JCPSLP Vol 21 No 2 2019 DIGITAL Edition

Journal of Clinical Practice in Speech-Language Pathology Journal of Clinical ractic i Spe ch-L l

Volume 13 , Number 1 2011 Volume 21 , Number 2 2019

Measurement and evaluation in practice

In this issue: Assessment and outcome measures for Aboriginal Australians A rural clinical placement An evaluation of client satisfaction with student-delivered speech-language pathology services in private practice Telepractice delivery of an autism communication intervention to parent groups: A feasibility study An examination of home reading practices of parents of young children with a hearing loss Listening to SLPs: How helpful are Australian English acquisition norms for velar stops to the child speech evaluation process?

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JCPSLP Editor Jae-Hyun Kim c/- Speech Pathology Australia

Editorial Committee Maree Doble Emma Finch Rachael Unicomb

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Measurement and evaluation in practice

From the editor Jae-Hyun Kim


M easurement and evaluation Journal of Clinical Practice in Speech- Language Pathology , a major clinical publication of Speech Pathology Australia, presents this issue about measuring and evaluating outcomes in our clinical practice. This issue begins with an invited article by Elizabeth Armstrong (Foundation Chair in Speech Pathology at Edith Cowan University), Ann Carmody (Edith Cowan University), Alice Claire Robins (Monash Health) and Tara Lewis (Institute for Urban Indigenous Health). In this article, the authors discuss assessment and are fundamental to the work of speech-language pathologists.

49 From the editor 50 Assessment and outcome measures for Aboriginal Australians with communication disorders – Elizabeth Armstrong, Ann Carmody, Alice Claire Robins and Tara Lewis outcomes – Barbara Dodd, Johanna Castles, Melissa Aar, Vanessa Hally, Jane McKimmie, Naomi Mitchell, Stuart Tibbetts, Michelle Wong and Meg Keage student-delivered speech-language pathology services in private practice – Carl Sokkar, Merrolee Penman, Jacqueline Raymond and Lindy McAllister communication intervention to parent groups: A feasibility study – Robyn Garnett, Bronwyn Davidson, Patricia Eadie, Ken Clarke and Deepti Aggarwal 78 An examination of home reading practices of parents of young children with a hearing loss – Michelle I. Brown, Marleen F. Westerveld, David Trembath and Gail T. Gillon 87 Listening to SLPs: How helpful are Australian English acquisition norms for velar stops to the child speech evaluation process? – Rachael Unicomb, Joanne Walters, Laura Pullin and Caroline Bowen 94 The perspectives of students involved in a classroom-based oral language intervention in their first formal year of schooling – Maria Lathouras, Susanne Garvis, Marleen Westerveld and David Trembath 100 Evaluating the treatment of co-occurring stuttering and speech sound disorder: Parents’ perspectives – Rachael Unicomb, Sally Hewat and Elisabeth Harrison 108 A five-year file audit of paediatric stuttering management: A research to practice comparison – Kate Bridgman, Shane Erickson, Rachael Unicomb and Bernadette O’Connor 117 Ethical conversations: Mobile service delivery and ethical issues – Susan Block, Tristan Nickless and Richard Saker 119 Viewpoint: Economic evaluation of health services – A critical differentiator – Joshua Byrnes 121 Around the journals 122 Resource review 123 Top 10 resources:Tips for aphasia outcome measurement that measures up! – Sarah J. Wallace 58 A rural clinical placement: Children’s 65 An evaluation of client satisfaction with 70 Telepractice delivery of an autism

