Roles and Responsibilities

ASHA requires that audiologists and speech-language pathologists (SLPs) practice in a manner that considers the impact of cultural variables as well as language exposure and acquisition on the individual and their family. Audiologists and SLPs provide services to diverse populations. Professional and clinical competence requires that audiologists and SLPs practice in a manner that considers each individual’s cultural and linguistic characteristics and unique values so that these professionals can provide the most effective assessment and intervention services (ASHA, 2004, 2006). ASHA-certified practitioners have met academic and professional standards that include knowledge of cultural variables and how they may influence communication and service delivery. See ASHA’s Audiology Certification Standards and Speech-Language Pathology Certification Standards. Clinicians are responsible for providing culturally responsive and clinically competent services during all clinical interactions. Responsiveness to the cultural and linguistic differences that affect identification, assessment, treatment, and management includes the following actions:

• Engaging in an internal self-assessment to consider the influence of one’s own biases and beliefs and their potential impact on service delivery
• Identifying and acknowledging limitations in education, training, and knowledge as well as seeking additional resources and education to develop cultural responsiveness (e.g., continuing education, networking with community members)
• Seeking funding for and engaging in ongoing professional development related to cultural responsiveness
• Demonstrating respect for each individual’s ability, age, culture, dialect, disability, ethnicity, gender, gender identity or expression, language, national/regional origin, race, religion, sex, sexual orientation, socioeconomic status, and veteran status
• Integrating each individual’s traditions, customs, values, and beliefs into service delivery
• Recognizing that assimilation and acculturation impact communication patterns during identification, assessment, treatment, and management of a disorder and/or difference
• Assessing and treating each person as an individual and responding to their unique needs, as opposed to anticipating cultural variables based on assumptions
• Identifying appropriate intervention and assessment strategies and materials that do not (a) violate the individual’s unique values and/or (b) create a chasm between the clinician, the individual, their community, and their support systems (e.g., family members)
• Assessing health literacy to support appropriate communication with individuals and their support systems so that information presented during assessment/treatment/counseling is provided in a health literate format
• Demonstrating cultural humility and sensitivity to be respectful of individuals’ cultural values when providing clinical services
• Referring to and/or consulting with other service providers with appropriate cultural and linguistic proficiency, including using

• a cultural informant—a member of, or someone familiar with, a given culture (Spradley & McCurdy, 1972) who can supply relevant information about that culture to a third-party member (e.g., a clinician);
• a cultural broker—an individual who acts as a bridge between diverse families and schools (Jezewski & Sotnik, 2001; Torres et al., 2015) or one who advocates for a given culture to a third-party member (e.g., a clinician); or
• an interpreter and/or a translator, where appropriate (see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators for further information)

• Upholding ethical responsibilities during the provision of clinically appropriate services

Clinicians have a responsibility to advocate for consumers, families, and communities at risk for or presenting with communication and related disorders and/or differences. Advocacy specific to cultural responsiveness includes

• collaborating with professionals across disciplines and with local and national organizations to gain knowledge of, develop, and disseminate educational, health, and medical information pertinent to specific communities;
• gaining knowledge and education of high-risk factors (e.g., hypertension, heart disease, diabetes, fetal alcohol syndrome) in specific populations and the incidence and prevalence of these risk factors that can result in greater likelihood for communication and related disorders and/or differences;
• providing education regarding prevention strategies for speech, language, cognitive, hearing, balance, voice, and feeding/swallowing disorders in specific populations;
• providing appropriate and culturally relevant consumer information and marketing materials/tools for outreach, service provision, and education, with consideration of the health literacy, values, and preferences of communities; and
• identifying and educating communities regarding the impact of state and federal legislation on service delivery.

Ethical Considerations

Cultural and linguistic responsiveness is as important to the provision of services as are scientific, technical, and clinical knowledge and skills. The ASHA Code of Ethics (ASHA, 2023) contains the fundamentals of ethical conduct, which are described by Principles of Ethics and by Rules of Ethics. Principles of Ethics form the underlying philosophical basis for the Code of Ethics, whereas Rules of Ethics are specific statements of minimally acceptable as well as unacceptable professional conduct. The following provisions in the Code of Ethics establish the responsibilities of the practitioner to provide culturally and linguistically competent services and research and to avoid discrimination in professional relationships:

• Individuals shall provide all clinical services and scientific activities competently (Principle I, Rule A).
• Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided (Principle I, Rule B).
• Individuals shall not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of age; citizenship; disability; ethnicity; gender; gender expression; gender identity; genetic information; national origin, including culture, language, dialect, and accent; race; religion; sex; sexual orientation; or veteran status (Principle I, Rule C).
• Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience (Principle II, Rule A).
• Individuals shall not discriminate in their relationships with colleagues, assistants, students, support personnel, and members of other professions and disciplines on the basis of age; citizenship; disability; ethnicity; gender; gender expression; gender identity; genetic information; national origin, including culture, language, dialect, and accent; race; religion; sex; sexual orientation; socioeconomic status; or veteran status (Principle IV, Rule M).

