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by Munaf Shaikh, MS, OTR/L, CEIS
In any health-related field, the main goal of the clinician is to help others. In order to achieve this, we must better equip ourselves with skills that enable us to work with people from other backgrounds and become culturally competent. According to Roberts (1990) to be culturally competent is to “honor and respect those beliefs, interpersonal styles, attitudes and behaviors both of the families who are clients and the multicultural staff who are providing policy, administration and practice.”
Early Intervention (EI) offers a variety of therapeutic, educational, and supportive services for families of children birth to three years of age, who either have a developmental delay or are at risk for developing a delay (Case Smith et. al., 1996, p. 648.) Early Intervention clinicians provide services for people of various backgrounds, and therefore, must have some understanding of practices and beliefs of other cultures in order to enhance service delivery. This article will outline some of the major areas of the Indian culture as they pertain specifically to Early Intervention, and discuss strategies to promote positive interactions with families from the Indian community in the United States
India is currently the second most populous country in the world, and over 3 million Indians live in the United States (Barnes et. al., 2002). Despite such a huge population of Indian families in America, research is limited in the area of Early Intervention for Indian families. The focus of research has primarily been on Indian adults in mental health or hospital settings, with very little written about services for children, especially those under 3 years of age. This article will serve as a guide for clinicians working with Indian children and their families.
India is a diverse country with regional differences in languages, foods, and traditions. There are, however, some general strategies that can be applied towards working with Indian families.
One of the most important elements in providing effective EI services is to establish positive rapport with families (Raines and Ewing, 2006). One simple technique clinicians can use is to remove their shoes prior to entering the home This means that they are entering with a clean body and mind and are not bringing “dirt” into the home. Some families regard their houses as temples, and entering temples with shoes is not an acceptable norm.
Another way clinicians can make the family feel comfortable is to use a general greeting such as Namaste (Hindu greeting) or Salaam (Muslim greeting). These can be used for either “hello” or “goodbye.” Clinicians may see that some Indian women will not make eye contact or avoid responding to a handshake. Lack of eye contact is a form of respect for a person of authority, and most family members will become uncomfortable if they are touched by strangers. It is, therefore, a good idea to avoid or minimize physical contact with adults, as much as possible. As a sign of friendship, members of the same sex may hold hands and hug in greeting at special occasions; however, showing affection with the opposite sex is not appropriate. In general, public displays of affection are not encouraged, even between married couples.
Clinicians must consider respectful ways to address family members. In India, everyone is considered related to one another; therefore, clinicians may be called Behen (sister) or Bhai (brother). Some parents use Teacher, Madam or Sir, out of respect for authority. Children are told to respect elders, and parents may request that their children call the clinician “uncle/aunt or teacher,” rather than using the first name.
Indian families generally accept the medical model and have faith in the intelligence and decisions of clinicians. As Almaida (1996) discusses, anyone who provide services is a doctor (p. 417). Because they feel that the clinician knows more than they do and is always right, family members may nod “yes” for everything, even when they are not sure. As a result, the parents’ role in EI may be passive, and progress with the family may be complicated. Furthermore, if the family feels that the strategies of the clinician conflict with their cultural beliefs, they may ignore the suggestion rather than voice their opinion or concern. This may lead to “no-shows” or cancellations for scheduled appointments. In order to establish strategies that are culturally competent, clinicians must take the time to explain their role and how they will be of assistance to the family. They must involve the family in the decision-making process and encourage their questions.
Almaida (1996, p. 417) states that treatment should revolve around the family, even when it is the individual adult who seeks treatment. In the Early Intervention system, too, clinicians are encouraged to place families at the head of the decision-making process.
The concept of family is a very important aspect of Indian culture, and understanding different roles within the family is crucial. A typical Indian mother may stay home and be responsible for the child’s self-care and education, while the father’s role is to go to work, take care of finances, make family decisions , and provide discipline. Since EI involves parental education and child development, the system fits well with the mother’s role. Clinicians will have to take extra steps to involve the father in EI services, especially if the father works full time and is minimally involved in the child’s education. Efforts may include setting up appointments around the father’s work schedule and reviewing the child’s progress each time the father is available for sessions. As head of the household, the father usually has the authority to disclose or conceal information from the rest of the family or clinician. It is a good idea to review medical records with the father, as the mother or members of the extended family typically may not have all of the information.
Unlike Western marriages that center on the bride and groom, the Indian marriage brings together two families who share common values and beliefs, education or employment levels, caste, and even finances. Therefore, in most Indian homes, the clinician will be greeted by various members of the extended family, including aunts, uncles, and grandparents. Everyone in the extended family has a role, and each family member may provide support at different points in an individual’s life.. After delivery of her child , a mother may return to her biological family for several weeks or more to receive care and to show that the marriage is accepted by both sides. The grandparents may come to live with the family to help raise the children if the mother returns to work. A child may move into the uncle’s home to better access a particular school or service. This value system allows for resiliency and flexibility in times of need.
