural competency, some instructors have reportedly offered “special instructional experiences,” such as media presentations, introspective study of one’s own culture and attitudes, observation of clinical experiences with minority groups, and opportunities for students to interact with persons from other cultures (Stockman et al., 2004, 2008; Horton-Ikard, 2009). This chapter aims to provide a tutorial explaining one such special instructional experience: the Cross Cultural Communication (CCC) project (adapted from a similar project originally used by Stockman at Michigan State University). In Section 1, the CCC project is described in terms of its theoretical underpinnings, goals, and objectives. Section 2 provides procedures for completion of the CCC project, allowing for course instructors to duplicate implementation of the project. In the third and final section of the chapter, an adaptation of the CCC project (The CCC-non-dedicated or CCC-ND) is described in terms of its application to a graduate-level seminar on infant language disorders. The CCC-ND demonstrates how MM education can be integrally infused into non-MM dedicated graduate classes in a university program.

SECTION 1: GOALS, OBJECTIVES, AND THEORETICAL FOUNDATION OF THE CCC PROJECT The goal of the CCC project is for speech-language pathology students to build a personal relationship with a “cultural other” as a step toward developing increased awareness and antiracist practices to be 202

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applied with future clients who come from backgrounds other than the students’ own. The objectives of the CCC project are: (1) to have real conversations with a partner who is culturally different than one’s self, and; (2) to reflect on the relevance of documented cultural differences and similarities as they might apply to cultural practice. The philosophy that guides the CCC project is EoC theory, a philosophy not separate from antiracist practice, but an adjunct to it. Its orientation should be distinguished from its predecessors: intergroup education, multiculturalism, and common culture.

Intergroup Education Even before the Civil Rights era, the “intergroup education” movement in the US grew from the racial and ethnic tensions of the times (see Banks, 1993, 1995). During World War II, the availability of northern, war-related industrial jobs resulted in a continuation of the Great Migration of African Americans to the large cities of the Northeast, West, and Midwest. The tensions that resulted, led educators to develop goals to foster interracial cooperation by working with students to reduce prejudice and develop democratic values. The goals of intergroup education were reflected in those of the multicultural movement of the Civil Rights era (Cook, 1954; Taba & Wilson, 1946).

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Multiculturalism Subsequently, multicultural education developed as an outgrowth of ethnic studies (e.g., AfricanAmerican studies, Latinx/Chicanx studies, Asian studies, women’s studies, and gender studies) stemming from the commonly held values of the social movements of the 1960s and 1970s. It was in that socio-political context that the combined voices of those who had been historically marginalized and oppressed demanded to be added to the conversation. Although the roots of ethnic studies can be traced to earlier movements (see Woodson, 1922), it wasn’t until the Civil Rights era of the 1960s that legal and policy mandates resulted in systemic and institutional change. An outgrowth of these new disciplines was multicultural education. Central to multicultural education were concepts of power and privilege, oppression and -isms (such as sexism, racism, and ethnocentrism). After the development of stand-alone ethnic studies courses, multicultural curricular content was then infused into liberal arts education. Later, multiculturalism made its way into curricular standards of accredited clinical and practical programs. These included schools of teaching, such as the Council for the Accreditation of Educator Preparation (CAEP, 2013), and medicine (the Liaison Committee on Medical Education (LCME, 2020), as well as allied health programs, such as nursing, occupational therapy, physical therapy, and speech-language pathology (see Accreditation Council for Occupational Therapy Education (ACOTE), 2018); Council for Clinical Certification (CFCC), 2018; Commission on Collegiate Nursing Education (CCNE), 2018; Facts, C. Q., Commission on Accreditation in Physical Therapy Education (CAPTE), 2020). Specifically, multicultural content was required to be addressed in accredited speech-language-pathology programs in 1985 (Stockman et al., 2004, 2008). Although there was some variation in the focus of this multicultural content, Banks (1995) identified five dimensions of MM education that were used widely to inform pedagogy and policy: (1) content integration, or infusion, of MM content in a subject area, using examples and content from various cultural viewpoints to illustrate key concepts, (2) the knowledge construction process, illuminating the implicit assumptions and biases of the researchers and writers who construct the commonly held knowledge of the field and including traditionally marginalized points of view, (3) prejudice reduction, 203

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developing positive attitudes of students toward people who are culturally different than themselves: aiming to reduce negative attitudes and misconceptions, (4) equity pedagogy refers to embracing culturally responsive teaching methods for the benefit of those who have been oppressed, and finally, (5) an empowering school culture and social structure goes beyond the pedagogical in addressing policy. It refers to restructuring of the policies and institutional organization of schools in order to allow students from diverse backgrounds to experience a supportive and empowering environment.

The “Common Culture” Multiculturalism (CCM) Counteroffensive Beginning during the Reagan administration (1981-1989), a cultural counteroffensive to multicultural education was mounted with criticism of burgeoning ethnic studies and multicultural education pedagogy. These critics began to embrace a more sanitized version of multiculturalism (i.e., “common culture” multiculturalism (CCM, see Ravitch, 1990a, 1990b)). CCM acknowledged the reality of diversity, but two essential concepts were missing from the CCM account: (1) the historical and political context of cultural difference and, (2) contesting unjust power and transforming inequalities (Giroux, 1992). First, the idea of multiculturalism was whitewashed (pun intended) by removing historical and political context from the discussion. For example, the struggles of the Civil Rights movement were not mentioned. Instead, a decontextualized, individualist perspective of history was floated; that no matter the power structure one was fighting against, that if a given person had the will to achieve, they could have overcome oppressive obstacles. In this way, the CCM ignorance of historical and political context was rooted in its second major oversight—dismissal of the need of the oppressed to fight against unjust power structures. It coded the denial of unjust power structures as disruptive and extremist, ignoring the needs of the oppressed to achieve equity through the transformation of interpersonal and institutional inequalities. Instead, the concept of pluralism (i.e., a varied, yet united, US culture) was embraced in defense of the dominant order. Pluralists would have said that pluralism “…seeks due recognition for the ways that the nation’s many racial, ethnic, and cultural groups have transformed the national culture…” and that “American culture belongs to us, all of us; the U.S. is us, and we remake it in every generation” (Ravitch, 1990b, p. 341). The pluralistic viewpoint elevated the importance of commonality while ignoring power, politics, privilege, and struggle. Overall, the common-culture version of multiculturalism was criticized for functioning to “reinforce the status quo, subvert minority resistance, and reproduce social and economic inequities” (Mansfield & Kehoe, 1994, p. 418).

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Antiracist Education It was in response to this CCM counteroffensive that antiracist education came to the fore (Cheng & Soudack, 1994; Lynch et al., 2017; Thomas, 1984). Antiracism was a third wave of multicultural education that, rather than hiding behind a mask of pluralism, recognized the need to acknowledge racism; to provide a historical context for it, and to assert a goal of addressing historical inequity. In this way, antiracist education reconceived of the idea of multiculturalism by laying bare those aspects of diversity that the common-culture proponents aimed to hide. A definition of antiracism will benefit, first, from a definition of racism.

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Racism Racism can be defined as any racist idea – any internalized mental construct that suggests one racial group is inferior or superior to another racial group in any way (Kendi, 2019). However, racism is not only internalized, but also interpersonal, structural, and institutional (Henricks, 2015; Jones, 2000; Pyke, 2010). Internalized racism is a set of mental constructs (i.e., ideas) about race that privileges some and oppresses others. Those internalized constructs (both about others and about ourselves) are then acted out in our interpersonal relationships, where we inflict those ideas upon others through our words and actions. Structural racism exists at the level of policy and procedure; racist policies and procedures being those that privilege some, and not others, unjustly based on race. Structural racism can be seen as the codification of internalized racism through policy development. Finally, institutional racism exists because of the effects of structural racism; racist policies, by design, create the racist character of our social and cultural institutions (e.g., our schools and hospitals, places of business, and worship, courtrooms and prisons, parks and gymnasiums, and legislatures). Although traditional models have pointed to racist thoughts being the origin of systemic and institutional racism, modern theorists have suggested just the opposite, that the origin of racism is the policy itself. It is racist policies that support the “majoritarian socioeconomic self-interest from which comes racist ideas to justify the unequal outcomes created by those policies, while ignorance and hatred are just the interpersonal fallout of racist policies and ideas” (Kendi, 2019). From this perspective, antiracism is any thought or action that aims to counteract racist policy; the onus for which is on White people (Berman & Paradies, 2010; DiAngelo, 2018)—requiring accountability and action on the part of the perpetrators of the racist behavior.