Principles of Ethics and Rules of Ethics are not intended to serve as justification for the denial of services or as the basis for discrimination in the delivery of professional services or the conduct of research and scholarly activities. Rather, “individuals shall enhance and refine their professional competence and expertise through engagement in lifelong learning applicable to their professional activities and skills” (Principle II, Rule C). Assessment and treatment should not vary in quality based on factors such as ethnicity, age, or socioeconomic status. Discrimination in any professional arena and against any individual, whether subtle or overt, ultimately dishonors the professions and harms all those within the practice.

Clinicians have an obligation to seek the information and expertise required to provide culturally responsive services and are asked to carefully consider the basis for determining their need to refer and/or deny services. ASHA’s Office of Multicultural Affairs can provide assistance and resources in making this determination and in identifying resources to continually enhance cultural responsiveness. The Board of Ethics’ Issues in Ethics Statement: Cultural and Linguistic Competence (ASHA, 2017) is designed to provide guidance to members, applicants, and certified individuals as they make these types of professional decisions.

If you are concerned about the appropriate interpretation and application of the Code of Ethics, staff members from ASHA’s Ethics team (ethics@asha.org) can provide further information and direction.

Developing Cultural Responsiveness

Developing cultural responsiveness is an ongoing process. It involves self-awareness and cultural humility, and it may require audiologists and SLPs to recognize what they do not know about the languages and cultures of the individuals, families, and communities they serve. As a result, they may seek culture-specific knowledge and experience in these areas. Per Kohnert (2008), the culturally responsive clinician has the ability to

• simultaneously appreciate cultural patterns and individual variation;
• engage in cultural self-scrutiny to assess cultural biases and improve self-awareness;
• utilize evidence-based practice to include client/patient/family characteristics, clinician expertise, and empirical evidence in clinical decisions; and
• understand the communication contexts and needs of clients/patients and their families by considering communication disorders within a social context.

Culturally responsive clinicians also identify bias and/or determine appropriateness of materials in assessment and treatment materials and practices. Additionally, culturally responsive clinicians recognize the role of social justice (fairness for all people, including the equitable distribution of resources in a society) by advocating for, promoting, and providing quality care and education for all individuals (Horton, 2021, Unger et al., 2021).

Developing cultural responsiveness includes

• self-assessment, including a review of the clinician’s personal history, values, beliefs, and implicit and explicit biases;
• an understanding of how these factors might influence perceptions of communication abilities and patterns;
• an understanding of how personal perceptions might influence interactions and service delivery to a variety of individuals; and
• transitioning understanding into actions that support an unbiased, culturally appropriate, and relevant clinical environment.

As cultural responsiveness has a relationship with cultural competence, the work of Cross (2012) is relevant to the present discussion. Cross’s (2012) continuum of cultural competence includes the following stages:

Cultural destructiveness—This stage includes policies, practices, and attitudes that are detrimental to cultures and individuals within those cultures.

Cultural incapacity—At this stage, agencies and individuals do not have the ability to assist those in need.

Cultural blindness—At this stage, the prevailing belief is that color or culture makes no difference or does not exist.

Cultural pre-competence—At this stage, cultural differences are accepted and respected. This includes ongoing self-assessment of cultural bias.

Advanced cultural competence—At this stage, the individual and/or agency holds culture in high esteem and works to contribute to knowledge regarding culturally competent practice.

Self-assessment may reveal where a clinician is along the continuum of cultural competence (see ASHA’s Cultural Competence Assessment tool). The steps to developing cultural responsiveness are as follows:

• Learning about an individual’s culture(s), language, experience, history, alternative sources of care, and power differentials.
• Developing a dynamic definition of what constitutes culture that allows for possible change, or redefinition, as all participants grow.
• Demonstrating respect for individual cultural backgrounds by integrating personal preferences and cultural practices into assessment and treatment, including recognizing the influence of culture on linguistic variations, which may result in variations in communication patterns due to context, communication intent, and communication partner.
• Recognizing that power in the clinical situation is reciprocal and that individuals receiving services are supported, are encouraged, and have the capacity to make choices and changes in their lives and to participate in service delivery as appropriate for their culture and personal preferences.
• Identifying cultural variables that are both explicit (e.g., external symbols, food, and language) and implicit (e.g., religious practices and beliefs, spiritual beliefs, educational values, age and gender roles, child-rearing practices, and fears and perceptions).
• Developing an ethnogenetic viewpoint that recognizes that groups, cultures, and the individuals within them are fluid and complex in their identities and relationships.
• Moving away from ethnocentrism, the belief that one’s way of life and view of the world are inherently superior to others’ and are more desirable.
• Moving away from essentialism, which defines groups as “essentially” different, with characteristics “natural” to a group (Fuller, 2002). Essentialism does not consider variation within a culture and can lead health care professionals to stereotype their patients. Health care professionals may incorrectly focus practice on beliefs about groups instead of individuals as a result.

Cultural Dimensions

Individuals within all cultures vary based on differences, preferences, values, and experiences. Culture is learned, not inherited. Hofstede (2011) identifies cultural dimensions that are globally applicable and are reflected in all aspects of life, including

• family life,
• child-rearing practices,
• education,
• employment, and
• health care practices.

