​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.

Why all the drama, Dr. Fabiano? Aren’t those nice things to do? Don’t they acknowledge People of Color (PoC)? No. And I’ll tell you why: Diversity, equity, and inclusion by white people’s standards is surface. It is “feel good.” It goes just far enough to say, “I acknowledge the problems but there’s an easy fix. We’ll have a *nice* international night. We can just *smile* and that will fix the problem.” White people generally engage in equity and inclusion initiatives as long as they don’t have to feel bad. If we don’t have to deal with anything that highlights our role in racism, we don’t have to upset the status quo. We’re SLPs after all, right? Not experts on racism! But here’s a truth bomb—these surface activities are safe for white SLPs and accomplish nothing. We ARE experts on racism, because racism is white people’s problem, not folks of color’s problem white folks have to sympathize with. So, regardless of what your line of work is, but ESPECIALLY because we work with folks with disabilities and their families, we have to unpack our whiteness and face how we perpetuate this harmful system. 

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Peel that top layer back and take a look.

Rather than an individual attribute (e.g., racism means that person is racist because they use racial slurs), racism is interwoven through our beliefs, experiences, and culture. Because it is society-wide, it is referred to as structural racism. Society is structured in a way that excludes substantial numbers of people from minority backgrounds from taking part in social institutions. As the sociologist Harry Brod explains, “One is always in the system. The only question is whether one is part of the system in a way which challenges or strengthens the status quo” (Brod, quoted in Johnson, 2006, p. 35). In other words, racism is the water we all swim in. We either benefit from structural racism or we are oppressed by it. We either work to dismantle it, or we work to perpetuate it; there is no neutral ground. The only way to dismantle privilege and oppression is to engage these systems directly. 

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Now let’s peel back another layer of racism in CSD and discuss bilingualism.

According to the Center for American Progress (2012), 55.4 million children over the age of 5 speak a language other than English in the home. Further, children of color are more likely to be bilingual and 62% of foreign-born family households include children under 18. More specifically, bilingual children in the US are likely to come from traditionally excluded and stigmatized racial and ethnic groups. In 2009, Kohnert and Medina published a 30-year review of the literature on bilingual children with communication disorders. They found that over a 30-year period (A THIRTY-YEAR PERIOD), only about 46 articles were published that included bilingual children with language impairment in their study samples. It gets worse—only 12 articles included bilingual children with speech sound disorders, only two in the area of autism, and none in the domains of traumatic brain injury (TBI) and stuttering. Compared to the literature on monolingual English-speaking children with speech and language disorders, approximately 150 papers are published per year that include monolinguals in their study samples (150 PER YEAR!). This discrepancy is systematic. It is clear there is a system in place for who gets studied and who doesn’t.

This begs the question, “Who’s sitting at the table when these decisions are being made?” “Who is choosing which children are important?” “Who determines what children get the best assessments and treatments and what children are left vulnerable to misdiagnosis?” With ASHA’s overwhelmingly white representation in academia, we know IT’S WHITE PEOPLE. It’s no wonder we are basing our assessment and treatment protocols on white, middle class, monolingual English-speaking children. That our tests are normed on white, middle-class, English-speaking children, and that our therapy approaches are based on the culture of white, monolingual, English-speaking children. White people are making all the decisions and white people are prioritizing white children.
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This problem goes deeper. U.S. graduate programs in speech–language pathology remain focused on a monolingual English training model (American Speech, Language, and Hearing Association (ASHA), 2015a; 2015b) and 95% of ASHA-certified clinicians report no bilingual skills (ASHA, 2019). Less than half of SLPs have received training in the use of interpreters in clinical practice (Santhanam et al, 2019). Graduate students are trained to assess and treat monolingual English-speaking children with communication disorders, as only a handful of U.S. graduate programs in speech–language pathology include coursework in bilingualism. For the majority of programs that do offer training in bilingualism, the coursework is not required.

Let’s peel back another layer.

Although roughly half of the SLPs in the United States have bilingual children on their caseloads, less than half of clinicians are actually evaluating their speech skills (Skahan et al, 2007). SLPs are avoiding assessment of bilingual children because they don’t have the knowledge of what constitutes typical and disordered speech sound development in this population. The result of this avoidance is that bilingual children who do, in fact, have a speech sound disorder are not receiving services because they are not being evaluated. Avoidance of assessment due to language is a form of discrimination (ASHA Code of Ethics, Principle 1, Part c, 2016). This results in underdiagnosis of speech sound disorders and results in a health disparity between children of color and their Anglo peers—bilingual children with communication disorders are not getting the services they need, when they need them.

The other side of the coin is overdiagnosis. SLPs, due to their limited linguistic skills and lack of training, are assessing in English only. Failure to consider Spanish during assessment can increase overdiagnosis of disorder in this population to as high as 9% in some states (Klingner et al, 2003). Typically developing Latinx children are being pulled out of class to receive unnecessary speech and language therapy (missing academic content) while their white peers are accurately identified as typical and are present full-time in the classroom. This leads to an educational disparity. Misdiagnosis extends beyond speech and language and into psychology, as Black and Native American/American Indian students are routinely over-identified for both communication and behavioral disabilities (National Center for Education Statistics, 2016). This is happening disproportionately. It is happening repeatedly. It is happening systematically. Like the machine that it is, white supremacy is cranking out the same results it always has, and we keep allowing it to do so. Many folks have drawn attention to the disparities in our field over the years, but as reliable products of white supremacy, we got in line as white SLPs, took our place in the system, and pulled all the levers to keep systemic racism going.
 

So now that we know, what do we do?

Well, when we know better, we do better. This is not a static endeavor; it’s a starting point for you to engage, name, and transform our sociopolitical realities (Freire et al, 1987). Colorblindness will not get us there. We must face and embrace difficult discussions. We will make mistakes… and we will change… and then we will do better. We need to set an example for what we will and won’t tolerate in the workplace for our colleagues and students. We must peel back the layers of structural racism and then keep peeling, even when it’s hard, because it’s never as hard as what folks of color are experiencing on the receiving end of white supremacy. Only when we face what it means to be white, can we create a space folks of color want to be in, and clinical practice that matches our diverse society. International food night won’t cut it. We need to help facilitate liberation. Keep peeling.