Antiracist Pedagogy

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Antiracist pedagogy can be defined as an active and conscious effort to explain and work against the persistent and multidimensional aspects of racism (Blakeney, 2005; Patterson in Hoffower, 2020). Even more specifically, antiracist education is “a commitment to educated students in ways that make racialized power relations explicit, deconstruct the social construct of race, and analyze the interlocking systems of oppression that serve to marginalize and exclude some groups while privileging others” (Hassouneh, 2006, p. 256). According to Lynch et al (2017), antiracist education has three components: visibilizing, recognizing, and strategizing. Visibilizing refers to making systemic oppression visible. Recognizing refers to recognition of personal complicity in oppression through unearned privilege. Strategizing refers to developing strategies to transform structural inequalities. Guided by these three key components, Lynch el al. (2017) suggests several important goals of antiracist pedagogy: 1. 2. 3. 4. 5. 6.

Becoming race-aware (Gillespie et al., 2002); with the goal of accepting complicity Taking “antiracist action” (Gillespie et al., 2002) Working toward removing institutional barriers (Tanemura et al., 2000) Bringing about social transformation (Swartz et al., 2014) Achieving systemic change (Srivastava & Francis, 2006) Generating a sustained challenge to institutional and micro-level racism (Gosine, 2012)

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Antiracist Educational Practice In order to translate the characteristics of antiracist pedagogy into practical procedures, Cheng and Soudack (1994) curated a list of prejudice and racism reduction strategies that have been shown to be relatively effective. Among them are: (1) heightening students’ awareness of racism through interracial contact; (2) increasing student’s direct contact with members of other cultural groups; (3) encouraging positive inter-group interactions and; (4) empowering students as change agents by developing plans to combat racism. This list is not exhaustive of the strategies mentioned by Cheng and Soudack (1994), but rather, highlights those strategies that are employed within the CCC project described later in this chapter. It seems that inter-group interactions (i.e., hanging out with others who are culturally different than one’s self) is common to at least three of these four strategies. Intergroup interaction across racial lines has been confirmed as a way to address implicit bias, as per the contact hypothesis (Amir, 1969; Petigrew, 1986; Shook & Fazio, 2008). Special class-projects based on the contact hypothesis have been confirmed as important pedagogical tools. Giroux (1992) stated, “…all schools should have teachers and students participate in antiracist curricula that in some way links up with projects in the wider society” (Giroux, 1992, p. 33). A systematic review of the frequency of use of various methods revealed that 44% of antiracism educators use specific activities in their educational efforts, and 63% use writing assignments, such as written reflections on texts or autobiographical writing (Lynch et al, 2017).

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A Theoretical Guidepost: Ethics of Care (EoC) as an Adjunct to CRT From a theoretical standpoint, antiracism has typically been studied from a social sciences standpoint, situated in Critical Race Theory (CRT) (Bell et al., 1989; Crenshaw et al., 1995; Delgado & Stefancic, 2017, 2000), but also specifically in relation to healthcare (Diffey & Mignone, 2017; Jones, 2000), and education (Ladson-Billings & Tate, 2006; Taylor et al., 2009). Central to CRT are two major themes: (1) white supremacy exists to perpetuate unequal societal power structure and, (2) transformation of policy and institutional organization should be attempted in an effort to pursue justice by redressing inequity and diminishing oppression. So, the goal of CRT is justice, antiracist practice being one of the methods for arriving at that goal. Although justice is the primary goal for institutional and broader societal transformation, an Ethics of Care (EoC) Approach highlights a value for care (in addition to justice) for those individuals with whom we are interdependent and in a relationship. This is the viewpoint provided by an EoC approach (Gilligan, 1982; 2013a). The EoC highlights the importance of context-based empathy and compassion as the grounds for making ethical decisions as compared to decontextualized moral codes as decision-making criteria, so that care is not separate from justice, but rather, “Justice is what love looks like in public” (p. 233; West, 2009). In other words, “the requisites for love and the requisites for citizenship in a democratic society are one and the same. Both voice and the desire to live in relationships are inherent in our human nature, together with the capacity to resist false authority” (Gilligan, 2013a, p. 12). As a result, the EoC is not an alternative to, but a complement to CRT, as illustrated by the following explanation: The moral injunction—do not oppress, do not exercise power unfairly or take advantage of others—lives side by side with the moral injunction to not abandon, to not act carelessly or neglect people who need help, meaning everyone including oneself. But they draw on different aspects of ourselves. Fairness and rights are matters of rules and principles. The logic is clear… Caring requires paying attention, see-

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ing, listening, responding with respect. Its logic is contextual, psychological. Care is a relational ethic, grounded in a premise of interdependence. But it is not selfless. (Gilligan, 2012, para. 18) EoC relies on the assumptions that we have varying degrees of interdependence with each other, that one’s choices affect others relative to their level of vulnerability, and that various contextual details are relevant to making the most ethical choice. Fundamentally, EoC can be distilled down to five essential elements: attentiveness, responsibility, competence, responsiveness (Tronto, 1998), and plurality/solidarity—caring (Tronto, 2013). Attentiveness is the requisite of recognizing others’ needs in order to respond to them. Responsibility is taking the decision-making onus upon ourselves. Competence means following through on and acting upon the decision with enough ability to act effectively. Responsiveness refers to understanding the particular reaction of the receiver of the care; paying attention to what has been expressed by them to judge the conditions of vulnerability and inequality. Finally, plurality/solidarity (aka, plurality, communication, trust, and respect; solidarity—caring) refers to a set of qualities necessary for people to come together to take collective action; that caring for the needs of others in society is integral to the practice of citizenship. Note: The goals and objectives of the CCC project are decidedly antiracist. First, the overall project aim is to increase cultural awareness. Awareness development is an antiracist goal as described by Gillespie et al. (2002). The CCC goals and objectives are not only antiracist, but also fundamentally situated in EoC theory. The lessons learned from the CCC project are gained not from a textbook, not from a lecture, but from authentic human relationships; relationships situated in naturalistic conversational environments, which are central to the learning experience. As such, the CCC participant has the opportunity to develop care and compassion for a person who is racially, or otherwise culturally, different from themselves. An EoC theoretical lean helps to explain the fact that so many who participate in the CCC project learn that, “People are hard to hate close up” (Brown, 2017, p. 63). These goals and objectives are obtained through procedures deemed to be commonly employed in antiracist pedagogy, namely, special projects and written reflections (Lynch et al, 2017).

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SECTION 2: PROCEDURES FOR COMPLETION OF THE CCC PROJECT The CCC project is a three-part process consisting of: (1) hour-long conversational interactions between an SLP student and a partner that differs culturally in some respect from the SLP student; (2) journaling on specified topics (including cultural similarities and differences, the relevance of said differences to clinical practice, cross-cultural comparison of provision for those with handicaps, and explanation and contradiction of stereotypes, and; (3) a multimedia presentation to the peers on the cultural and linguistic differences, including suggestions for negotiating said cultural differences.

Conversational Interactions Students are expected to either independently locate or be assigned a CCC partner—a person who will serve as a conversational partner for the project. The partner needs to be someone who is, in some respect, culturally different than themselves, and with whom the student is relatively unfamiliar. They also need to be willing to meet two times over the course of the term for an hour-long meeting to discuss their 207

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cultures. The total required meeting time is to be no less than two hours of contact time, from the two, individual hour-long meetings. The meetings must be dispersed evenly across the semester to allow time for students to write reflective journal-entries following each meeting. The distribution of the meetings also allows time for the journal entries to be graded by the course instructor. Students are strongly encouraged to meet in a public place (such as a coffee shop, restaurant, library or bowling alley) to encourage socialization and reduce any anxiety or risk (on the part of either party) associated with meeting with a stranger in public. Student responsibilities include initiating and arranging each meeting beforehand, and participating in conversations during the meetings. The style of the conversations is encouraged to be casual and free flowing. Even so, the interaction is not purely social; the assignment dictates that specific conversational topics are expected to be addressed. Students are to keep in mind that the goal is to discover similarities and differences between their own and their partner’s cultural characteristics. They must glean enough information from their meetings that following each conversation, so that they are prepared to complete a reflective journal entry describing what was discussed. Note: The CCC conversational interactions are examples of engagement in intercultural meetings. Intercultural engagement is an antiracist strategy as described by Cheng and Soudack (1994).

Journal Entries Following each meeting, students are expected to journal on several specific topics.

Cultural Similarities and Differences First, students must write on the topic of cultural similarities and differences. Although cultural characteristics can be analyzed in various ways, this assignment uses the “cultural mosaic” framework (Stockman et al., 2004, 2008). The framework lists some elements of culture that create patterns of cultural similarities and differences across and within groups (i.e., language, social interaction/communication, history, values, beliefs, attitudes, behavior/customs, material culture, learning styles, and social organization). The framework is useful in providing an additional list of professional practices to which cultural elements can be compared to determine clinical relevance.

