Tips for screening children from diverse cultures
In many cultures, parents play peekaboo with babies, but it may be called something else. When translating or explaining the ASQ® item, it is important to describe the activity in simplified terms that the non-native speaker can understand.
In the course of your screening program, you’re sure to work with children from families who don’t speak English at home or who come from different cultures. You can use ASQ to check the development of children from diverse cultures as long as you consider the possibility of needed adaptations. You want to be sure that language and cultural differences don’t result in an inaccurate picture of a child’s development.
From the beginning
From the very beginning, focus first on establishing a respectful relationship and understanding the family’s cultural values and child-rearing beliefs. Be prepared to set aside your own biases and try to see through the lens of the family. If you encounter practices that you don’t subscribe to (such as parents carrying their children all the time), recognize those as cultural judgments and set them aside.
If you are unfamiliar with the family’s language and culture, enlist the help of an interpreter and/or a “cultural broker.” Seek advice on introducing the purpose of screening and ASQ through a cultural lens and ask for insight on cultural considerations you should keep in mind (for instance, what is appropriate dress, or should elders or others be present when meeting the family?). Some families may be mistrustful. Caregivers may be concerned that children will be labeled and possibly excluded from programs as a result of screening.
The value of a cultural broker
A cultural broker, also referred to as a community health worker, can serve as a bridge between the practitioner/program and the family.
Often someone who speaks the family’s language and comes from the same community, a cultural broker can review the ASQ questionnaires in advance for appropriateness; can advise the practitioner on cultural considerations such as how to greet the family, how to dress, who to speak with, who should be present, whether eye contact is appropriate; and can help to explain cultural reasons why a family might be mistrustful of the process.
On the family’s side, a cultural broker can answer questions about the purpose of screening and how it can benefit their child.
For more insight, try these resources
The Spirit Catches and You Fall Down (the story of a culture clash between a well-meaning medical community and an immigrant family)
Someone familiar with the community may also be helpful in determining whether cultural adaptations are necessary. Items on ASQ have been carefully selected, but there may be items that are not appropriate for a given family, culture, or geographic area.
For instance, in many cultures, children play with their own reflection, but some hold the belief that using a mirror can steal a child’s spirit or cause their teeth not to grow in; in such a case, you would want to omit the item that asks parents whether their child pats a mirror. (See this scoring adjustment chart for instructions on scoring when items are omitted.)
In another example, some cultures have strong beliefs against putting children on the floor to play until a certain age, which precludes completion of many of the gross motor items. Practitioners can, however, see if caregivers are comfortable trying activities on a table or bed, which respects the values of the families while at the same time obtaining crucial information about the child’s developmental progress.
Sample cultural substitutions
In working with researchers around the world to translate ASQ for study in their cultures, Kimberly Murphy, a researcher with the University of Oregon, discovered many practices and routines in common, as well as differences particular to each culture.
Here are some examples of substitutions that may be appropriate:
1. Original (Personal-social)
Does your child serve herself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?
Alternate version 1.
Does your child serve herself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop rice from a bigger bowl to a smaller one?
Alternate version 2. (it is not common practice in some cultures for children to “serve themselves” food)
Is your child able to take sand from one container (such as a play bucket) with a shovel of large spoon and put it into another?
2. Original (Communication)
When you ask, “What is your name?” does your child say both her first and last names?
When you say, “What is your name?” does your child say her first name and her family name?
As a first step of translation, Kimberly recommends putting the ASQ items in as simplified or plain English language as possible so that translators can capture the intent in the translation.
For more pointers on translation, download Guidelines for Cultural and Linguistic Adaptation of ASQ-3 and ASQ:SE.
Specific skills in the questionnaires may not be practiced by children or may be developed at different developmental stages or ages.
For example, an item that addresses the child’s ability to feed him- or herself with a spoon may not be relevant in cultures in which chopsticks are the primary eating utensil. An obvious substitution for some families may be chopsticks; however, children may not master this skill until later than eating with a spoon because:
- families may not encourage children to feed themselves until they are older, and
- eating with chopsticks may require more advanced fine motor and cognitive skills than eating with a spoon.
ASQ allows you to substitute familiar and common materials and tasks for materials or activities that are offensive, unfamiliar, or unavailable to families, as long as the substitutions retain the intent of the original item. (“Cheerios” is a common item in U.S. households that is the right size for testing children’s grasping ability, for instance; for immigrant or foreign households, it’s perfectly fine to substitute a similarly sized item that would allow caregivers to observe the same sorts of skills.)
Substitutions may be appropriate for items in cultures that
- encourage independence later than Western cultures do
- focus more on family interactions than playing with toys
- place importance on children being quiet or unobtrusive
- have gender expectations in which girls, for instance, aren’t encouraged to play with balls
You can improvise in cases where families have no access to suggested materials. Children in Hawaii, for example, rarely use zippered coats, making items requiring the use of zippers difficult to observe. In order to assess these items, you can provide a large purse with a zipper that could be substituted for the zippered coat.
When items aren’t available in the home, another option is to encourage parents to look for objects outside the home. Many parks, child care centers, and schoolyards may have the needed objects. For example, in the southwestern United States, many homes are built without stairs. To complete gross motor items involving stairs, parents may use playground equipment in a local park or building.
Be aware, too, of items that refer to objects in the environment. For a child who lives in a remote community without any buses, you might wish to substitute a different reference for the item on the 60-month questionnaire that examines a child’s ability to use comparative words: “A car is big, but a bus is _______ (bigger).
Interpreting results and providing feedback
As with your initial introduction to the family, consult with a cultural broker if you can for advice on what is appropriate for communicating screening results and deciding follow-up (who should be involved in the discussion, for instance).
In interpreting results to begin with, weigh the cultural information you have gathered and consider that children from other countries may develop at different rates. (In a comparison between American and South Korean children, development proceeded at a very similar pace, but at certain ages, South Korean children’s scores were significantly higher in the fine motor domain while American children’s scores were higher in the gross motor domain.)
It’s critical to listen and learn from families about their beliefs about rearing their kids. Be sure to gather the family’s feedback about what concerns they have, what they think is the cause of any issues, and what interventions they think are appropriate. Parent concerns are highly predictive of school-aged problems and behavioral issues. Listen for cues of what can be done to address concerns.
You may be knowledgeable about the evidence base, but even more important is collaborating with the family to devise next steps that are meaningful within their cultural context (which will improve the odds of follow-through). Don’t be too quick to jump to advice-giving; rather, follow the family’s lead.
In determining follow-up activities, be aware of cultural norms. In Guatemala, for instance, a mom would not feel comfortable getting on the floor to play with her baby—she sees her role as a caregiver rather than a playmate. So in working with that mom, you would suggest activities that develop the child’s skills in a different way. Finally, in making follow-up referrals, recommend agencies that are sensitive to the family’s culture and familiar and trusted in the community.
Changing your way of thinking to look through the lens of a family’s culture is a learning process, but well worth the effort. When you make adaptations for a better cultural fit, you give children the best chance of showing what they can really do, make sure they get the services they need, and increase the odds of screening success, for everyone.
(Originally published November 2014)
Translations of ASQ®-3 and ASQ®:SE-2 are in development in a number of languages. ASQ-3 questionnaires are currently available commercially in English, Spanish, Arabic, French, and Vietnamese. ASQ:SE-2 questionnaires are available commercially in English and Spanish. ASQ-3 and ASQ®:SE are available in Somali and Hmong in Patient Tools, Inc.
Opportunities exist for people to participate in pilot studies for other languages. For more information, email firstname.lastname@example.org.
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