JCPSLP Vol 21 No 2 2019 DIGITAL Edition

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.

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JCPSLP Volume 21, Number 2 2019

Journal of Clinical Practice in Speech-Language Pathology