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Relevance to Clinical Practice In this regard, the next requirement of the CCC project is that students must use their reflective journals to discuss the way that their partner’s cultural similarities and differences might be hypothetically relevant to clinical practice. In this section, students are asked to imagine that they had a future client with cultural characteristics similar to their partner. This process involves first naming the cultural similarity or difference, and then making specific predictions about how such characteristics might be relevant to particular activities of clinical SLP practice. They are encouraged to provide an in-depth analysis of differences beyond the basics (i.e., more than simply concluding that “we must listen to our client” or “client differences must be taken into account”). Rather, they are encouraged to describe procedures that would allow specific activities of practice to be modified given a particular cultural element. Note: Discussion of procedures for negotiating cultural differences that could be carried into future clinical practice can be seen as an antiracist exercise in foreshadowing potential systemic change, as described by Srivastava and Francis, (2006 208

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Stereotypes Outside of information about cultural differences, students are required to write on only two topics: stereotypes and handicaps. Stereotypes are defined as a particular type of generalization, generalizations being mental constructs (i.e., specific types of ideas) that are generally helpful in allowing us to understand the world (Banich & Caccamise (2011). A generalization becomes a stereotype, when it is a prejudgment about a given social group that limits their opportunity to defy the generalization (Beeghly, 2015; Schneider, 2005). Furthermore, students are encouraged to view stereotypes as untrue in that they do not exist in the real world, but rather, are symbolic representations (i.e., ideas) that exist in the mind in order to simplify an understanding of a group of people. Although untrue, stereotypes have been and continue to be used to oppress others. The stereotypes section of the journal must describe existing stereotypes of their partner’s cultural group. However, this section must go beyond a description; it must also include an analysis that aids in counteracting those stereotypes. Two suggestions for counteracting the stereotype are to: (1) give it historical context and, (2) provide a positive reframe for it. Historical context includes a description of the historical reasons for, and circumstances in which, the stereotype developed. Reframing involves reconsidering a positive way of viewing the negative stereotype(s). Note: Reflective journaling can serve as an antiracist action as described by Gillespie et al. (2002). Journaling specific to counteracting stereotypes serves the antiracist function of changing racist ideas.

Handicaps The second additional topic on which students are required to write in their journals is handicaps. The topic of handicaps must be discussed in the journal entry in terms of the provisions for people with handicaps in their CCC partner’s culture. The discussion can include the general value for people with handicaps, as well as what social provisions are made for those with handicaps in that culture. This section often includes specific data on the adequacy of educational and healthcare policy provisions, for instance. Finally, the student may address how these values and provisions differ from those provided in the student’s culture. Note: Analyzing cross-cultural contrasts in provisions for people with handicaps exemplifies what Tanemura Morelli and Spencer (2000) have described as the antiracist practice of elucidating institutional barriers.

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Multimedia Presentations The CCC project culminates in an end-of-term multimedia presentation. The oral presentation is delivered via PowerPoint or Prezi and is meant to allow each student to summarize and synthesize the information from both journal entries. It also allows students to learn beyond their individual projects. By listening to their peers’ presentations, they gain knowledge about the cultures of all of the partners of all of the students in the class.

Evaluation Procedures The journal entries are graded according to a grading rubric (see the journal grading rubric, Addendum B). Journals are graded on: (1) content, i.e., whether all the guidelines of the assignment are met and, 209

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(2) form, i.e., the organization, clarity and grammatical adequacy of the written presentation. Rubrics are completed by the course instructor following submission of each journal entry and then returned to the students. Students are expected to use the completed rubric and feedback from the first journal to improve the quality of the second journal. A separate grading rubric is completed for the multimedia presentation. This second rubric evaluates both professional and formal aspects of the oral presentation (see Addendum C).

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SECTION 3: DESCRIPTION OF AN ADAPTATION OF THE CCC PROJECT TO A SINGLE, GRADUATE COURSE The previously mentioned CCC journal project was designed to be implemented in a MM-dedicated course. If an MM-dedicated course instructor wants to implement it into their own course, they should refer to Part 2 and follow those instructions. There is, however, the opportunity for instructors of nondedicated courses (such as Language Disorders or Motor Speech Disorders, for instance) to use a similar project, adapted for use in a MM non-dedicated course; a CCC non-dedicated, or (CCC-ND) project. This type of tutorial is especially valuable because those who teach ND courses are much less likely to offer such special instructional experiences as opposed to instructors of dedicated MM courses (Stockman et al., 2008). This section, Part 3, of the chapter illustrates one such example in which adaptations to the CCC project were made to fit the needs of a graduate-level Infant Language Disorders (ILD) course (Whited & Boult, under review). Although offering such content in an MM course is a step in the right direction, integral infusion ideally requires infusion of MM content into the entire curriculum. In order to meet the ideal of integral infusion, this tutorial illustrates the procedure for implementing curricular infusion of MM content into a graduate, ILD course. At the institution where the ILD course was offered, a dedicated MM course was required in the undergraduate curriculum. For this reason, most students had already completed a CCC project similar to the one described in Part 2. The CCC-ND was developed in order to extend the experience of the knowledge gained from the MM-dedicated class into a non-dedicated class. The CCC-ND was designed to ensure that MM knowledge was learned integrally, across the curriculum, beyond the dedicated class alone. The ILD class provided a logical platform to implement this adaptation of the CCC project, since the class contains an existing overt focus on building relationships with families of small children. Parents and caregivers of small children are known to be the children’s most important language teachers (DeVeney et al., 2017), and it is the responsibility of the SLP to support parents in these efforts. However, before an SLP can adequately support parents, it is essential that they learn how to negotiate cultural differences. In addition, SLPs need an opportunity to witness the interdependent nature of their lives with those that they will serve (Whited & Boult, under review; Stockman et al., 2004; 2008). This project provides graduate students with an opportunity to experience both cultural negotiation and the interdependent nature of relationships first-hand in order to develop needed skills and improved perspective.

CCC-ND Goals and Objectives The goals of the CCC-ND were to teach graduate-level students: a) to practice the principles of active listening, self-other awareness through experiential learning; b) to increase cultural awareness through firsthand interaction with a person of a different culture; c) to understand the lived experiences of parents 210

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of children with disabilities and; d) to reframe oppressive ideas based on the care for a cultural other developed within an authentic relationship. The CCC-ND project involved three tasks: 1) a series of conversations with a person from a different culture who also had a family member with disabilities; 2) reflective journaling completed after the conversations and; 3) an in-class small-group discussion guided by the instructor at the end of the semester. These tasks were used generate data that was analyzed qualitatively to identify emergent themes. Similarities and differences between the major sections of the CCC project will be described in each section. Note: As with the original CCC project, the goals and objectives of the CCC-ND project are also grounded in anti-racist principles. Like the original CCC project, the overall project aim is to increase cultural awareness. Also, the goals and objectives of this adapted project are fundamentally situated in EoC theory. Central to the learning experience of the CCC-ND project is authentic human relationship situated in naturalistic conversational environments.

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Conversations The students were required to find a partner from another culture who also had a person with a disability in their family. They were encouraged to meet in person in a public place, but phone conversations and online video conferencing were allowed, if necessary. The instructor gave the students a script of a possible way they could introduce the topic to their partner and explained the reasons for the conversations to ease awkwardness and potential misunderstanding. The students were encouraged to have more than one conversation with their partner, if possible. However, since they were focused on families with children with disabilities who often have limited time, the students were not required to have more than one conversation. The students were encouraged to enjoy an unstructured conversation, but the project stipulated general guidance on the following topics to cover, if possible: a) discussion of home and work life; b) the process of their child’s education; c) establishment of relationships; d) the nature of interactions with professionals; e) the nature of interactions with the public and; f) any listening techniques they used to ensure the conversation was focused respectfully on the family member. CCC-ND conversations were modified from the original CCC conversations in two major ways: 1) partners were required to be someone who was not only culturally different, but who also had a family member with a disability and, (2) the conversation was less structured, in that conversational topics were suggested and given general guidance, but no topics were required. The rationale for these changes was the following: (1) conversational partner had to have a family member with a disability in order for students to learn how disability as a sociocultural variable was integrated into the life of a person from a different cultural background. Firsthand experience with a person with these intersecting differences has the potential to teach students about similarities and differences in the ways that handicapping conditions are interpreted by people from different backgrounds. Furthermore, the decision to require no specific topics of conversation was made because the objective of the CCC-ND was to identify themes that emerged from the project. A relatively less structured conversation was encouraged for this reason. Note: The conversational interactions in this CCC-ND project are examples of engagement in intercultural meetings, which is an antiracist strategy as described by Cheng and Soudack (1994).

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Journals The required journal entries covered the content of their conversation as well as interpretation of, and reflection on, what their partner said about the earlier discussed topics (see a through f). No other requirements were implemented for the journal entries. Although there were no page limits, each entry ranged from 6-10 pages, double-spaced, in 12-point font. CCC-ND journals were modified from the original CCC journals. Similar to the less formal conversation, journal entries required less structure as well. Journals were a direct report on, and interpretation of, the meaning of the information shared during conversations. This open-ended format was preferred in this context in order to investigate naturally occurring themes that emerged in student writing. Note: The written reflections in the CCC-ND project are based on cross-cultural meetings with a person from a different cultural background, who had a family member with a handicap. Similar to the original CCC project, written reflection on cross-cultural experience has been identified as an element of antiracist pedagogy (Gillespie et al., 2002; Tanemura Morelli and Spencer (2000).