outcome measures for Australian Aboriginal and/or Torres Strait Islander peoples with communication disorders. We are particularly excited to have contribution from Alice Claire Robins, a Yuin woman and a speech-language pathologists and Tara Lewis, an Iman woman from Central Queensland and a speech-language pathologist. The second article of the issue reports on the speech and language outcomes for children who received interventions from SLP students in rural and remote clinical placements (Dodd, Castles, Aar, Hally, McKimmie, Mitchell, Tibbetts, Wong, & Keage). The third article reports on client satisfaction with student-delivered SLP services in private practice (Sokkar, Penman, Raymond, & McAllister). These two articles suggest SLP students provide a valuable service contribution across diverse settings. The fourth article is a feasibility study exploring the telepractice delivery of an autism communication intervention for a group of parents (Garnett, Davidson, Eadie, Clarke, & Aggarwal). In the fifth article, Brown, Westerveld, Trembath, and Gillon evaluate home reading practices of parents of young children with hearing loss. The sixth article in the issue is an interesting study about Australian SLPs’ perspectives on /k/ and /g/ acquisition norms (Unicomb, Walters, Pullin, and Bowen). Lathouras, Garvis, Westerveld, and Trembath report on the perspectives of students involved in a classroom-based oral language intervention. Unicomb, Hewat, and Harrison report on parents’ perspectives of the treatment of co-occurring stuttering and speech sound disorders. These articles emphasise the value of listening and learning from our stakeholders in evaluating our interventions. The last research article of this issue is a five-year file audit of the Lidcomb program for children who stutter (Bridgman, Erickson, Unicomb, & O’Connor). This study identifies gaps between research and practice by evaluating the community caseloads about paediatric stuttering and informs future clinical and research directions. In ‘Ethical conversations’, Susan Block, Tristan Nickless, and Richard Saker have provided an insightful discussion about ethical issues surrounding mobile service delivery. Joshua Byrnes contributed an informative article on economic evaluation of health services for our Viewpoint section. Lucy Sutherland, Emily Moore, Kristine Shrubsole and Sarah Wallace contributed Around the journals, Resource review and Top 10 articles. The Editorial Board would like to thank the authors for this issue. We would also like to thank the anonymous reviewers who kindly contributed their time to enable for the journal to deliver high-quality clinical contents. We also thank our production team Carla Taines and Bruce Godden, and our Speech Pathology Australia Publications Manager, Rebecca Faltyn.


JCPSLP Volume 21, Number 1 2019

Measurement and evaluation in practice

Assessment and outcome measures for Aboriginal Australians with communication disorders Elizabeth Armstrong, Ann Carmody, Alice Claire Robins and Tara Lewis

This paper reflects on issues surrounding clinical assessment and outcome measures with Aboriginal clients with communication disorders. The paper situates speech- language pathology assessment practices within a broader context of clinical assessment related to Aboriginal peoples accessing health services generally, and discusses what “assessment” could look like with a better understanding regarding an Aboriginal worldview, and incorporating notions of cultural security. It critically evaluates current measures used in speech- language pathology practice, their purpose, and processes involved in their application. Finally, the authors draw on their own clinical and research experiences to suggest ways of modifying existing tools if necessary, and using new methods to further the development of culturally appropriate and secure assessment practices within speech- language pathology. How they worded the report made me feel really emotional, I didn’t understand and thought they were saying bad things about my child. (Aboriginal mum, Member of the Home Interaction Program for Parents and Youngsters (HIPPY) Midland, WA) A ustralia has always been a multilingual country; many Aboriginal 1 peoples continue to speak multiple languages and dialects of those languages, although this varies across geographical regions. Colonisation brought a variety of Gaelic languages, with German at one stage being the dominant or preferred language used in business and newspapers in Melbourne and Adelaide (Ellis, Gogolin, & Clyne, 2010). English was later imposed as the dominant language largely for purposes of power, exploitation and domination, and the myth that Australia was a monolingual mono-cultural country emerged and has been perpetuated since (Ellis, Gogolin, & Clyne, 2010). This has led to a context of “invisibility” of many Indigenous languages and dialects