Hofstede (2011) also identifies the following as the broadest and most encompassing dimensions of cultural variability:

• Individualism–collectivism—how individuals are integrated into groups
• Power distance—how human inequality and/or the power of one group over another is interpreted
• Masculinity–femininity—emotional roles as divided between genders
• Uncertainty avoidance—society’s stress level in the event of an unforeseeable future
• Long- and short-term orientation—whether people’s efforts are focused on the past, present, or future
• Indulgence versus restraint—instant versus delayed gratification and the control of desire

Please see Examples of Cultural Dimensions for definitions and explanations of the terms above.

Bearing in mind that these cultural dimensions are applied broadly to each country and that individuals may demonstrate individual differences within their country’s culture, Hofstede (2011) developed a Country Comparison tool. This tool displays a graphic visualization of each country’s dimensions in numerical terms, as well as a display of two or more countries’ dimensions for comparison.

Additional dimensions include

• cultural value orientations (e.g., time orientation),
• verbal communication (e.g., turn-taking expectations, amount of talking allowed among conversational partners),
• nonverbal communication (e.g., eye contact, personal space use), and
• relational communication norms (e.g., greeting rituals, conversational expectations for various types of individuals).

Cultural dimensions occur along a continuum, and an individual may demonstrate behavior that falls anywhere along that continuum. A wide variety of factors may influence how cultural dimensions are manifested by each individual, including

• individual differences;
• individual circumstances;
• assimilation—the process of someone in a new environment totally embracing the host culture (Riquelme, 2013); and
• acculturation—the integration of the host culture with the native culture to varying degrees (Riquelme, 2013).

Implications of Cultural Dimensions

Cultural dimensions influence verbal and nonverbal behaviors in communicative interactions. They affect how individuals convey trust or distrust and what they interpret as friendly, unfriendly, interested, or bored behaviors. For example, friendliness is conveyed by

• listening without interrupting the speaker in a high power distance culture;
• using formal and specific language in a strong uncertainty avoidance culture;
• verbally disclosing information in an individualistic culture; and
• using an assertive style of communication in a highly masculine culture.

Please see Examples of Cultural Dimensions and the Cultural Dimensions section for definitions and explanations of the terms above. Failure to recognize these variations in interactions can result in crucial miscommunications. For example, professionals educated in a particular setting (e.g., U.S. schools) may value low power distance and may attempt to treat students, clients/patients, and families as equals, encouraging them to participate in the development of therapeutic goals and objectives. However, people from high power distance cultures may question the competence of a professional who attempts to include them in the development of interventions (Hwa-Froelich & Westby, 2003). This discrepancy may negatively impact communication.

An audiologist or SLP whose cultural beliefs are consistent with independence and active experimentation may face conflicts with families whose cultural beliefs support dependence and compliance if there is a lack of awareness of these cultural differences (Hyter & Salas-Provance, 2021).

Research suggests that when clients/patients view themselves as similar to their health care providers in terms of cultural and linguistic background, the health care provider–patient relationship is strengthened. Patient-centered communication is one factor noted to affect perceived personal similarity (Street et al., 2008).

The impact of cultural dimensions should be considered within the environment and within clinical interactions. Clinicians are encouraged to be mindful of intersectionality—the way in which systems of inequality that are based on discrimination due to cultural dimensions meet to create unique dynamics and the reality that each system has the potential to reinforce other systems. This concept further emphasizes the importance of developing rapport with an individual to determine the various social influences that may impact treatment outcomes. Please see Crenshaw (1989), a seminal work on intersectionality, for further information.

Cultural Responsiveness Versus Stereotyping

Cultural responsiveness requires audiologists and SLPs to consider how values and norms are uniquely shaped. Even when individuals share similar cultural backgrounds, their values are shaped by their own experiences and interpretations of these experiences. Stereotyping uses preconceptions of a particular population and may result in inappropriate behaviors, clinical judgments, and decisions.

For example, cultural responsiveness in dysphagia services includes the identification of the individual’s personal food history and preferences. Stereotyping in dysphagia services could lead to recommendations based solely on the food preferences most often associated with the individual’s cultural background.

Difference Versus Disorder

Cultural responsiveness requires clinicians to distinguish a communication difference from a communication disorder. A clinically competent clinician will gain sufficient knowledge of an individual’s cultural and linguistic background to avoid making an assumption that a communication pattern(s) constitutes a disorder when the pattern(s) may in fact be reflecting cultural and linguistic variation.