Small Group Discussions Instead of a multimedia presentation (the final requirement of the original CCC project), the final requirement of the CCC-ND was a small-group discussion. The discussions were held with the instructor at the end of the semester in small groups (of 4-5 students) using a virtual (Zoom) format. The content of the discussions focused on sharing collective experiences and learning from peers in the context of this CCC-ND project. During the discussion, the instructor reiterated goals of antiracist education such as heightening students’ awareness of racism and empowering students to be change agents. The instructor made it clear that students’ honesty was important during the discussion, and that no beliefs or views different from the instructor’s would cause a deduction in their participation grade. Note: Small group discussion provides an opportunity to reiterate the principles set forth in critical race theory, EoC, and antiracist practices. Also, as mentioned in the description of the original CCC project, discussion of the process of negotiating cultural differences as it relates to future clinical practice can be seen as an antiracist exercise in foreshadowing potential systemic change, as described by Srivastava and Francis (2006). Situated in an LD course, the discussion focused specifically on clinical practice related to LD, allowing for focused conversation on this particular disorder area.

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Evaluation Procedures The entire project was worth a total of 100 points. The journal was worth 75 points, with points earned based on how many of the required topics were included in written discussion. Strong participation in the group discussions was awarded 25 points according to a participation rubric.

OUTCOMES AND CONCLUSION While the complete results of the CCC-ND project are reported elsewhere by Whited and Boult (under review), it is fitting to state here that students reported significant learning after completing it. Learning was revealed in terms of gaining cultural knowledge, shifting perspective, and acknowledging intersec212

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tionality. Students reported gaining knowledge in the areas of race, religion, and disability. In addition to knowledge acquisition, they reported shifting perspectives regarding both race and disability, and that stereotypes (either positive or negative) were reduced by having a real-world conversation with someone who defied those stereotypes. This shift in perspectives seemed to be facilitated by having listened to their project partner converse about the perspective shift they underwent when a person with a disability became a member of their family. Similarly, students often reported acknowledging intersectionality of multiple identities (based on, race, disability, religion, etc.). First, they realized that multiple identities led to unique, versus stereotypical, cultural expression on the part of their partner. Furthermore, they realized that multiple oppressions increased the likelihood of decreased access to social services. For example, several of the students’ journal entries emphasized an awareness that children with disabilities, especially those who come from a traditionally minority racial, ethnic, or religious background, face circumstances due to multiple oppressions that need to be met with humility and care. These outcomes were made possible by submersion into relationships with individuals from differing and intersectional backgrounds through the CCC-ND project. The instructional experience that led to this learning is one example of a special experience with EoC goals using antiracist practices. Such experiences seem to have utility in terms of increasing the cultural competence of SLP students as they prepare for future employment serving a diverse clientele.

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FUTURE DIRECTIONS This project provides a tutorial describing the procedure for implementation of a special project related to MM course content in SLP curricula. This one project, by no means, claims to solve the larger societal ill of social injustice. Instead, projects, such as the CCC and CCC-ND, should be seen as tools in a larger arsenal to be used to aid in bending one small piece of the arc of the moral universe slowly toward justice. Furthermore, such projects should be seen as only one element within an array of pedagogical options that make up an integrally infused pedagogical model. Although integral infusion has been suggested as the optimal model, whereas general infusion has been suggested to be less than optimal, further study is needed to confirm the topography of the integral-infusion landscape. In charting this territory, several things seem to be clear: First, it is evident that topics of diversity should extend to the full range of the diversity of human experience. Race is currently at the forefront of the social justice movement, but to exclude other marginalized groups from the discussion is shortsighted and fails to attain the ethic of caring for all people inclusively. Secondly, it seems clear that any curricular delivery model should include both a dedicated MM course in addition to the well-planned infusion of MM content throughout ND courses. It has been suggested that a general infusion model is less than optimal in that it seems unlikely that general infusion could adequately address topics of social justice. Relatedly, a final point of clarity is that the pedagogical focus should be made explicit -- requiring programs to reflect on whether course content focuses on decontextualized content (that clarifies differences across groups of people) and/or focuses on topics of social justice (such as advocacy and community engagement on behalf of clients). Potentially, both could be addressed via two dedicated MM courses – one that focuses on decontextualized knowledge and a second that focuses on issues of social justice. These two courses in addition to infusion of MM content throughout the curriculum may be optimal in meeting the ideal of integral infusion. Although, such a plan, on its face, seems optimal, future research is needed to investigate this 213

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hypothesis regarding student outcomes using various models. It is also possible that modifications to the projects described in the current study could optimize student learning, and that additional special projects could be used to further expand student knowledge – to increase students’ general awareness and impart in them a social justice orientation.

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Diffey, L., & Mignone, J. (2017). Implementing anti-racist pedagogy in health professional education: A realist review. Health Education and Care, 2(1), 1–9. doi:10.15761/HEC.1000114 Gillespie, D., Ashbaugh, L., & DeFiore, J. (2002). White women teaching white women about white privilege, race cognizance and social action: Toward a pedagogical pragmatics. Race, Ethnicity and Education, 5(3), 237–253. doi:10.1080/1361332022000004841 Gilligan, C. (1982). In a different voice. Harvard University Press. Gilligan, C. (2012). Looking back to look forward: Revisiting in a different voice. [email protected] (9). http:// nrs.harvard.edu/urn-3:hlnc.essay:Gilligan.Looking_Back_to_Look_Forward.2011 Gilligan, C. (2013a). Joining the resistance. John Wiley & Sons. Giroux, H. A. (1992). Post-colonial ruptures and democratic possibilities: Multiculturalism as anti-racist pedagogy. Cultural Critique, (21), 5–39. doi:10.2307/1354115 Gosine, K. (2012). Accomplished Black North Americans and antiracism education: Towards bridging a seeming divide. Critical Sociology, 38(5), 707–721. doi:10.1177/0896920510380077 Hassouneh, D. (2006). Anti-racist pedagogy: Challenges faced by faculty of color in predominantly white schools of nursing. The Journal of Nursing Education, 45(7), 255–262. doi:10.3928/0148483420060701-04 PMID:16863105 Henricks, K. (2015). Racism, Structural and Institutional. In The Wiley Blackwell Encyclopedia of Race, Ethnicity, and Nationalism. Wiley. https://onlinelibrary.wiley.com/doi/book/10.1002/9781118663202 Hoffower, H. (2020, June 8). What it really means to be an antiracist, and why it’s not the same as being an ally. Business Insider. https://www.businessinsider.com/what-is-antiracism-how-to-be-antiracist-2020-6 Horton-Ikard, R., Munoz, M. L., Thomas-Tate, S., & Keller-Bell, Y. (2009). Establishing a pedagogical framework for the multicultural course in communication sciences and disorders. American Journal of Speech-Language Pathology, 18(2), 192–206. doi:10.1044/1058-0360(2008/07-0086) PMID:19106206 Horton-Ikard, R., Muñoz, S. B., & Maria, L. (2010). Addressing multicultural issues in communication sciences and disorders. Contemporary Issues in Communication Science and Disorders, 37(Fall), 167–173. doi:10.1044/cicsd_36_F_167

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Huseman, J., & Waldman, A. (2017, June 15). Trump administration quietly rolls back civil rights efforts across federal government. Pro Publica, 15. Hyter, Y. D. (2014). A conceptual framework for responsive global engagement in communication sciences and disorders. Topics in Language Disorders, 34(2), 103–120. doi:10.1097/TLD.0000000000000015 Individuals with Disabilities Education Act, 20 U.S.C. § 300.304 (2004). Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90(8), 1212–1215. doi:10.2105/AJPH.90.8.1212 PMID:10936998 Kendi, I. X. (2019). How to be an antiracist. One World.