in Australia, and frequent lack of acknowledgment of Indigenous students as learners of English as an additional language or dialect (EAL/D) (Sellwood & Angelo, 2013). In order to ensure equity and diagnostic accuracy in speech- language pathology services for Aboriginal clients, speech- language pathologists (SLPs) in Australia need to be cognisant of current issues related to the integrity of post- colonial Englishes versus the notion of “standard Australian English” (SAE) and related concepts of domination and power. Particular attention needs to be paid to what is being assessed, measured, and treated when the SLP and the client do not have the same cultural background, and may speak different languages or dialects, as well as having different worldviews. While much work has been done in translation of speech-language pathology assessments into a variety of languages, there has been less discussion of underlying tenets of language and language use which are crucial for clinicians to understand if the surface level features of phonology and syntax, for example, are to be put into perspective. This is of particular importance in the discussion involving the language(s) of Aboriginal Australians and how linguistic competence is assessed in a speech-language pathology context. In the Aboriginal context, there is a rich linguistic and cultural history. Colonisation, however, directly and swiftly impacted language, with many speakers being forced to abandon their own first language(s) in schools, missions and other institutions, and adopt English (Fozdar, Wilding, & Hawkins, 2009). This not only led to devastation within communities forced to give up a central part of their identity (their language). It ultimately led to the demise of numerous Aboriginal languages. Of the 250 languages spoken prior to colonisation, only 145 (many of which are now only spoken by small numbers of people) remain (Department of Communications, Information, Technology and the Arts, 2005). Malcolm (2018) articulates the way(s) in which Aboriginal people adopted English but developed their own dialect – Australian Aboriginal English (AAE) – in his definition of dialect: A dialect … is a linguistic and social phenomenon which arises in response to a particular communication need common to a group of people. The existence of the dialect implies, with respect to the language from which it derives, both continuity and change. In the case of Aboriginal English, there is linguistic continuity



Alice Claire Robins (top) and Elizabeth Armstrong


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Journal of Clinical Practice in Speech-Language Pathology

how speech-language pathologists may be unwittingly contributing to the disproportionate rate of vulnerable youth being placed in special education in US schools through the use of biased assessments. Gould (2008a) documents “significant detrimental impacts” for Australian Aboriginal children where standardised assessments have been used to medicalise linguistic variation. Recent studies identifying up to 50% of cohorts of Aboriginal children as having language “difficulties” or “disorders” are a case in point (e.g., Kippin et al., 2018). Kippen et al. acknowledged the Clinical Evaluation of Language Fundamentals (CELF) (Wiig, Secord, & Semel, 2013) was not reflective of the linguistic background of the participants by adjusting the scoring. However, they were unable to account for the participants’ unfamiliarity with the culture of testing (Farrugia-Bernard 2018) and the “alien” content (i.e., contexts, underlying schemas). For example, the stimulus pictures and pragmatics of the “Formulated sentences” subtest require experience with testing culture, and American social contexts and schemas. Engaging in testing procedures where the language, format and content are unfamiliar can have negative impacts for participants (Macqueen et al., 2018). Treatment and goal-setting Assessment relates directly to treatment and treatment outcome measures, which inherently involve some form of “goal-setting”. In addition to language/communication impairment/ competence measures, personal goals are now also taken into account and used as potential measures of treatment outcomes (Hersh et al., 2012). The way(s) in which these goals are developed are just as important as the way(s) language assessments are undertaken. The notions of an individual’s “goals” and associated “person-centredness” (Leplege et al., 2007) are often described in relation to treatment processes but it must be noted that these notions are primarily western concepts. In collectivist societies, goals may not be individual but may relate just as much to family and community. Pre-determined notions of “family”, e.g., wife, husband, daughter, son, rather than notions related to extended family networks and responsibilities delegated to particular extended family/community members can also interfere with appropriate discussions and “negotiation” of what “goals” and activities are, relevant to the clients. In order to explore some of the issues raised above, current practice will be examined in both paediatric and adult contexts. Current SLP practice Working with children Assessment practices for SLPs working with Aboriginal children are currently the subject of debate. While substantial evidence exists (Gould, 2008a; Pearce & Williams, 2013; Pearce, Williams, & Steed, 2015; Toohill, McLeod, & McCormack, 2012) which clearly contraindicates the use of standardised tests, the Clinical Evaluation of Language Fundamentals (Wiig, Secord, & Semel, 2013) and other standardised tests continue to be used to diagnose communication disorders (e.g., Kippin et al., 2018). Changes to scoring and validation using natural language samples fail to address the irrevocable truth that this type of “testing” assessment is an arbitrary but very powerful social construct. It establishes a standard linguistic, pragmatic, cultural and worldview that is not