Distinguishing between communication differences and communication disorders involves the ability to

• recognize that cultural dimensions and individual variation may influence eye-gaze behavior; facial expressions; body language; rules of social interaction; child-rearing practices; perceptions of mental health, physical health, illness, and disability; and patterns of superior and subordinate roles in relation to status by age, gender or gender identity, and class (Lau, 2006; Murry et al., 2011);
• review cultural and linguistic variables and factors that may influence communication to determine if the communication patterns of an individual may be related to their cultural background (Penn et al., 2017);
• determine if the communication pattern is related to the individual’s linguistic background (see Multilingual Service Delivery in Audiology and Speech-Language Pathology);
• understand that differences may be related to the amounts and types of different exposure to and development of new cultural communication patterns;
• recognize that assimilation and level of acculturation may influence individual communication patterns and behaviors;
• identify a disorder as a breakdown in communication that is sufficient to negatively influence the effective use of symbols and message processing in the language used by the speaker;
• identify a communication difference as a variation of a symbol system used by a group of individuals that reflects and is determined by shared regional, social, or cultural/ethnic factors;
• recognize that a regional, social, or cultural/ethnic variation of a communication system is rule based and should not be considered a disorder of speech or language (e.g., an accent or a dialect does not reflect an articulation disorder; Hamilton et al., 2018); and
• incorporate the cognitive learning styles of individuals and avoid the expectation of mainstream methods for problem solving and communication (Davis & Stanford, 2020).

Although clinicians work to avoid misidentifying language/dialect differences as disorders, research has demonstrated that children from minoritized backgrounds who may speak nonmainstream English dialects are less likely to receive needed services than similar White peers (Morgan et al., 2015, 2016). Rather than a strictly dialect versus disorder framework, Oetting et al. (2016) recommend that clinicians use a disorder within dialect framework to keep the conversation about the nature and prevalence of childhood language disorders across dialects at the forefront when considering screening, assessment, and treatment planning and when providing education about the services clinicians provide.

Terminology

Clinicians consider their use of person-first or identity-first terminology (e.g., “person with autism” vs. “autistic person”) and remain aware that terminology used to describe individuals may vary based on individual identity and preference. When there is a preference for either person-first or identity-first language, that preference should be honored. When in doubt clinicians may ask the individual to whom they are referring.

Similarly, clinicians should be aware of appropriate pronoun use. Using an individual’s correct personal pronouns shows respect to the individual and creates an inclusive environment. Please see Supporting and Working With Transgender and Gender-Diverse People for further information.

Response to Intervention and Dynamic Assessment

Early intervention services are used to determine which children have intrinsic learning problems that cannot be attributed to lack of experience with the tasks. Response to intervention and dynamic assessment are early intervention processes that help decrease unnecessary referrals for special education services for children who can benefit from modified instructional techniques. These approaches may also differentiate an underlying disability from a difference because they are highly focused on intended outcomes, individual needs, and data resulting from reliable screening measures (Hosp, n.d.).

Cultural Responsiveness in Clinical Service Delivery

Clinically competent service providers recognize and address the cultural and linguistic variables that affect service delivery while individualizing assessment and treatment strategies. This individualization ensures that the audiologist or SLP does not make overgeneralizations regarding a person’s cultural or linguistic background. When providing services, audiologists and SLPs consider

• if the environment setup is inviting;
• if the environment is accessible;
• the need to modify scheduling and appointment times due to cultural and individual values that may influence availability;
• the appropriateness and cultural sensitivity of materials used during assessment and intervention activities; and
• individual perceptions of assessment, possible diagnosis, and intervention strategies.

The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care (Office of Minority Health, n.d.) provide a framework for all health care organizations to best serve the nation’s increasingly diverse communities.

Clinical Topics Practice Portal pages include additional information regarding the potential impact of culture as it relates to specific clinical topics.

The Assessment Process

When conducting assessments, audiologists and SLPs consider the individual’s level of acculturation and assimilation within the mainstream culture. In addition, practitioners determine how familiar and comfortable the individual is with social, interpersonal, academic, and testing practices, as familiarity with testing procedures may influence performance during the assessment process. An evaluation may have to be completed over multiple sessions if there is a need to assess an individual in more than one language, collaborate with an interpreter, utilize alternate assessment formats, and find and/or establish norms for a given population. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators as well as ASHA’s page on Dynamic Assessment for more information.

Gathering a Case History

Case histories include information about the individual’s communication characteristics as they compare to others from the same community. Whenever possible, case histories are collected using open-ended questions rather than asking respondents to select from options that may not be appropriate for them. Clinicians do not make assumptions about individuals or their families based on general cultural, ethnic, or racial information. The case history process is used to gather specific knowledge of the diverse views represented.

Ethnographic interviewing encourages the interviewee to provide information that they feel is relevant rather than to respond to clinician-presented questions. This style of interviewing can provide insight into individual perceptions, views, desires, and expectations. Strategies for ethnographic interviewing include

• using open-ended questions rather than “yes” or “no” questions;
• restating what has been said by repeating the exact words rather than paraphrasing or interpreting;
• summarizing statements and providing the opportunity for correction in case of misinterpretation;
• avoiding multiple questions posed in rapid succession and/or multipart questions;
• avoiding leading questions that tend to direct the person to a specific response; and
• avoiding using “why” questions because such questions may sound judgmental and may increase defensiveness (Westby et al., 2003).

Assessment Tools

Under most conditions, the use of standardized tests alone is not a comprehensive approach to determine whether an individual has a communication disorder. Test scores are invalid for the test taker who is not reflected in the normative group for the test’s standardization sample, even if the test is administered as instructed. In these cases, standardized tests cannot be used to determine the presence or absence of a communication disorder. However, these tests can provide valuable descriptive information about the individual’s abilities and limitations in the language of the test (e.g., a test administered in English will assess an individual’s ability in English).