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Ladson-Billings, G., & Tate, W. F. (2006). Toward a critical race theory of education. Critical race theory in education: All God’s children got a song, 11, 30. Liaison Committee on Medical Education. (2020). Standards: Functions and Structure of a Medical School. Retrieved from: https://lcme.org/publications/ Liptak, K., & Holmes, K. (2020). Trump calls Black Lives Matter a ‘symbol of hate’ as he digs in on race. CNN Politics. https://www.cnn.com/2020/07/01/politics/donald-trump-black-lives-matter-confederaterace/index.html Lynch, I., Swartz, S., & Isaacs, D. (2017). Anti-racist moral education: A review of approaches, impact and theoretical underpinnings from 2000 to 2015. Journal of Moral Education, 46(2), 129–144. doi:1 0.1080/03057240.2016.1273825 Mansfield, E., & Kehoe, J. (1994). A critical examination of anti-racist education. Canadian Journal of Education/Revue Canadienne de L’éducation, 19(4), 418-430. Mendible, M. (1999). What is multiculturalism? In T. Riggs (Ed.), St. James encyclopedia of popular culture. Academic Press. National Institutes of Health. (2021, April 26). Ending Structural Racism: UNITE. U.S. Department of Health & Human Services. https://www.nih.gov/ending-structural-racism/unite Pettigrew, T. F. (1986). The intergroup contact hypothesis reconsidered. In M. Hewstone & R. Brown (Eds.), Social psychology and society: Contact and conflict in intergroup encounters (pp. 169–195). Basil Blackwell. Plessy v. Ferguson, 163 U.S. 537, 539 (1896). https://www.oyez.org/cases/1850-1900/163us537 Pyke, K. D. (2010). What is internalized racial oppression and why don’t we study it? Acknowledging racism’s hidden injuries. Sociological Perspectives, 53(4), 551–572. doi:.4.551 doi:10.1525op.2010.53 Ravitch, D. (1990a). Diversity and democracy: Multicultural education in America. American Educator: The Professional Journal of the American Federation of Teachers, 14(1), 16–20. Ravitch, D. (1990b). Multiculturalism: E pluribus plures. The American Scholar, 59(3), 337–354. Reina, V. J., Pritchett, W. E., & Wachter, S. M. (Eds.). (2020). Perspectives on fair housing: The city in the twenty-first century. University of Pennsylvania Press.

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Schneider, D. J. (2005). The psychology of stereotyping. Guilford Press. Shook, N. J., & Fazio, R. H. (2008). Interracial roommate relationships: An experimental field test of the contact hypothesis. Psychological Science, 19(7), 717–723. doi:10.1111/j.1467-9280.2008.02147.x PMID:18727788 Srivastava, S., & Francis, M. (2006). The problem of authentic experience: Storytelling in anti-racist and anti-homophobic education. Critical Sociology, 32(2-3), 275–307. doi:10.1163/156916306777835330 Stefancic, J., & Delgado, R. (Eds.). (2000). Critical race theory: The cutting edge. Temple University Press.

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Stewart, S. R., & Gonzalez, L. S. (2002). Serving a diverse population: The role of speech-language pathology professional preparation programs. Journal of Allied Health, 31(4), 204–216. PMID:12491949 Stockman, I. J., Boult, J., & Robinson, G. (2004). Multicultural issues in academic and clinical education: A cultural mosaic. ASHA Leader, 9(13), 6–22. doi:10.1044/leader.FTR5.09132004.6 Stockman, I. J., Boult, J., & Robinson, G. C. (2008). Multicultural/multilingual instruction in educational programs: A survey of perceived faculty practices and outcomes. American Journal of Speech-Language Pathology, 17(3), 241–264. doi:10.1044/1058-0360(2008/023) PMID:18663109 Swartz, S., Arogundade, E., & Davis, D. (2014). Unpacking (white) privilege in a South African university classroom: A neglected element in multicultural educational contexts. Journal of Moral Education, 43(3), 345–361. doi:10.1080/03057240.2014.922942 Taba, H., & Wilson, H. (1946). Intergroup education through the school curriculum. The Annals of the American Academy of Political and Social Science, 244(1), 19–25. doi:10.1177/000271624624400104 Tanemura Morelli, P. T., & Spencer, M. S. (2000). Use and support of multicultural and antiracist education: Research-informed interdisciplinary social work practice. Social Work, 45(2), 166–175. doi:10.1093w/45.2.166 PMID:10710989 Taylor, E., Gillborn, D., & Ladson-Billings, G. (2009). Foundations of critical race theory in education. Routledge. Thomas, B. (1984). Principles of anti-racist education. Currents, 2(2), 20–24. Tronto, J. (2013). Caring democracy: Markets, equality, and justice. New York University Press. Tronto, J. C. (1998). An ethic of care. Generations: Journal of the American Society on Aging, 22(3), 15–20. PMID:12785337 United States Executive Office of the President, Office of Management and Budget. (2020, September 4). Memorandum for the Heads of Executive Departments and Agencies; Training in the Federal Government. A memo from Russell Vought, Director. Retrieved from the White House Web site: https://www. whitehouse.gov/wp-content/uploads/2020/09/M-20-34.pdf West, C. (2009). Brother West. Hay House, Inc. West, C. (2017). Race matters, 25th anniversary: With a new introduction. Beacon Press.

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Whited, J., & Boult, J. (under review). Integrally infusing multicultural instruction: An experiential learning project. Wilkerson, I. (2011). The warmth of other suns: The epic story of America’s great migration. Vintage. Woodson, C. G. (1922). The Negro in our history. Associated Publishers.

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ADDITIONAL READING America & Moore: Diversity Education, Research & Consulting. (2020). 21-day racial equity habit building challenge. https://www.eddiemoorejr.com/21daychallenge Antiracism Resources at Paul Robeson Library. Getting Started. (2020). Rutgers University Libraries. https://libguides.rutgers.edu/antiracism Burgstahler, S. E., & Cory, R. C. (Eds.). (2010). Universal design in higher education: From principles to practice. Harvard Education Press. Camicia, S. P. (2016). Critical democratic education and LGBTQ-inclusive curriculum: Opportunities and constraints. Routledge. doi:10.4324/9781315885254 GLSEN LGBTQ Inclusive Curriculum Resource. (2019). Developing LGBTQ-inclusive curriculum resources https://www.glsen.org/activity/inclusive-curriculum-guide Kendall, M. (2021). Hood feminism: Notes from the women that a movement forgot. Penguin. Krenshaw, K. (2022). On intersectionality. The New Press. Kurashige, L. (2016). Two faces of exclusion: The untold history of anti-Asian racism in the United States. UNC Press Books. doi:10.5149/northcarolina/9781469629438.001.0001 Project Implicit. (2011). https://implicit.harvard.edu/implicit/ Racial Equity Tools. (2020). https://www.racialequitytools.org/ The Smithsonian Institution. (n.d.) Talking about Race. National Museum of African American History & Culture. https://nmaahc.si.edu/learn/talking-about-race

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KEY TERMS AND DEFINITIONS Antiracist Educational Practice: Rooted in antiracist pedagogy, specific educational strategies that aim to reduce prejudice and racism. Antiracist Pedagogy: An active and conscious effort to explain and work against the persistent and multidimensional aspects of racism. Antiracist Practice: Antiracist practice is one of the methods of pursuing racial justice typically viewed through a Critical Race Theory lens. Critical Race Theory: Critical race theory is a theory that guides anti-racist practice via the assumptions that white supremacy exists to perpetuate unequal societal power structure, and transformation of policy and institutional organization should be attempted in an effort to pursue justice by redressing inequity and diminishing oppression. Ethics of Care (EoC): The EoC theory holds that moral action includes justice but centers on care and benevolent action, virtues that are shown within the context of interpersonal relationship.

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Handicap: Handicaps are (as defined by the World Health Organization (WHO)) the result of an impairment or disability that limits or prevents the fulfillment of one or several roles regarded as normal depending on age, sex and social and cultural factors. Integral Infusion: Integral infusion is the embedding of MM curricular content into the entire curriculum via careful planning, with a broad definition of cultural diversity, via both an MM-dedicated course or courses and infusion of MM content into ND courses. Intersectionality: Intersectionality is a framework that accounts for the interconnected advantage and privilege, discrimination and oppression based on multiple social categories such as race, ethnicity, class, gender, sexual orientation, age, disability status, etc. MM Education: MM education encompasses MM pedagogy along three continua: (1) focus of content (on one social variable, such as race, to the entire array of cultural difference), (2) pedagogical focus (on social action vs. decontextualized study of cultural difference), and (3) service delivery models (ranging from generic infusion of content throughout course to integral infusion, encompassing a dedicated course with well-planned, integration of MM content throughout the curriculum). Multicultural/Multilingual (MM): MM describes the array of human cultural and linguistic differences. Racism: Any internalized mental construct that suggests one racial group is inferior or superior to another racial group in any way. Stereotype: A widely held and over-generalized conceptualization or mental image about a particular sociocultural category of people.

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APPENDIX A Position Papers Position Paper on Social Dialects Position Paper on Provision of Instruction in English as a Second Language by SLPs in School Settings Professional Issues Statement on the Clinical Education of Students with Accents ASHA’s Response to Racism Ethics Issues Code of Ethics, Principle 1, Rule C Issues in Ethics: Cultural and Linguistic Competence Certification and Accreditation Standards

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2020 Certification Standards – See Standard IV-D 2017 Accreditation Standards – See Standard 3.0B

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APPENDIX B

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Figure 1.

APPENDIX C

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Figure 2.

