As we enter the new millennium, we are faced with new challenges of how to provide clinical services to culturally and linguistically diverse populations. Thus, the role of culture and the treatment of stuttering must be examined on a case by case basis.

In order for clinicians to competently provide services to a person who stutters, they need be aware of and sensitive to many issues. Some of these issues are; 1) changes in multicultural populations; 2) variations of language-learning environments in which many multicultural children are being reared; 3) effects of poverty on many multicultural children; 4) the speech-language pathologist’s role and responsibility regarding clinical assessment and therapeutic management (Adler, 1993).

The continued growth of multicultural populations in the United States will necessitate an increase of awareness and sensitivity on the part of our profession. Thus, requiring changes in our traditional assessment and treatment practices with people who stutter. Moreover, differences in race, gender, ethnicity, and socioeconomic status require an understanding of a variety of mores, behaviors, and linguistic patterns which may be demonstrated by culturally and linguistically diverse populations (Adler, 1990).

A culturally competent clinician is sensitive to issues related to culture, race, gender, sexual orientation, and social class. However, cultural competence is more than simply acquiring knowledge about ethnic-racial groups. It is a very complex combination of knowledge, attitudes, and skills (Lipson, Dibble & Minarik, 1998).

Culture defined by Adler (1993) is any group of people who share a common history and a set of relatively common behaviors and/or communication patterns. Taylor (1986) refers to culture as a set of perceptions, technologies, and survival systems used by members of a specific group to ensure the acquisition and perpetuation of what they consider to be a high quality of life. Culture is arbitrary and changeable. It is learned and exists at different levels of conscious awareness. Culture is also a double-edged sword, on one hand social groups live together because of shared values, beliefs, and practices. Within groups we see disharmony because of judgments of ones’ own values, beliefs and practices.

Multicultural considerations in the assessment and treatment of stuttering are not new. Primarily because of areas in which culture influences communication styles. Verbal and nonverbal communication styles are major factors to be considered during the assessment and treatment process. Rules for eye contact, proxemics, and silence as a communication style are some of the nonverbal behaviors to be considered. Verbal communication styles may involve laughter as a communication device, appropriate topics of communication, when and how to interrupt, and use of humor.

Inevitably speech clinicians will come in contact with clients from various cultural backgrounds that differ from that of the clinician. The assessment of stuttering is an ongoing process and many factors addressed during the assessment need to become part of the treatment process. Thus, it is imperative that most of the areas listed be addressed (Lipson, Dibble, and Minarik, 1998).

Where is the client from? If an immigrant, how long have they resided in this country?

What is the client’s ethnic affiliation?

Who are the supporters of the client: family, friends, extended family members?

Does the client live in an ethnic community?

What is the client’s first language for speaking and reading?

Does the client speak and/or read a second language?

How would you describe and characterize the nonverbal communication style of the client?

How would you describe and characterize the verbal communication style of the client?

What is the client’s religion, and what role does it play in daily activities?

What is the client’s social economic status?

What are the health and illness beliefs and practices of the family?

What are the customs and beliefs involving birth, illness, and disorders?

With the answers to the questions above and taking into account dysfluency types, frequency of dysfluencies, physiologic correlates of dysfluencies, attitudes, and awareness, hopefully the clinician will be able to develop an effective culture-independent treatment plan.