Formal test environments and assessment tools may be unfamiliar to individuals who have not had exposure to the mainstream educational context and to the culture of testing that includes both nonverbal and verbal components. Nonverbal aspects of the testing culture include

• perception of time;
• how one is expected to learn;
• how one is expected to respond to the examiner, regardless of gender, culture, age, and/or socioeconomic background;
• attitudes toward display of abilities;
• attitudes toward guessing, using the process of elimination, storytelling, or conversing with an unfamiliar individual;
• test abstraction (e.g., naming protocols that require providing already shared information or situations in which the individual is required to assume a “make-believe” attitude in order to engage in an expected manner); and
• nonlinguistic aspects of pragmatics (DeJarnette et al., 2015).

Verbal aspects of the testing culture include

• form of language,
• functions of language,
• content of language,
• organization of language, and
• pragmatic rules of social interaction.

Accommodations and Modifications

For the purpose of this page, an accommodation of an assessment process refers to an adjustment or change to the environment or mode of response in order to (a) facilitate access and interaction and (b) remove barriers to participation without changing what the test measures. For the purpose of this page, a modification refers to a change in material, content, or acceptable response. Accommodations and modifications may be necessary to gain useful information about the individual’s abilities and limitations. However, some changes may invalidate a standardized score. Selected examples of accommodations and modifications include

• rewording and providing additional test instructions other than those allowed when presenting trial items;
• providing additional cues or repeating stimuli that may not be permitted on test or task items;
• allowing extra time for responses on timed subtests;
• skipping items that are inappropriate for the individual (e.g., items with which the individual has had no experience);
• asking the individual for an explanation of correct or incorrect responses (when not standard procedure); and
• using alternate scoring rubrics.

It is important to note that there can never be one-to-one translation for test items. Languages vary across many factors, including order of acquisition of vocabulary, morphology, and syntactic structures. Well-developed standardized tests are difficult to find for individuals who use a language other than or in addition to spoken English. See ASHA’s Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology for more information.

It is the clinician’s responsibility to document all accommodations and modifications made during the assessment process in all reporting.

Considerations for Audiologic Assessment

Some audiologists may rely on physiological measures in an attempt to circumvent the influence of language factors on assessment outcomes. However, all components of the audiologic evaluation, including speech audiometry, should be completed if possible. It is important to note that

• speech reception threshold testing is intended to measure the threshold for hearing intelligible speech and is not intended to measure vocabulary, familiarity, or intelligence;
• responses may reflect the phonemic inventory of the language(s) spoken (see Phonemic Inventories and Cultural and Linguistic Information Across Languages);
• a lack of familiarity with test items and/or the testing process may compromise speech scores; and
• speech testing materials are language specific. It is not appropriate to simply translate and then use a test that has been developed and normed in a specific language. Compromised performance may be due to language background rather than hearing and/or processing disorders.

Treatment

Treatment should be initiated with an understanding of the environmental and language context of the individual and their family, and every effort should be made to minimize or remove physical, cultural, linguistic, and institutional barriers to intervention. Culturally relevant stimuli and experiences are to be included in intervention programs as appropriate. Audiologists and SLPs consider the nature of family and caregiver involvement during intervention. Selected considerations that may influence (a) individual expectations of the clinician and (b) the therapeutic process include

• the individual consistently deferring to the audiologist/SLP as the expert,
• cultural differences that influence the nature and level of the individual’s participation based on the perceptions of their role,
• therapy techniques that promote behavior patterns inconsistent with family values, and
• how language and communication patterns are taught and influenced by the individual’s culture and values.

Factors considered when selecting appropriate audiologic intervention include the impact of cultural influence on the

• acceptance of hearing loss as a disability,
• perceived value of medical intervention,
• cultural and social significance attached to hearing loss,
• role of gender as it relates to treatment options,
• language of treatment, and
• listening environment or hearing health of the individual.

Counseling

Culturally diverse views of disorders and disabilities are considered when providing counseling because cultural variations affect beliefs about the causes of a disorder as well as how the person with a disorder should be treated. Cultural views may also influence individual goals as well as the caregiver’s goals for the person with the disorder or disability.

Each family unit has a system in which each member affects all other members (Bronfenbrenner, 1979). Relationships are built and maintained through communication and may be significantly impacted by a communication disorder. When counseling individuals and families, it is important to recognize the unique relationships of a family system, including how a family member’s disorder affects relationships among the members as well as the functioning of the family system.

Cultural dimensions that influence counseling include

• the effect of the disability on life participation in culturally relevant contexts;
• the need for and/or acceptance of special treatment or education;
• acceptance of the use of technology for treatment;
• recognition that the family and/or the mainstream may judge some practices to be harmful;
• cultural values that conflict with mainstream values in terms of independence, individualism–collectivism, power distance, avoiding uncertainty, masculinity–femininity, hedonism, time orientation, indulgence, and restraint; and
• the individual’s and the family’s views of the role that each member plays—or should play—in the family.