with other Englishes, since the dialect represents maintenance of English, but there is also change, since the speakers of the dialect also maintain continuity with their cultural origins, with their experience of language contact, and with their contemporary life as a speech community, and these necessitate a change in English as they adopt it. (Malcolm, 2018, p. 7) For the purposes of this paper, which is focused on clinical practice, we will use the term “home language” instead of AAE. The term AAE remains controversial even within Aboriginal communities, whereas “home language” is more commonly used and we feel may be more accessible to Aboriginal clients. “Home language” does not refer to traditional Aboriginal language per se; rather it refers to the same phenomena discussed around AAE. It is spoken by most Aboriginal peoples (with its own diverse sub-varieties), has its own phonology, grammar, and semantics, and differs from SAE in a number of ways, particularly in terms of semantics, discourse patterns, and pragmatics (Armstrong, McKay, & Hersh, 2017; Butcher, 2008; Malcolm, 2018). Attempts at assessment of linguistic competence must clearly be undertaken with such knowledge in mind in order for assessments to be accurate. For SLPs, an appreciation of dialect is essential if “difference” is not to be wrongly identified as “error” or “bad English” – particularly in the case where one dialect is privileged over another, with the majority dialect used being labelled “standard” and the minority dialect “non- standard”. It is important to emphasise that there is no hierarchy in language typologies, i.e., one dialect is not superior/inferior to another dialect, and a dialect is not inferior to a “language”. It should also be pointed out that many Aboriginal peoples do not use the term “dialect” and the discussion at times may seem academic. However, suffice to say that different forms of English should be acknowledged as separate entities, and are equivalent to each other. Concerns about current assessment practices The above comments speak to the point that SLPs must know what it is they are assessing before allocating meaning to measurements that may or may not reflect the linguistic competence of their clients. In writing about mental health assessment in relation to Aboriginal Australians, Adams, Drew, and Walker (2014) raise issues concerning the way(s) in which historical and political factors have influenced both how and why assessments are undertaken, and how they are perceived by Aboriginal peoples. They discuss the power involved in assessment and assessment results that still today drive decision-making about Aboriginal peoples’ welfare and access to resources: “Inappropriate assessments resulting in poor ‘test’ outcomes not only perpetuate the marginalisation of Aboriginal people, but can result in inadequate treatment and access to appropriate services” (Adams et al., 2014, p. 272). Misuse of assessment tools in speech-language pathology may similarly perpetuate stereotypes of high rates of “disorder”/pathology in Aboriginal populations. Pillay and Kathard (2015) raise the pitfalls in using philosophies of essentialism and reductionism in our clinical practices, resulting in the reification of “norms” based on increasing modular and smaller segments of broad social phenomena. Farrugia-Bernard (2018) discusses