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Chapter 11

An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers: Simulated Interpreter Encounter RaMonda Horton Midwestern University, USA Elia Olivares https://orcid.org/0000-0003-4048-9077 DePaul University, USA

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ABSTRACT Cross cultural competence and responsiveness (CCCR) is an important aspect of clinical service delivery in speech-language pathology (SLP). Beyond the issue of CCCR, there is also a need to address how professional practices can facilitate justice in traditionally marginalized populations. Limited language access can facilitate inequities and disparities within institutions and systems when it is not considered in clinical service delivery. However, within the feld of SLP there is a limited amount of information available on the efectiveness of pedagogical strategies needed to facilitate student CCCR and train SLPs in how to minimize barriers posed by language access. Simulation, using standardized patients, is a strategy from the medical feld that has been used for such purposes. There are few published reports on the use of simulation for fostering various aspects of CCCR development among SLP students. Therefore, the purpose of this chapter is to provide an overview of a research project examining the efectiveness of a simulated interpreter encounter for multicultural training.

DOI: 10.4018/978-1-7998-7134-7.ch011

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 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers

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INTRODUCTION Health and educational disparities, along with shifting demographics among various racial/ethnic groups, make it necessary for training programs in allied health professions to adopt pedagogical frameworks, models, and strategies that will facilitate CCCR in pre-professional students (Franca & Harten, 2016; NCES, 2019; Frey, 2018). CCCR has been defined as the ability to effectively interact with and deliver services to individuals from diverse backgrounds (ASHA, 2017, Horton-Ikard et al., 2009). CCCR involves the acquisition and implementation of the awareness, knowledge, and skills needed to effectively deliver services to individuals from culturally and linguistically diverse backgrounds (Camphina-Bacote, 2002; Sue, 2001). It is one area of preparation that many pre-professional programs and instructors may struggle with as they attempt to train pre-professional students who enter into the field of speech-language pathology ([SLP], Stockman, Boult, & Robinson 2008). Beyond the need to clarify teaching methods for CCCR, there is also a need to address how professional practices can facilitate justice in traditionally marginalized populations that SLPs serve. The shifting demographic trends indicate that there is continued growth in the number of individuals who are multi-lingual. However, the number of bilingual speech-language pathologists remains rather low. Monolingual English speaking SLPs comprise the majority of practicing clinicians in the United States (ASHA, 2021). This presents significant challenges to providing access and opportunity to culturally responsive services to clients and families in educational and healthcare settings. Language access is a topic that has received a great deal of attention over the last decade since it can impact who receives services. Limited language access has been linked to inequities and disparities that can be facilitated or reproduced by institutions, systems, and practitioners when language is a significant component of the health literacy skills needed to make decisions about resources and support that should be available to them (Agency for Healthcare Research and Quality, 2019). The National Health Law Program (2019) notes that several federal laws guide the provision of language access for health care services including Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. In educational settings, IDEA speaks directly to the importance of language access for families and students who receive or will receive special education services. In efforts to facilitate justice for those with limited English proficiency, The Federal Interagency Working Group on LEP C/O Federal Coordination and Compliance Section for the Civil Rights Division U.S. Department of Justice (2011) developed a planning tool to guide organizations receiving federal funding on ways to improve language access. This planning tool specifically addresses the importance of training staff on the importance of language access and specifically notes that, “Training should explain how staff can identify the language needs of an LEP individual, access and provide the necessary language assistance services, work with interpreters” (p.6). Based on the shifting demographics, professional mandate for CCCR (Council for Clinical Certification, 2018), and ethical and federal guidelines for anti-discrimination concerns about those with limited English proficiency (ASHA, 2016), it is important that SLPs receive adequate training on useful approaches and strategies that can remove the barrier of language access when providing clinical service delivery. Therefore, the purpose of this chapter will be to provide an overview on the importance of multicultural training and a novel teaching approach that was used to facilitate CCCR when SLPs are working with families and interpreters.

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BACKGROUND Multicultural Training Multicultural education and training has been described as the implementation of curricular methods that can be used to promote student understanding and advocacy of human rights, social justice, equity, and diversity (Ali & Ancis, 2005). It has also been described as specialized training and/or preparation to provide services to culturally and linguistically diverse populations (Rogers & Obryon, 2014). Updated models of multicultural training focus on the extension of CCCR beyond the three primary components of awareness, knowledge, and skills to also include desire, motivation, encounters, and flexibility (Camphina-Bacote, 2002; Patterson et al., 2018; Franca & Harten, 2016). Traditionally, training programs for speech-language pathology (SLP) students, involves completion of an academic and clinical component. Both instructional formats make it possible for programs and instructors to evaluate student content or knowledge acquisition, and application of discipline specific knowledge in practical settings and/or scenarios (Hill et al., 2010). Within the field of communication sciences and disorders (CSD) academic content related to CCCR and multicultural aspects of service delivery can be addressed within a specialized course, infusion throughout program curriculum, or both (Horton-Ikard & Munoz, 2010; Stockman et al., 2008). Stockman et al.’s (2008) argument for integral infusion to address all aspects of CCCR noted that the “will and skill” of individual faculty members was important for its implementation. However, the scholarship of teaching and learning literature has only recently begun to offer instructional methods for students to develop CCCR beyond increasing awareness, sensitivity, or content knowledge has remained stagnant (Radford, 2018).

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Instructional Strategies to Facilitate CCCR Several reports indicate that a variety of strategies are helpful in facilitating student content knowledge of multicultural issues. These strategies include, but are not limited to, group discussions, reflection papers, journaling, and lectures, (Griffer & Perlis, 2007; Mitcham et al., 2013). Unfortunately, there has been little discussion on instructional strategies that are useful in helping students to apply content knowledge gained from their academic setting, or demonstrate the practice of CCCR in clinical fields like speech-language pathology. The skills component of CCCR has been described as the practical abilities and/or behaviors that will be necessary for practitioners to provide culturally appropriate and relevant services to individuals from culturally and linguistically diverse backgrounds (ASHA, 2017). These abilities may include selecting appropriate assessment materials based on clients’ background; using effective cross-cultural-communication skills; and adapting treatment methods and materials to be culturally responsive (ASHA, n.d.). However, student demonstration of CCCR may be somewhat difficult to assess for programs that have difficulty in establishing and maintaining clinical practicums with diverse populations. One pedagogical strategy, from the medical field, that has received a great deal of attention in helping to foster and evaluate student level of CCCR and application of knowledge gained from multicultural course content is simulation and the use of simulation with standardized patients (Long, 2012; Marion et al., 2008). Simulated learning activities can help address some of the logistics of how to provide practice and evaluation opportunities for a student’s capacity to demonstrate CCCR. However, there are

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no published reports on the use of simulation and standardized patients for the purpose of facilitating and fostering different aspects of CCCR in speech-language pathology.

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Simulated Learning and Standardized Patient Encounters The use of simulation in the clinical education of pre-professional students is not a new concept. The medical field has been using simulated learning techniques for several decades (Cendan & Lok, 2012). Various types of simulated learning activities have been discussed in the literature including, but not limited to, those that use computer based programs/clients, virtual reality, mannequins, and standardized patient (SP) scenarios. There is a substantial body of literature supporting the use of simulation across a variety of allied? health care disciplines such as social work, physical therapy, nursing, and other fields (Beker et al., 2006; Emlet, 2010; Long-Bellil et al., 2011). Given that graduate programs in communication sciences and disorders are reporting increased difficulty in obtaining sufficient and diverse clinical placements and populations, alternative training methods and strategies will be needed to insure student opportunities and development of necessary skills (Zraick, 2012; Dudding & Nottingham, 2018). An expanding scope of practice, demands for interprofessional education, increasing costs of degrees, and limited availability of off-campus supervisors and preceptors all provide motivation for adopting innovative clinical education methods and techniques that will meet the learning needs of pre-professional SLPs (Dudding & Nottingham, 2018; Read, 2014). Simulated experiences expose student practitioners to realistic situations or events in a controlled setting. Best practices in simulated learning, requires that instructors develop a learning agenda that will provide students with an opportunity for deliberate, repeated practice that includes dynamic feedback (Jansen, 2015; Teteris, 2012). The benefits of simulated learning appear to have a positive impact on training programs, faculty, students, clinical supervisors, and the clients requiring care (Jansen, 2015). Simulated experiences can also encourage students to ask questions and take risks without fear of repercussions, which can in turn build on student skills and self-confidence (Jansen, 2015). The use of simulated experiences can allow for implementation of efficient and effective methods for teaching and assessing clinical skills (Zraick, 2012). As a pedagogical tool, simulated learning experiences can provide students with a format for integrating theory and practice without risk to patients (Bruce et al., 2003; Picou & Tharpe, 2015). Implementation of clinical simulated experiences allow students to apply didactic information from the classroom to their service delivery in practical settings. These experiences present students with the opportunity to develop practical skills within a safe and supportive environment. Simulated learning scenarios also provide students with clinical opportunities to work with low-incidence and/or diverse populations they may have not otherwise been provided in an external setting (Gutmann, 2016; Zraick, 2012; Hill et al., 2012; Min-Yu Lau et al., 2016). Simulated learning encounters, with and without standardized patients (SPs), have been useful as a strategy in the field of speech-language pathology for targeting skills related to communication, assessment, clinical reasoning, and interviewing skills with adult patients with aphasia, voice, swallowing disorders (MacBean et al., 2013; Hill et al., 2012). Furthermore, SPs have been found to improve crosslinguistic communication in clinical medical encounters (e.g., Pinto Taylor et al., 2019). SP encounters typically involve the use of actors to simulate a specific set of traits, behaviors, or characteristics of a patient with a particular condition (Shiarzi, et al., 2011). The SP is expected to carry out the encounter in the same fashion as a real patient who might find themselves in a similar situation. Training of the actors and development of scripts and other tools help to insure that the encounters are 227

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“standardized”. The use of simulated learning with SPs who speak a language other than English may prove to be a useful tool for facilitating CCCR in a fashion that other strategies may not accomplish.