Some cultures may have remedies or practices that mainstream professionals do not understand or embrace—and that they may even view as harmful. Professionals must discern whether cultural beliefs and practices are truly cultural variations or are harmful to the individual. Culturally sensitive counseling can provide information as well as alternative safe treatments (Westby, 2007).

In addition, religious or spiritual beliefs and practices may take precedence before educational or medical recommendations can be considered or accepted. If these beliefs or practices are misunderstood or unknown to professionals, they may interfere with or undermine educational and medical interventions (Fadiman, 2012; Shannon & Tatum, 2002; Swihart et al., 2021).

Please see ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology for further information.

Public Policy

A number of laws and regulations have implications for the culturally responsive provision of audiology and speech-language pathology services. Implications for practice relate, for example, to the implementation of standardized procedures, access to and participation in services, language proficiency, mandated accommodations to facilitate participation by individuals with disabilities, access to federal funding, availability of interpreters, classroom inclusion, disproportionate representation by race and ethnicity of children with disabilities, reducing health care disparities, and privacy.

Americans With Disabilities Act (ADA)

The ADA is intended to protect persons with disabilities and to guarantee them access to and participation in society. The statute is specifically directed at employment, public accommodations, public services (i.e., services delivered by state and local governments), transportation, and telecommunication. To be protected by the ADA, one must have a disability, which is defined by the ADA as a physical or mental impairment that substantially limits one or more major life activities; have a history or record of such an impairment; or be perceived by others as having such an impairment.

Equal Educational Opportunities Act

The Equal Educational Opportunities Act of 1974 states, “All children enrolled in public schools are entitled to equal educational opportunity without regard to race, color, sex, or national origin.”

Executive Order No. 13166

Executive Order No. 13166 (2000) requires federal agencies to examine the services they provide, identify any need for services to those with limited English proficiency, and develop and implement a system to provide those services so that persons with limited English proficiency can have meaningful access to them. See the U.S. Department of Health and Human Services’ Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons [PDF]. This is applicable to health care providers who receive federal funds (e.g., via Medicare, Medicaid, or the State Children’s Health Insurance Program).

Family Educational Rights and Privacy Act (FERPA)

FERPA (34 CFR Part 99) protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children’s education records. These rights transfer to the student when they reach the age of 18 years or attend a school beyond the high school level. Materials are to be provided in a manner that is culturally and linguistically accessible so that individuals can understand their rights. See FERPA Regulations.

Health Insurance Portability and Accountability Act (HIPAA)

Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. This act gives individuals aged 12–18 years the right to privacy. The provider must have a signed disclosure from the affected person before giving out any information on provided health care to anyone else, including the patient’s parents. The AS provisions also address the security and privacy of health data. Materials are to be provided in a manner that is culturally and linguistically accessible so that individuals can understand their rights.

Individuals With Disabilities Education Act (IDEA)

The IDEA 2006 Regulations made significant steps toward addressing problems with inappropriate identification and disproportionate representations of children with disabilities by race and ethnicity. A provision of the IDEA requires states to review ethnicity data in addition to race data to determine the presence of disproportionality. Disproportionality refers to the overrepresentation or underrepresentation of a particular demographic group in a special education program relative to the number in the overall student population (National Education Association, 2007). If significant disproportionality is determined, the state is required to review and revise policies, procedures, and practices, and the local education agency is required to reserve the maximum amount of funds under Section 613(f) of the statute to provide early intervening services to children in the local education agency, “particularly, but not exclusively” to those in groups that were significantly overidentified. These regulations clearly define steps that states must take to address the problem of disproportionality in special education. See IDEA Part B: Culturally and Linguistically Diverse Students.

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act — also known as the Affordable Care Act (ACA)—addresses the expansion of health care coverage to populations that may not have been served in the past, explicitly linking health literacy to patient protection and then offering funds/grants for programs to increase cultural responsiveness. The ACA (2010) uses specific language regarding patient–provider communication—including provisions to communicate health and health care information clearly, promote prevention, ensure equity and cultural competence, and deliver high-quality care.

Title VI of the Civil Rights Act

Title VI of the Civil Rights Act of 1964 (1989) prohibits discrimination in any federally funded program on the basis of race, color, or national origin. This includes any public or private facility, such as a hospital, clinic, nursing home, public school, university, or Head Start program that receives federal financial assistance, such as grants, training, use of equipment, and other assistance. According to the Office of Civil Rights, all providers who work for any agency funded by the U.S. Department of Health and Human Services are required to provide language access services to patients who do not speak English.

State Laws and Regulations

Differences in state regulations are reflected in a number of requirements (see ASHA’s State-by-State webpage for further information).