Ann Carmody (top) and Tara Lewis


JCPSLP Volume 21, Number 2 2019

reflective of language socialisation across cultures (Akhtar & Jaswal, 2013). Significant concerns have been raised about the use of standardised tests with AAE speakers, where the tests have been normed on speakers of SAE. Gould (2008a), Gould (2008b), Pearce and Williams (2013), and Lewis, Hill, Bond, and Nelson (2017) have warned of misinterpretation and misdiagnosis of disorder being probable results of such a misuse of standardised tests with a target group that has not been included in the normative sample and requires a different approach to assessment. Lewis et al. (2017) go further and highlight the fact that while some inclusion of discourse measures accommodating home language has been used in both research and clinical contexts, the underlying components of worldview are often neglected in assessment procedures. Monolingual assessment of a multilingual or multi- dialectal child’s non-preferred dialect or language does not reflect their complex linguistic background, nor does it inform the assessor of what the specific child’s linguistic experience has been and therefore what the clinician would “expect” to see. Developmental language audits offer one solution as they map exposure to languages/dialects, timing of exposure and percentages of input in various languages or dialects, and are key to valid assessment (Pascoe, Mahura, & Le Roux, 2018). Other practices include the use of adult speakers as models to modify the scoring procedures on tests such as the DEAP (Pascoe et al., 2018). In Australia, linguistic tools are available which enable a clinician to analyse a language sample provided in home language (e.g., Konigsberg, Collard & McHugh, 2012). In many cases, analysis using such tools reveals robust speech and language development with sophisticated use of narrative structure not apparent in standardised or SAE-based analysis. Working with adults Many of the issues above also arise in the adult practice area. Standardised language tests are used in the Australian context with Aboriginal clients around 43% of the time (Hersh, Armstrong, Panak, & Coombes, 2015). These tests are primarily of US (WAB, BDAE, Philadelphia Naming Test) or UK origin (CAT, PALPA) and based on a western worldview. These tests may be used in combination with some discourse measurement, but discourse features typically being measured are those of SAE rather than home language, and focus on a narrative structure that is based on western narrative forms. The nature of Aboriginal narratives is fundamentally different from western narratives (Malcolm, 2018; Malcolm & Sharifian, 2002), hence judgements of “disorder” based on discourse samples in this context are inherently problematic (Armstrong, McKay, et al., 2017). In the traumatic brain injury (TBI) population, issues become even more obviously problematic, with diagnosis of “pragmatic difficulties” and “cognitive communication difficulties” often dependent on cultural norms and worldview (see Armstrong et al., 2017 for further discussion). As part of the Missing Voices project (Armstrong et al., 2015), instances were observed where a lack of awareness of linguistic issues confused diagnosis and treatment. For example, a young Aboriginal woman who stayed for an extend period in a local hospital following a sub-dural haematoma was initially labelled as potentially having aphasia as she was not speaking after a stroke. She was described in the medical notes as very quiet and

very compliant with ward processes but did not speak. Finally, a psychiatrist (to whom she was referred due to suspected depression) and social worker identified that despite potential communication disorder, English not being her first language was potentially the major barrier to her communication, as she was in fact able to speak her first language. Another example was that of a man receiving treatment for apraxia of speech using correction and practice of sounds not present in his first language which was not English. “Functional” measures such as the AusTOMS (Worrall & Egan, 2001) are commonly used as outcome measures. The AusTOMS typically involves a clinician determining the scale and does not involve the individual themselves or family, hence ratings may be different. While the AusTOMS uses language consistent with the International Classification of Functioning, Disability and Health (ICF), it does not take into account the Aboriginal view of health, which does not just include the health of the individual. Instead it refers to the “social, emotional and cultural wellbeing of the whole community” and considers the whole life view, taking into account the life-death-life cycle (National Aboriginal Community Controlled Health Organisations (NACCHO), 2018). Without cognisance of such a view, the result may ultimately be a poorer outcome for clients from a culturally and linguistically diverse background who do not share the same viewpoints as the clinician. Recommendations for assessment practices/outcome measurement General principles At this point in time, there are few definitive tools and processes to be used with Aboriginal clients specifically within speech-language pathology. Clearly, given the diversity of such clients, there is no “one-size-fits-all” approach that is appropriate. However, general principles, and an approach that is critical, reflective and iterative/ dynamic will provide a good basis for ensuring culturally secure and appropriate practices. The following discussion provides some broad principles as well as examples of emerging tools that are specifically designed for use with Aboriginal clients. Providing a culturally secure environment The Indigenous Allied Health Australia’s Cultural Responsiveness Framework (Indigenous Allied Health Australia, 2015) provides a sound foundation on which to base a culturally secure clinical environment. Health professionals should consider strategies that build relationships and develop an understanding of the patient’s communication style, their social networks and supports. Employing a yarning approach (Bessarab & Ng’andu, 2010; Lin et al., 2017) may be appropriate in some situations and may foster open communication and trust towards health professionals. Some Aboriginal peoples may experience a strong sense of anxiety when attending hospitals from the outset or when working with non-Aboriginal health professionals due to previous negative experiences with the health system, a fear of hospitals and intergenerational trauma. Building rapport, and employing culturally secure and responsive practices are necessary at all times. Holding consultations outdoors, for example, for some people may help to reduce anxiety and improve overall communication by assisting interactions to be less like an interview or interrogation.