1. It is extremely important for speech clinicians to recognize that there is no standard cultural group. Each group represents a wide variety of subcultures, depending on the degree of assimilation into the general American culture, the socioeconomic level of the subculture, the geographic location of the subculture, the educational level of the members of the subculture, and so forth. There are also individual family variations within the subculture influenced by the above-mentioned factors. Cultural orientation will only give direction to questions concerning the importance of general cultural influences. The awareness of variability will help prevent cultural stereotyping on the part of the clinician.
2. Some cultures are extremely private about their family and personal lives. The clinician should respect this privacy and not discuss such matters if the client is from such a culture.
3. Some cultures protect their children to the point where the child has great difficulty in adjusting to the school setting. This could include dealing with adults, other than family members, on a one-to-one basis.
4. Within some cultures it is impolite to speak in a "loud" voice. A child from one of these cultures might speak very softly, to the point where it is difficult to understand what is being said. This may not be shyness, but rather, a cultural influence carried over from the home.
5. Since various cultures respond to the handicapped in different ways, it is very important for the clinician to know the response of the client’s culture to handicapped persons.
6. Establishing rapport with the family may be difficult if the clinician is female and the culture of the family does not accept the female in this type of role. There may also be problems if the clinician is from another culture. Both of these factors may be compounded by the fact that the clinician represents a "figure of authority. "
7. The role of the child within the family unit varies from culture to culture. If the cultural family unit is child-oriented, a home program may be able to be instituted, since the parents are involved with their children. However, if the cultural family is not child-oriented, parental cooperation is not likely to occur, regardless of attempts on the part of the clinician.
8. In cultures that are not child-oriented, the parents are usually not involved in the child’s effort on the school environment. It may be advisable to increase the rewards and encouragement the child receives in the school environment to compensate for the lack of support from the home.
9. In some cultures, the female rarely comes into contact with people of other cultures, relating only with people of her own culture. This can create problems both in terms of home visits by the clinician and the establishment of home program.
10. There may be instances where a child is unwilling to communicate with a person of another culture. The clinician should be sensitive to this possibility.
11. Failure on the part of a child to maintain eye contact with the clinician may be a cultural factor. It should not be misinterpreted as an attitudinal sign or a secondary mannerism associated with stuttering.
12. Depending on the culture, it may not be appropriate for the clinician to touch the child. This is particularly true for some Indian tribes where the hair is considered sacred. A pat on the head would be most inappropriate with a child from such a tribe.
13. If the family is required to sign forms or other documents for the testing of a child, this may, depending on the culture, embarrass or shame the family. If this is the case, the parents may not sign the forms or documents.
14. Mannerisms used by a bilingual child to cover up his or her lack of English proficiency may be misinterpreted as secondary mannerisms associated with stuttering. The clinician should check to see if the mannerisms occur when the child is speaking his or her native language. If not, there is still a possibility that the child is stuttering while speaking in English. This factor should be checked very carefully and appropriate action taken if the child is stuttering.
15. If a child were demonstrating some stuttering in his or her native language, it would be advisable to remedy the stuttering problem before enrolling the child in a program for English as a second language. Communication stress is an important factor in the development and maintenance of stuttering, and the demands for learning and speaking English would create even more communication stress on the child and make the problem worse.
16. * Number 16 was eliminated due to its non-relevance to this text.
17. Communicative stress can often be found within the culture itself if oral ability is a source of peer recognition and status. Various cultures view oral ability as an important factor for status within the community. This cultural attitude can have a profound effect on the treatment of stuttering. The clinician should be aware of this factor and determine its influence on the particular child she is working with.
18. Various cultures have different attitudes towards stuttering, and it is important that the clinician determine the attitude of the family. In some cultures it is viewed as a curse or has some religious overtones. The family’s attitude will have a direct influence on the treatment of the problem.
19. Many stuttering treatment programs stress the importance of eye contact as a goal of therapy. The clinician should keep in mind that this is considered a negative behavior in many cultures, particularly for the female.

Source: W.R. Leith, "Treating the Stutterer with Atypical Cultural Influences," in K. St. Louis (ed.), The Atypical Stutterer (New York: Academic Press, 1988), pp. 30-32. Reprinted with permission.

Clinicians must be cognizant of the following considerations with service delivery to multicultural stuttering populations. Cole (1989) identified several issues that could possibly affect the service delivery process when multicultural populations are involved. These issues are:

1. more minorities with communication disorders;
2. more minority children born at risk;
3. different etiologies and prevalence;
4. difficulty establishing norms;
5. cultural variations regarding views on health and disorder;
6. potential cultural conflict in clinical settings;
7. different service delivery preferences among minority groups and;
8. more linguistic heterogeneity in minority populations.

It is necessary that we, as clinicians, view each treatment session being subject to cultural rules of both the client and the clinician. Therefore, keeping in mind that because of cultural and linguistic differences, clients may respond differently to standard types of stuttering treatment because of their cultural and language backgrounds. If the assumption is made that there are similarities between client and clinician, rather than recognizing differences, this could lead to cultural conflicts during clinical encounters.

Clinicians should recognize that learning about multicultural populations is an on-going process involving constant reassessment and revisions of ideas, awareness, and greater sensitivity to cultural diversity. It appears to be of critical importance that we find ways of continuing to learn from various multicultural populations to understand the patterns of people that govern face-to-face relations, and to prepare clinicians to function within cultural systems that are foreign but no longer incomprehensible.

Adler, S. (1990). Multicultural clients: Implications for the SLP. Language, Speech, and Hearing Services In Schools, 21, 135-139.

Adler, S. (1993). Multicultural communication skills in the classroom. Boston:Allyn and Bacon.

Cole, L. (1989). E. Pluribus Pluribus: Multicultural imperatives for the 1990Ős and beyond. Asha, 31(9), 65-70.

Leith, W.R., (1988), Treating the stutterer with atypical cultural influences. In St. Louis, The atypical stutterer, 9-33. New York: Academic Press.

Lipson, Dibble, and Minarik (1998). Culture and nursing care: A pocket guide. San Francisco: School of Nursing, University of California San Francisco Nursing Press.

Taylor, O. (1986). Treatment of communication disorders in culturally and linguistically diverse populations. San Diego: College-Hill Press.

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