ASHA Resources

• 2020 Standards and Implementation Procedures for the Certificate of Clinical Competence in Audiology
• 2020 Standards and Implementation Procedures for the Certificate of Clinical Competence in Speech-Language Pathology
• ASHA Code of Ethics
• ASHA State-by-State
• Cultural Competence Check-Ins
• Cultural Competence for Everyone: A Shift in Perspectives
• Dynamic Assessment
• Examples of Cultural Dimensions
• Health Insurance Portability and Accountability Act
• IDEA Part B: Culturally and Linguistically Diverse Students
• Issues in Ethics: Cultural and Linguistic Competence
• Palliative and End-of-Life Care
• Perspectives of the ASHA Special Interest Groups
• Response to Intervention (RTI)
• Scope of Practice in Audiology
• Scope of Practice in Speech-Language Pathology
• Social Determinants of Health 
• Special Interest Group 14, Cultural and Linguistic Diversity
• Special Interest Group 17, Global Issues in Communication Sciences and Related Disorders
• Supporting and Working With Transgender and Gender-Diverse People
• Taking Action Against Microaggressions: Micro Course Series
• The Complexity of Health Disparities: More Than Just Black–White Differences
• Understanding the Individuals with Disabilities Education Act (IDEA)
• Why Is Yogurt Good for You? Because It Has Live Cultures
• Working With Culturally and Linguistically Diverse (CLD) Students in Schools

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• A Guide to Cultural Competence in the Curriculum: Speech-Language Pathology [PDF]
• Americans with Disabilities Act of 1990
• Department of Health and Human Services: Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons [PDF]
• Equal Educational Opportunities Act of 1974
• Executive Order No. 13166
• Family Educational Rights and Privacy Act (FERPA)
• FERPA regulations
• Georgetown University National Center for Cultural Competence
• National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care[PDF]
• Office of Minority Health, U.S. Department of Health and Human Services
• Title VI of the 1964 Civil Rights Act
• That’s Unheard Of

American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of speech-language pathology [Preferred practice patterns]. https://ww.asha.org/policy/

American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology [Preferred practice patterns]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2017). Issues in ethics: Cultural and linguistic competence [Ethics]. https://www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

Americans With Disabilities Act of 1990, Pub. L. No. 101-336, § 2, 104 Stat. 328 (1991).

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Harvard University Press.

Civil Rights Act of 1964, § 6, 42 U.S.C. § 2000d et seq. (1964).

Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. The University of Chicago Legal Forum, 1989, 140, 139-167. https://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=1052&context=uclf

Cross, T. (2012). Cultural competence continuum. Journal of Child and Youth Care Work, 24, 83–85.

Davis, A. S., & Stanford, S. (2020). Shifting the mindset of racism through cognitive learning styles in communication sciences and disorders. Journal of the National Black Association for Speech Language and Hearing, 15(3), 87–89.

DeJarnette, G., Rivers, K. O., & Hyter, Y. D. (2015). Ways of examining speech acts in young African American children: Considering inside-out and outside-in approaches. Topics in Language Disorders, 35(1), 61–75. https://doi.org/10.1097/TLD.0000000000000042

Equal Educational Opportunities Act of 1974, 20 U.S.C. § 1701 et seq. (1974).

Exec. Order No. 13166, 3 C.F.R. (2000).

Fadiman, A. (2012). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. Macmillan.

Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g et seq. (1974).

Fuller, K. (2002). Eradicating essentialism from cultural competency education. Academic Medicine, 77(3), 198–201.

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, 3(1), 107–117. https://doi.org/10.1044/persp3.SIG1.107

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1938 (1996).

Hofstede, G. (2011). Dimensionalizing cultures: The Hofstede model in context. Online Readings in Psychology and Culture, 2(1), Article 8. https://doi.org/10.9707/2307-0919.1014 [PDF]

Hopf, S. C., Crowe, K., Verdon, S., Blake, H. L., & McLeod, S. (2021). Advancing workplace diversity through the culturally responsive teamwork framework. American Journal of Speech-Language Pathology, 30(5), 1949–1961. https://doi.org/10.1044/2021_AJSLP-20-00380

Horton, R. (2021). Critical perspectives on social justice in speech-language pathology. IGI Global.

Hosp, J. (n.d.). Response to intervention and the disproportionate representation of culturally and linguistically diverse students in special education. RTI Action Network. https://www.rtinetwork.org/learn/diversity/disproportionaterepresentation [PDF]

Hwa-Froelich, D., & Westby, C. (2003). Frameworks of education: Perspectives of Southeast Asian parents and Head Start staff. Language, Speech, and Hearing Services in Schools, 34(4), 299–319. https://doi.org/10.1044/0161-1461(2003/025)

Hyter, Y. D., & Salas-Provance, M. B. (2021). Culturally responsive practices in speech, language, and hearing sciences (2nd ed.). Plural.

Individuals with Disabilities Education Act of 2004, 20 U.S.C. § 1400 et seq. (2004).

Kohnert, K. (2008). Language disorders in bilingual children and adults. Plural.

Lau, A. S. (2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. Clinical Psychology: Science and Practice, 13(4), 295–310. https://doi.org/10.1111/j.1468-2850.2006.00042.x

National Education Association. (2007). Truth in labeling: Disproportionality in special education.