JCPSLP Volume 21, Number 2 2019

Journal of Clinical Practice in Speech-Language Pathology

assist family members with communication difficulties, as well as inform SLP practice regarding community values, norms, protocols, and existing facilitatory practices. Specific recommendations for working with children and families Lewis et al. (2017) have proposed a “yarning” methodology as more culturally appropriate for Aboriginal children than standardised testing. Lewis’s Gumerri Assessment moves away from a deficit-based question–answer format to a more conversational, strength-based interaction between clinician and child. The use of universal processing models and frameworks for development (e.g., Stackhouse & Wells, 1997; Locke, 1997) can also provide structure for observation, as can dynamic and criterion referenced probes. Other innovative practices include using qualitative/ ethnographic data collection methods (Lewis et al., 2017). These practices use a lens of viewing the linguistic performance of the child as representative of dialectal and sociocultural diversity speech and language impairment. Using language-/dialect-specific frameworks to analyse language samples (Malcolm, 2018, Pascoe 2018) ensures that normative benchmarks reflect the linguistic and sociocultural environment of the child. Establishing speech community-specific normative data (Lowell & Maypilama, 2018) allows us to develop normative benchmarks where multiple languages exist within a speech community and concepts of deficit vs difference need to be established. Use of a strength-based collaborative approach is most in line with concepts of family-centred primary and cultural security, where projects are developed in response to community concern and are constructed through collaboration (Amery, Wunungmurra, & Gumbala, 2018). Further general principles of practice are outlined in table 1. Specific recommendations for working with adults Piloting of the first speech-language pathology assessment tool designed with and for Aboriginal people with communication disorders, the Aboriginal Communication Assessment After Brain Injury (ACAABI) (Armstrong, Ciccone et al., 2017) has been completed, with the tool to be made available in 2019. The ACAABI consists of an “impairment” section as well as client/family rating scales in which both wording and content have been developed with Aboriginal community members. It has also been translated into one Aboriginal language (Nyangumarta) in order to explore potential translation feasibility. For an overview of culturally appropriate tools related to cognition that may be also useful for SLPs, see overviews by Armstrong, Ciccone, et al. (2017), Dingwall and Cairney (2010) and Dingwall, Lindeman, and Cairney (2014). The Kimberley Indigenous Cognitive Assessment (LoGiudice et al., 2006) is also of particular relevance. Clinical yarning techniques (Lin, Green, & Bessarab, 2016) are also very relevant to SLP assessment and treatment, encompassing elements of cultural security as well as discourse assessment opportunity. Preliminary results on application of such techniques in adult communication therapy suggest that Aboriginal clients appreciate a “yarning” style of therapy, adhering to a therapy protocol of twice/week therapy over an 8-week period. The therapy involved two-way dialogue, story- telling, client-centred communication and careful listening around issues and events that were important to the

Aboriginal health liaison officers should be consulted to provide guidance as appropriate, and interpreters involved if needed. The source of referral is also important. Referrals from family and community are a clear indication that the person’s communication is divergent from that expected in their speech community. Referral from outside the person’s speech community can mean the appropriate target for intervention is the perception of others in the person’s environment. Ensuring congruence with community practices Clinical processes should require a greater emphasis being placed on assessment and intervention that is tailored to the child’s/adult’s linguistic experience and is congruent with cultural language socialisation practices in their community rather than assessment and treatment goal choices being offered from a largely predetermined framework (Ball & Lewis, 2011). Assessment techniques such as those already available (described above in the paediatric area) and those emerging (described below in the adult area) offer ways towards enacting this general principle. As also noted above, the notions of “goal-setting” and “client-centred practice” are largely western concepts and may not align with Aboriginal views of health. It is important to note that Aboriginal clients may not have the same goals as clinicians. For example, the family/client may have little contact with unfamiliar people and communication with familiar people/their kinship group may be functional. Goal- setting often occurs with the patient’s next of kin; however, when working with an Aboriginal patient, a more inclusive approach may well encompass a wider kinship network. Working with extended family One way of ensuring the above principle is adhered to is working with extended family and acknowledging extended kinship systems in the whole clinical process. Outcome measures are often also important for clinical reporting and service delivery purposes and choices of appropriate measures should can incorporate wider family involvement. While such measures may not inherently be compatible with an Aboriginal worldview, sensitive application of the measures (i.e., open discussion with family and community members where possible, and acknowledgment of potentially differing perspectives, values and linguistic strengths) may yield at least perceptions and ensuing goals that align better to the client’s and family’s aspirations than many current practices that see limited uptake of services – with many Aboriginal clients “voting with their feet” as in other areas of health care (Katzenellenbogen et al., 2013). Investing in community-based capacity building instead of individualised service delivery There has been increasing emphasis recently on the importance of a public health approach to communication disorders, particularly in relation to peoples who are considered “underserved”, “at-risk” and/or “hard to reach” (by health service providers) (Wylie, McAllister, Davidson, Marshall, & Law, 2014). While some caution should be applied to the use of these descriptors in line with the above discussion, the idea of working with a focus on community rather than the individual could be applied within the Australian Aboriginal context. SLPs working with communities (importantly in a two-way manner) may well increase community knowledge of SLP and strategies to