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Cross Cultural Communication Skills: Interpreter Collaboration as a Necessary Skill More than 50% of practicing SLPs work in school-based settings with the rest of practitioners working in early intervention, medical, and private practice settings. One role of the culturally competent and responsive SLP, when working with students and families from linguistically diverse backgrounds, is to minimize barriers to receiving services. Another is to facilitate caregiver understanding the special education process (ASHA, 2013). One task that allows individual SLPs to demonstrate the practice of CCCR is collaboration with interpreters. SLPs possess knowledge about language differences and receive training on cross-cultural communication. They can use these skills to access and collaborate with interpreters to remove language barriers that may contribute to poor family, educational, or health outcomes (Diamond & Jacobs, 2009). Furthermore, effective collaboration with interpreters, may prove to be a necessary skill set in the CCCR toolbox given that the profession is primarily composed of monolingual SLPs (ASHA, 1985). As the demand for educationally based SLP services in various languages continues to grow, the need for speech-language pathologists to work effectively with interpreters in the provision of service delivery is inevitable (Saenz & Langdon, 2019). Collaboration between health professionals, educators, and interpreters becomes important to adequately meet the needs of the multilingual population served. Health professionals are advised to seek interpreters as not only a communication aid but also as a practical and informative guide (Hadziabdic & Hjelm, 2013). However, the lack of familiarity and awareness of the importance of using a professional interpreter has been noted to act as a barrier for the service delivery of culturally and linguistically diverse individuals (Santhaman, 2019; Langdon & Saenz, 2016a). IDEA-2004 Part B (subpart D) 300.304 indicates that evaluation procedures should be: “ non-discriminatory, administered in child’s primary language; and administered/scored by trained and knowledgeable professionals”. Section 300.322e also indicates that the use of interpreters should be implemented when working with families who may not use English as their primary language. Furthermore, the Office of Minority Health’s (2013) National Standards for Culturally and Linguistically Appropriate Services (CLAS) Standards 5, 6, and 7 place high priority on effectively collaborating with interpreters as important competencies to help address changing demographics, eliminate health disparities, improve service delivery, and fulfill ethical, regulatory, and legislative responsibilities. Existing research has shown there is limited knowledge and an apparent need for more specialized training and education among SLPs in working with interpreters (Langdon & Saenz., 2016a; Guiberson & Atkins, 2012; Palfrey, 2013; Kritikos, 2003; Pechak et al., 2018; Summers et al., 2015). The framework in which collaboration between the SLP and the interpreter occurs calls for the examination of various factors in not only the use of interpreters but also in the training and education of the participants (Krystallidou, 2016; Langdon & Saenz, 2016b; Weiner & Rivera, 2004; Dysart-Gale, 2005). In order to ensure effective collaboration between a SLP and an interpreter, the complexities and dilemmas of interpreter use, beyond bridging language need to be understood for the purposes of assessment, intervention, and/ or information sharing (Langdon & Saenz, 2016a; Hadziabdic & Hjelm, 2013; Huang, Siyambalapitiya, & Cornwell, 2019).

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The Action, Ratification, Task framework (i.e., the A.R.T. framework) proposed by Krystallidou (2016), not only discusses the role of the interpreter as a provider of verbal behavior but accounts for how non-verbal behavior is signaled, communicated, and negotiated within the collaboration. This analysis of interactions between the collaborators and participants is merely one significant function that occurs within the encounter (Krystallidou, 2016; Langdon & Saenz, 2016a). Other logistical and detailed considerations under a framework or guide for interactions between service professionals and interpreters follows the paradigm of meeting to collaborate and educate before, throughout and after the interpretation. This paradigm is often cited to be effective ways to effectively prepare and work with an interpreter across various professions (Weiner & Rivera, 2004; Juckett & Unnger, 2014; Langdon & Saenz, 2016a). Likewise, in the field of SLP, Langdon and Saenz (2016a) recommend the use of a tripartite briefing, interaction, and debriefing or (BID) framework during collaborative SLP and interpreter encounters. Langdon and Saenz (2016a) outline a protocol to help guide SLPs and audiologists in their preparations and planning stages prior to interviews, conferences, and the assessment components of service delivery. The BID framework focuses on the use of the following several key areas of interpreted encounters: • •

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Briefng (B)-provides recommended practices for meeting with the interpreter to prepare for interviews, conferences, or assessment, prior to direct interaction with client and family. For example, the SLP would provide a clear description of the purpose of the meeting to the interpreter. Interaction (I)-addresses strategies and skills that should be used when engaging in interpreted encounters and the tripartite context. Behaviors in this area include understanding and implementing appropriate environmental arrangements, and avoiding side conversations. Debriefng (D)-focuses on behaviors and practices needed to refect on the encounter once the client and/or family member has exited the context and environment.

Currently, there are no published reports on the use of simulation and standardized patients for the purposes of facilitating and fostering different aspects of CCCR in speech-language pathology. The skills necessary for effectively and efficiently collaborating with an interpreter represent a unique set of cross-cultural communication skills that SLPs in educationally based and health care settings need to employ when working with multilingual families. We completed pilot study to determine if a simulated, standardized patient and interpreter encounter would be an effective tool for facilitating and evaluating the CCCR of students enrolled in a multicultural course. We wanted to know if the implementation of a standardized patient encounter would help identify the strengths and weaknesses of students’ ability to demonstrate effective cross-cultural communication skills when collaborating with interpreters to facilitate language access. From an instructional perspective we were also interested in identifying the positive and negative aspects of participating in this type of simulated learning encounter, as reported by pre-professional students?

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 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers

MAIN FOCUS OF THE CHAPTER Overview of Pilot Study and Method The study was approved by the Institutional Review Board at the authors’ university. The study included several different components including the administration of typical classroom practices, participation in the simulated learning experience using the campus simulation lab; faculty observation and evaluation of student skill during the simulated learning encounter, and collection of evaluative feedback from participants. The simulated learning experience focused on the effective collaboration and use of interpreters. It was designed to provide students with practice applying global and specific knowledge from course content they encountered during their first quarter of graduate school. After exposure to content, students engaged in a simulated learning activity during their regularly scheduled class time in two separate cohorts.

Participants The participants for this study were recruited from a first year cadre of graduate students in a preprofessional, CAA accredited MA speech-language pathology program (N=44). These students were enrolled in the required multicultural course during their first quarter of graduate studies. The majority of the students in the course were white, female, and monolingual but did include students who were BIPOC, male, monolingual and bilingual. All students enrolled in the course were required to complete all of the assignments for the course, including the simulated learning experience. However, students needed to provide consent for the use of their information, data, and materials for research purposes. An overview of the study was outlined in a recruitment packet provided to students by an independent faculty member. The recruitment packet contained consent forms with unique identifiers that were used to match all forms and paperwork throughout the study. The packet also contained data collection forms used for the entire quarter with their unique identifier: The independent faculty member explained the informed consent process and answered student questions regarding the study. The informed consent process explained the voluntary nature of the project, how anonymity of participants would be preserved throughout the quarter, and the types of data that would be collected. Thirty of the 44 students enrolled in the course provided informed consent for the use of their data and materials. The authors, as instructors for the course, were not provided with any of this information until grades for the quarter were submitted. Upon grade submission, the independent faculty member provided all student packets to the authors.

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Typical Classroom Practices The multicultural course provided instruction on evidence based-practices for meeting the needs of individuals from culturally and linguistically diverse populations across the lifespan. This was the second year that the course was offered in the curriculum. The course met once a week for nearly three hours. The course was designed to meet a number of program learning objectives and discipline standards for required knowledge and skills as outlined by ASHA at the time (2016). All activities for the course, including the simulated learning interpreter encounter, were aligned with one or more program objectives and council standards.