Oetting, J. B., Gregory, K. D., & Riviere, A. M. (2016). Changing how speech-language pathologists think and talk about dialect variation. Perspectives of the ASHA Special Interest Groups, 1(16), 28–37. https://doi.org/10.1044/persp1.SIG16.28

Office of Minority Health. (n.d.). The national culturally and linguistically appropriate services standards in health and health care. U.S. Department of Health and Human Services. https://www.thinkculturalhealth.hhs.gov/clas

Patient Protection and Affordable Care Act of 2010, 42 U.S.C. § 18001 (2010).

Riquelme, L. F. (2013). Cultural competence for everyone: A shift in perspectives. Perspectives on Gerontology, 18(2), 42–49. https://doi.org/10.1044/gero18.2.42

Shannon, S. E., & Tatum, P. (2002). Spirituality and end-of-life care. Missouri Medicine, 99(10), 571–576.

Spradley, J. P., & McCurdy, D. W. (1972). The cultural experience: Ethnography in complex society. Science Research Associates.

Street, R. L., Jr., O’Malley, K. J., Cooper, L. A., & Haidet, P. (2008). Understanding concordance in patient–physician relationships: Personal and ethnic dimensions of shared identity. The Annals of Family Medicine, 6(3), 198–205. https://www.ncbi.nlm.nih.gov/pubmed/18474881

Swihart, D. L., Yarrarapu, S. N. S., & Martin, R. L. (2021). Cultural religious competence in clinical practice. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK493216/

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. https://doi.org/10.1353/hpu.2010.0233

Torres, K., Lee, N., & Tran, C. (2015). Building relationships, building cultures: Cultural brokering in family engagement. https://education.uw.edu/sites/default/files/programs/epsc/Cultural%20Brokers%20Brief_Web.pdf [PDF]

Unger, J. P., DeBonis, D. A., & Amitrano, A. R. (2021). A preliminary investigation of social justice perceptions among U.S. speech-language pathologists: Clinical implications. American Journal of Speech-Language Pathology, 30(5), 2003–2016. https://doi.org/10.1044/2021_AJSLP-20-00286

Westby, C. (2007). Child maltreatment: A global issue. Language, Speech, and Hearing Services in Schools, 38(2), 140–148. https://doi.org/10.1044/0161-1461(2007/014)

Westby, C., Burda, A., & Mehta, Z. (2003). Asking the right questions in the right ways: Strategies for ethnographic interviewing. The ASHA Leader, 8(8), 4–17. https://doi.org/10.1044/leader.FTR3.08082003.4

Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Cultural Responsiveness page:

• Rhoda L. Agin, PhD, CCC-SLP
• Noma I. Anderson, PhD, CCC-SLP
• Alaina Davis, PhD, CCC-SLP/L
• Danai Kasambira Fannin, PhD, CCC-SLP
• Nancy M. Gauvin, EdD, CCC-SLP
• Joyce L. Harris, PhD, CCC-SLP
• Deborah A. Hwa-Froelich, PhD, CCC-SLP
• Joan C. Payne, PhD, CCC-SLP
• Rebecca K. Reeves, MA, CCC-SLP
• Kenyatta O. Rivers, PhD, CCC-SLP
• Barbara Rodriguez, PhD, CCC-SLP
• Diane M. Scott, PhD, CCC-A
• Irene G. Torres, MS, CCC-SLP

In addition, ASHA thanks the members of ASHA’s Multicultural Issues Board and the Working Group on Cultural Competence in Professional Service Delivery whose work was foundational to the development of this content.

Members of the Working Group on Cultural Competence in Professional Service Delivery were Carol Westby (chair), Catherine Clarke, James Lee, Hortencia Kayser, Carmen Vega-Barachowitz, and Claudia Saad (ex officio). Celia Hooper and Brian Shulman, vice presidents for professional practices in speech-language pathology; Mary Jo Schill and Alison E. Lemke, vice presidents for administration and planning; and Barbara Moore, vice president for planning, served as the monitoring officers.

Members of ASHA’s Multicultural Issues Board included Bopanna Ballachanda, Arnell Brady, Julie K. Bisbee, Nancy Flores Castilleja, Marcella Coleman, Candice Costa, Catherine J. Crowley, Diana Diaz, Ianthe Dunn-Murad, Nancy Eng, Debra Garrett, Nikki Giogis, Thomas J. Hallahan, Kathryn Helms, Ella R. Inglebret, Emi Isaki, Ronald C. Jones, Edgarita Long, Nidhi Mahendra, Tedd B. Masiongale, Joe A. Melcher, Wesley Nicholson, Janna Oetting, Alina de la Paz, Constance Dean Qualls, Rebecca K. Reeves, Luis F. Riquelme, Barbara Rodriguez, Marlene Salas-Provance, Toni Salisbury, Yasmeen Shah, Linda McCabe Smith, Greta Tan, Irene Torres, Carmen Vega-Barachowitz, Kenneth E. Wolf, and Michelle Yee. Vicki Deal-Williams and Karen Beverly-Ducker served as ex officios. Monitoring vice presidents for administration and planning Lyn Goldberg, Michael Kimbarow, and Alison E. Lemke provided guidance.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Cultural responsiveness [Practice Portal]. https://www.asha.org/Practice-Portal/Professional-Issues/Cultural-Responsiveness/.