JCPSLP Volume 21, Number 2 2019

Table 1: Principles of practice in paediatric settings

Principle 1: Do no harm

SLPs need to consider that they can inadvertently do harm when they use standardised assessment tools with diverse populations. Diagnoses that infer children are less than standard are hurtful to families and can result in disengagement with school (Macqueen et al., 2018). This may include academic research, time spent chatting to adults in the community, time spent sitting in the playground or playing games, while observing and noting patterns of use and linguistic repertoire. It may also include using a guide or local interpreter. For dynamic or criterion referenced tasks, engage a small group of teacher-selected stronger students or older students from the same speech community as the client. Aboriginal peoples have been clear in their preference for PHC programs (NACCHO, 2018) which focus on community engagement and empowerment. Engagement with PHC programs may provide statistics useful in planning speech-language pathology services. PHC practice allows SLPs to address underlying causes of speech and language difficulty, i.e., working with local housing department to address over-crowding, this reduces transmission of bacteria causing ear disease. Referring a child for assessment is a brave step for many Aboriginal families whose own experience with health personnel may not have been positive. Taking this step is usually only done once family and community members have been consulted and many strategies applied. This high level of concern needs to be acknowledged and family perceptions unpacked as this information is clinically significant. Being singled out is rarely viewed as positive by Aboriginal children. It typically makes delivering services individually less effective. Small groups can be selected with the assistance of the Aboriginal liaison officer or teacher. Selection of groups may be on the basis of age, capacity, family groups or may be multi age. Training older students as tutors for younger community members has many benefits, including allowing older students to review and practise early concepts of literacy which they may have missed. Aboriginal families are more familiar with variation in communication styles than many monolingual/mono- cultural families. This means they are more familiar with discussing various aspects of language and of viewing language in a “meta” way. This ability to talk means discussing concepts like phonological repertoire, phonological awareness and differences in use is comfortable, and encourages great family discussion. Aboriginal children with neurotypical robust linguistic development may not have been exposed to the types of discourse and vocabulary used by teachers in conventional classrooms. It is critical that we view this need for exposure as necessary, not because there is a deficit, but because classrooms reflect and support the dominant cultural and linguistic practices that are significant mechanisms for academic success (Jones, 2013).

Principle 2: Become familiar with linguistic patterns of home language

Principle 3: Engage with primary health care (PHC) providers

Principle 4: Acknowledge a family’s concerns around a child’s difficulties Principle 5: Don’t single a child out for assessment or treatment

Principle 6: “Skill up” and “empower”

Principle 7: Talk about language

Principle 8: Talk about “exposure” not “treatment”

grammatical surface features) is essential to being able to work cross-culturally. The discussion here has raised issues that are pertinent to current speech-language pathology practice involving Aboriginal clients and families. While the development of ultimate best practice principles is ongoing, there are urgent points of practice that need to be addressed. These relate to potential harm caused by clinical practices that do not incorporate community expectations, theoretical considerations, worldviews and cultural practices. Ongoing discussion and addressing of such issues in a discipline dealing with language and culture as their central raison d’être is essential. Acknowledgment We would like to acknowledge Carol Ryder, Tutors and Mums (Home Interaction Program for Parents and Youngsters (HIPPY), Midland, WA) for their input to this paper and support of speech pathology. References Adams, Y., Drew, N. M., & Walker, R. (2014). Principles of practice in mental health assessment with Aboriginal Australians. In P. Dudgeon, H. Milroy, & R. Walker (Eds.), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practices (2nd ed). Australia: Commonwealth of Australia.

