​Imagine this: you hear about a new test of an Important Swallow Measure and check out the article for its normative data. You see this table:

The next day, you try out the test and your 25-year-old patient scores 1.57 seconds.

Is their Important Swallow Measure within normal limits?
 
Hold that thought while we consider what within normal limits even means.
 
Whenever we make a clinical judgement, we’re doing some kind of assessment of whether the patient’s behavior is normal, functional, or disordered. Often, we collect quantitative data from our patients and then want to see how their performance compares with “normal limits.” To define those limits, we typically ask: What are the lower and upper values that include the vast majority (commonly 95%) of the results from a healthy sample?
 
In some areas of our field, finding these values might be relatively straightforward, like a score on a published norm-referenced cognitive assessment. But a lot of the normative data for up-and-coming quantitative measures of swallow function are coming straight from research articles that aren’t trying to provide a normal range (like this one). These articles might look like they present the data we want—even when they don’t. So we need to be careful not to accidentally use the wrong values to make clinical judgements, just because they are the only values available.
 
There are a number of appropriate ways to define a normal range. For example, we might use +/- 2 standard deviations (SD) from the mean to capture ~95% of the normal values (if we know the data is normally distributed). Or, we could define normal limits based on percentiles (especially if the data is skewed). For example, 90% of US women’s heights fall between the 5th percentile of 4’11” and the 95th percentile of 5’8” [1]. If you don’t remember much about SD and percentiles, don’t worry. Just know that these are both meaningful ways to describe a range within which most of the values fall. And, therefore, they are good measures to use when defining normal limits or thresholds.
 
Now let’s go back to that table. Is your 25-year-old patient’s score of 1.57s within the normal range?

Written by: Grace Neubauer, MS, CCC-SLP
Edited by: Natalie Douglas, PhD, CCC-SLP
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​By: Leah Fabiano-Smith, PhD, CCC-SLP

I was on the plane to Orlando, heading to the ASHA Convention. I realized I had an issue of the ASHA Leader in my carry-on, so I pulled it out to browse through. I was thumbing through the pages when I saw a page full of brief quotations. The question at the top of the page read, “How are you incorporating diversity into your clinical practice?”

​Respondents from all over the country shared their diversity initiatives. One SLP said, “We’re hosting an international night! Folks will bring foods that represent their cultures to share with everyone.” Another SLP shared, “We’re decorating the halls of our school to represent the different cultures of the world.” Yet another suggested something like, “We’re celebrating African-American History month with literature about the underground railroad.” I immediately stuffed the Leader back into my bag and pulled out my laptop. I had completed my presentation days ago on misdiagnosis of speech sound disorders in bilingual children, a topic I speak on nearly every year; however, I felt compelled to add a couple slides. The first listed the quotes I found in the Leader article. At the bottom of the slide I wrote in all caps THIS IS NOT ENOUGH.

​ 
Maybe you’ve said the following:
“Where are you from? No, where are you REALLY from?”
“You speak English really well for a ______ person!”
“Can you teach me words from your native language?”
“What are you?”
“You don’t look ______.”
 
But let’s think again. What makes me assume I know your culture and who you are from visual appearance?
 
The previous statements are actually considered to be microaggressions. They send the message that an individual is “other”, “different”, or “less-than” in some way. Sue et al. (2007) identifies microaggressions as daily verbal, behavioral, or environmental insults that can either be intentional or unintentional, and that can impact clinical interactions between a clinician and client.

Tell me what is most central to your identity:
 
Is it your age?
Disability?
Ethnicity?
Gender?
Sex?
Sexual orientation?
National origin?
Language?
Race?
Religion?
Veteran status?
… or something else?
 
If you had a hard time choosing one you probably, like most people, fit into more than one category. Oftentimes culture operates at a place of intersectionality. One box does not fit all areas of your cultural identity. Culture is the fabric that makes you who you are and is always evolving. But importantly, our assumptions about culture shape our interactions with our clients. These are the invisible biases that can prevent a clinician from being qualified to practice.

Everyone else, welcome! Let’s go on a journey together. Consider this topic an enchanted forest; the path through may be arduous, but we will all leave with our practices transformed for the better. Is it possible that quarantine at our house is involving a lot of Frozen 2? Perhaps. ​