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 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers

The course curriculum and assigned readings focused on helping students develop all components of CCCR. Historically, the course has used the following pedagogical methods to facilitate student learning: in-class lectures, video and other media, and small group discussion. Prior to the standardized patient interaction students received instruction on dimensions of CCCR; cross cultural communication; sociolinguistic considerations when interpreting assessment results; bilingualism, and working with interpreters. The course used the following tools and strategies to facilitate student learning: in-class lectures, digital media, and small group discussions. Content describing the necessary skills needed for effective interpreted encounters was provided through didactic lectures. Additionally, specific vignette segments of Langdon’s (2002) video highlighting various components of the BID framework and process for working with interpreters was shown to students. Students were also provided with an in-class activity in which they were asked to identify general skills and specific behaviors for each of the BID components.

Simulated Learning Overview Planning for the Simulated Encounter The standardized patient experience for students enrolled in the multicultural course took place on campus. The Clinical Skills and Simulation Center (CSSC) at the university provides staff, resources, and support in implementing simulated experiences. A meeting was held with the course faculty and the Director and Assistant Director of the CSSC to assist in the coordination of the simulated learning experience. This meeting was held nearly three quarters prior to the simulated learning experience. The staff at the simulation center worked with the authors to coordinate room location and times, identify actors for standardized patients, and ensure that the necessary technical support was provided for the duration of the learning experience. The nature of this experience required identifying Spanish speakers who could assume the role of a parent to a preschool student with suspected speech-language issues, as well as, individual interpreters who also spoke Spanish. The graduate students were introduced to the CSSC during the first two weeks of their Interprofessional Education course during their first quarter and provided with a tour and overview of the environment and logistical information.

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The Simulated Learning Scenario The scenario offered the SLP students the opportunity to use cross-cultural communication skills, content knowledge about bilingual speech development for Spanish speakers, and strategies to effectively interact with an interpreter to convey information to parents who do not speak English based upon Langdon and Saenz’s (2016a) BID framework. Each session was completed within a 25-minute timeframe. These sessions were digitally recorded using the platform and guidelines for learning experiences in the CSSC. Audio and video recording occurred for the purposes of faculty observation and evaluation.

Student Learning Objectives The specific learning objectives for the simulated learning experience were to: 1) identify barriers to effective cross cultural communication; 2) distinguish dialectal and English Language Learning Variation from markers of speech and/or language impairment.; 3) employ the use of effective strategies and options to collaborate with interpreters.; and 4) employ the use of effective strategies and options to

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 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers

explain the results of an assessment findings, elicit parental information, and make treatment recommendations to a parent who has LEP.

Description of Simulated Learning Environment The CSCC was used for completion of the simulated experience. Each room is equipped with video monitoring and recording capabilities, an intercom system, a two-way mirror, and an observation room. Students were responsible for arranging the environment for their encounter. For each encounter, there was an interpreter, actor/standardized patient who was a Spanish speaking parent, monitor, and a graduate student clinician.

Materials, Data Collection, and Procedures

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Student Pre-Brief, Scenario, and Debrief Student pre-brief. Students were provided with guidelines to help them prepare for the simulated learning encounter. They were provided with the case study two weeks in advance and were told to review it. Students were instructed to specifically extract key pieces of information from the case study so that they could discuss the reason for the referral, summary of background information, caveats regarding assessment modifications, and review of hearing and oral mechanism screening results. Finally, they needed to be able to provide a brief, concise, succinct, and accessible overview of the assessment tools used and their findings. Students were also given the opportunity to practice this in pairs during regular classroom time. Students were allowed 25 minutes total for the encounter: 5minutes for the briefing, 15 minutes for the interaction, and 5 minutes for the debriefing. Students were told that their time could not exceed 25 minutes. Simulated learning scenario. The scenario involved student presentation of speech-language evaluation results of a nine-year-old, English/Spanish bilingual student and treatment recommendations to her monolingual Spanish speaking parent based on a case study and script provided by instructors. The case study report was 14 pages in its entirety, and excerpts from the case study are provided in Table 1. On the day of the event SLP students were asked to arrive on their assigned date at least 15 minutes before their scheduled encounter time. They were asked to adhere to the program’s clinical dress code and wear their white coat. Students were also required to check in with the floor monitor and course faculty upon their arrival. They were allowed to bring paper, pencil, clip board, and the case report for the interaction. Students were told to leave all personal belongings and cell phones outside of the encounter area and were given lockers to store their belongings. We also requested that they bring their laptop and participant id number (for filling out their online evaluation after the experience). During the actual encounter students were asked to monitor their time to make sure that they were on task and able to carry out the entire BID process. Student debriefing. The simulated interpreted encounter had a “nested” debriefing period within the BID process. This provided the graduate student with the opportunity to receive feedback from the interpreter on things that went well or issues to keep in mind for future interactions. Immediately after the experience, a faculty member informally addressed the students within that cohort in the atrium and asked, “What did you think?” or “How did it go?” Students were provided an opportunity to share their immediate thoughts and feelings relevant to the encounter, interaction, and/or environment.

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 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers

Table 1. Extracted case study excerpts Area of Interest

Description

Reason for Referral

Child referred for a speech and language evaluation by her father due to concerns with her ability to be understood in both Spanish and English.

Background Information

A file review and a parent interview were conducted to gain additional information. Unremarkable for developmental, medical and social background, academic history and preexisting speech and language concerns.

Evaluation* Speech Sound Production

Formal Spanish assessment results: Errors observed were of the sound “s” in initial, medial, and final positions at the sentence level. Formal English assessment results: Speech-sound productions included differences that are identified as appropriate characteristics of bilingual speakers whose primary language is Spanish. Informal English and Spanish assessment results: Language samples consistent with formal assessment findings. Increase in speech rate noted in both languages.

Language

No concerns in English or Spanish

Pragmatics

Age appropriate

Voice, Fluency

Adequate

*Note. Assessment was conducted in both English and Spanish. In order to be identified with language disorder, the language disorder needs to be present in both languages.

Students were also encouraged to access the online feedback form and evaluation rubric immediately after the experience to provide their perceptions of the experience. At the conclusion of all student encounters, a follow-up discussion regarding the experience was also conducted. This discussion was initiated by the instructors during the next regularly scheduled classroom meeting time.

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Actor and Interpreter Orientation and Training The interpreters were recruited from a community agency in the surrounding area that works to provide local organizations with trained interpreter services. The parent actors were recruited from Spanish speakers who were employed by the CSSC. The community interpreters and individuals who were hired to act as the standardized patient or parent participated in a 90-minute training session two weeks prior to the scheduled SP encounters. Part one of the session consisted of introductions, an overview and description of the purpose of the standardized patient experience, and an explanation and description of the BID model for interpreting. Part two consisted of demonstration of the BID process within a parent meeting through the use of an excerpt from the same video that students viewed, “Working with interpreters to serve bilingual children and families” (Langdon, 2002). The case study and script were also introduced and a mock run through of the scenario was completed in small groups. The last part

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 An Instructional Strategy to Facilitate Pre-Professional Training in Removing Language Access Barriers

of the session involved discussion of logistics of the event and touring of the location and rooms to be used for the experience.

Assessment and Evaluation of Student Performance and Simulated Learning Encounter Items assessed were: 1) use of the GS/BID process and expected behaviors during interpreted encounters; 2) student feedback; and 3) interpreter/parent actor feedback. Evaluation of GS and BID process. Student performance using the BID framework was evaluated using a Faculty/Student Evaluation Rubric. An additional evaluative component was included in the rubric to evaluate general skills (GS). The GS portion emphasized general interpersonal communication skills (active listening, responding to nonverbal cues) during the interpreted encounter. Recall, that the learning encounter was recorded. The authors were able to access video recordings in order to evaluate student implementation of skills using the rubric to assess if skills were demonstrated or not demonstrated. Students were also asked to complete the rubric to self-evaluate their performance. The maximum amount of points that a student could earn using the rubric was 46. For each item on the rubric students could receive a score of 1 if they did not demonstrate a specific behavior or strategy within the skill area. Students received a score of 2 if they demonstrated the behavior or strategy. The rubric was divided into four major areas for the GS/BID process and Appendix A provides examples of items that were scored. Participant feedback forms. An open-ended student feedback form, with three questions, was completed by student participants upon their completion of the simulated learning activity: What were two things that you liked about the simulated activity (Pros)? What were two things that you did not like about the activity (Cons)? What are some recommendations for improving the activity (Recommendations)? A different feedback form, with forced choice and open-ended questions, was completed by the actors and interpreters upon their completion of the simulated learning activity (See Appendix B).

RESULTS

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Strengths and Weaknesses During the Simulated Exercise In order to answer research question one, student scores from the faculty evaluation rubric were converted to percentages. In order to determine which areas were easier or more difficult, (i.e., strengths vs weaknesses) differences in percentage accuracy across the four GS/ BID components (i.e., general skills, briefing, interaction, and debriefing) were examined using a Friedman test. The Friedman test indicated that there were significant differences between the four distributions (χ2(3) = 55.872, p