participant, in a conversation that was not an interview controlled by the clinician (Ciccone, Armstrong, Hersh, Adams, & McAllister, 2018; Lin et al., 2016). While potential usefulness of adaptations of the AusTOMS have been noted, alternatives include individualised rating scales that could be used to tailor goals and outcomes to be more culturally and personally appropriate to the client and their family. Greater inclusion of family/community members in ratings and goal-setting may improve clinical processes and ultimate outcomes for clients. Further recommended general principles of practice are outlined in table 2. Conclusion The notion of SLPs assessing communication/language(s) other than their own is fraught from many perspectives. Language reflects one’s culture and worldview; hence to “assess” someone’s language unless you know that particular language/dialect is problematic (even through interpreters). When assessing the language of someone who speaks another dialect of the same language as the SLP, the possibility of confusion exists. Both client and SLP may be unsure which dialect is in use, and therefore the dialect against which communication skills are being measured. Knowledge of dialect and acknowledgment of different semantic systems (as well as phonological and


JCPSLP Volume 21, Number 2 2019

Journal of Clinical Practice in Speech-Language Pathology

Table 2: Principles of practice in adult settings

This includes phonology, syntax, semantics and pragmatics.

Principle 1: Become familiar with linguistic patterns of home language Principle 2: Ensure interpreting services are available as needed

Ask clients/assisting Aboriginal hospital liaison officers (AHLOs) in hospital settings if the client needs an interpreter (even in the case where the client and/or family members speak English).

Principle 3: Include extended family in assessments

Inclusion of extended family in assessment and treatment both in hospital and community settings ensure external validity for any diagnoses of disorder or difference through comparison with pre-injury function. Efforts to contact family if client is off country in hospital should be made through the use of the AHLO. In particular, clearly explain the nature and purpose of the assessment to brain injury survivors and their families. Visual imagery and the use of analogies for brain function (e.g., a river being blocked with rocks/silt, fuel lines being blocked in a car, being analogous to an artery in the brain being blocked). Ensure that activities are relevant to the client’s language/ dialect/culture as well as being familiar and of interest to an adult. Be mindful that standardised tests, e.g., involving naming (when purpose is not clear) may be considered demeaning to some Aboriginal clients so should be used carefully and with maximal explanation and sensitivity to the client’s response (brokered through an AHLO). It is important to establish literacy level of the client/family before assuming written information will be understood. Checking with clients and their families on comprehension of materials is important. Intergenerational workshops on issues that affect the whole community, i.e., hearing loss, ear disease facilitate community to generate their own strategies. Discussion of issues related to general health, family, country, community status, e.g., eldership, will provide a context in which to then establish the potential presence of a communication disorder, with the client, family and AHLO providing a variety of perspectives on the client’s communicative competence. The term “goals” may not be familiar or meaningful to many Aboriginal clients. It may be more appropriate to discuss clients’ “concerns.” Even a clinician who emphasises general “functional” areas of communication may not focus on issues that Aboriginal clients see as important. For example – “no language impairment” on the AusTOMS is “consistent verbal and written language output”. In an Aboriginal context, this does not consider the individual as a whole (i.e., perhaps the person was not literate prior to their stroke/injury or had a strong emphasis on non-verbal communication rather than consistent verbal communication to convey their message).

Principle 4: Provide clear explanations re purpose of assessment Principle 5: Ensure relevance of testing or treatment activities

Principle 6: Gauge literacy levels of client and family

Principle 7: View the client holistically

Principle 8: Talk about “concerns” rather than “goals”

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JCPSLP Volume 21, Number 2 2019

Journal of Clinical Practice in Speech-Language Pathology

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