Traditionally, parents raise their sons to become the head of the household (Bumiller, 1990). The eldest son becomes the “breadwinner,” “social security,” or” retirement plan” for the parents. A boy will continue the blood line and a mother will be honored for bringing a child who will promote the family name. Sons may therefore be given more attention than daughters, Some families may see a son with a developmental delay (especially in the cognitive realm) as a child who will not be very helpful in the future. They would rather invest more time on the “healthy” children. Education is the best strategy in this matter. It is crucial that clinicians discuss the strengths of each child, boy or girl, during each session and assist the family in finding resources in the community, as needed.
Kaur et. al., (2006) find that most Indian children in EI are referred due to language concerns. Children learning two languages simultaneously will generally show delays initially, as their brains must process two different languages (Barron-Hauwaert, 2004). It is important to review with Indian families that even though a two-year-old may not currently be speaking in either language, the child will develop bilingual and multilingual abilities with age. The parent might find it helpful to use both languages with the child in daily activities to promote language development. Using the easier word within two languages is a good strategy. For example, Janvi’s parents encouraged her to use the Gujarati word, "haathi," and Aarti’s parents encouraged the Tamil word,"ani." Both words are easier than the English word, "elephant." The families repeated the Indian word along with the English word so that their children had opportunities to process both words. A clinician may also find it helpful to use traditional books/songs that are more meaningful for the families as part of therapy to promote language development.
Education is highly valued by Indian families, and, as for parents from most cultures, it is upsetting for them to hear that their child has a cognitive delay. With high educational expectations for their children, Indian families may fear that their children will be outcasts and bring shame to the family from the community. Some families may deny their child’s delays and refuse to seek other resources such as special education services through the public school system. For example, when Jay was 2½ years of age, his parents were introduced to the idea of special education services due to Jay’s pervasive developmental delay (PDD) diagnosis. It took nearly six months of encouragement before the family agreed to have a referral for special education services, as they believed that Jay would “grow out of it.” Encouraging his parents to meet with other Indian families who were receiving special education services was very helpful. In addition, EI clinicians can use handouts, brochures, visits to school systems, and frequent discussions about services.
Delays in self-care skills are common among Indian families and are related to the mother’s role in the family, namely feeding, dressing, and cleaning her children. Most assessments test for independence of typical children but do not consider children from cultures where independence may not be the norm or most valued trait for children. Children in India are encouraged to work collectively and form neighborhoods where each member is responsible for the group. Working on goals set by the family and the community is greatly valued. In an individualistic society such as the United States, where independence is valued, a discussion about cultural differences with the family will be helpful. The clinician can state that children, who are fed by mothers at home, often will not eat by themselves in school and that becoming independent with mealtime will help the child in a school setting. Since education is a highly respected value, most families will become more willing. One strategy to maintain the mother’s role as well as promote child independence is providing graded activities. For example, Diya’s mother wanted Diya to feed herself. We encouraged Diya to hold the spoon as her mother used it to feed her. Diya’s mother assisted with the first bite and we encouraged Diya to take the next one. As time progressed, Diya’s mother was able to reduce the amount of help she gave Diya, thereby promoting her daughter’s independence. Other mothers may choose to continue alternating bites, thereby fulfilling their traditional roles, as well as promoting independence.
Most EI developmental tools assess children based on the use of eating utensils. However, most Indian children are taught to eat with their hands. They are told to use God’s utensils and feel at one with food. Some families may eat sitting on the floor and their food might be placed on a small stool to show respect for the meal they will have. Discrepancies between the “western” ideals and Indian culture may also place a great deal of stress on parents who want their children to succeed at home and within their community. It is helpful to outline strategies from each culture that impact the family, and to discuss which strategies the family feels comfortable using.
In working with Indian families, clinicians may find that caregivers encourage their children to use the right hand over the left. The right hand in Indian culture defines purity and respect. Most parents were taught as children that they must give and take with their right hand. Children born using left hands are seen as inferior. This becomes an issue when families try to promote the use of right hand during play. Reema’s grandmother, for example, would consistently take toys out of Reema’s left hand and place them in her right hand. She explained that when growing up in India she was considered clumsy and incompetent for being left-handed. Clinicians can discuss that during the first year of life, most babies will grasp toys in their left hand and manipulate them with their right, as manipulation is a more complex and coordinated movement (Case-Smith et. al., 1997). They can explain that handedness usually develops between 3 to 4 years of age as children become more refined in fine motor play , as well as suggest several options for people who are left-handed, and clarify that it is not a sign of inferiority. What worked with Reema’s family was exploring 2-handed play activities that fostered bilateral hand development. Reema’s family members saw that the grandmother was encouraging play with both hands, and they were able to follow through on the exercises. For themselves, clinicians should remember that out of respect for the culture, they should give and take objects with the right hand or both hands, especially food that may be offered during a session.
The goal of this article has been to discuss cultural competency in terms of Early Intervention services with the Indian community in the United States. This article has attempted to provide some general guidelines for practitioners who work with the Indian population, although not all families will fit into neat categories. Therefore, it is always important to assess the needs of the individual client and family. Clinicians will find that once rapport has been effectively established, Indian families with whom they are working, will be the biggest and most important resources of cultural information. The goal for all clinicians should be to continue to seek out methods to promote cultural competency within their work with Indian families, as well as other cultures. Our work affects not just the individual families with whom we work, it will have an impact on generations to come.
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