The Case of Alejandro Flores



Jason Moffitt

CSD 627: Multicultural issues in Communication Disorders

11/2/12

Case Study Assignment (20%)

The Case of Sonny Santos

This case focuses on a 6 year old low-income, non-English speaking Filipino patient and family. As you read through this story, pay special attention to issues involved in medical decision-making such as gender roles and values, and interest in treatments outside of traditional western medicine based on culturally constructed folk illness beliefs.

Background

When Sonny Santos was born, his parents were excited and very proud.  Sonny was their first child born in the United States, in a world far away from their tradition and family in Manila, the Philippines.  The Santos’ had worked very hard to move to North Carolina a year before Sonny’s birth, and they felt that his arrival helped connect them with their new home. 

It is six years after Sonny’s birth, and the Santos family has grown even larger.  There are now 5 children (2 older than Sonny, one 3 year-old and a 20-month-old) and Sonny’s grandmother living in the same apartment.  Sonny’s mother, Mrs. Santos, takes care of her family as best she can, and she feels lucky to have her mother there to give her advice and a helping hand.  Mr. Santos works very hard as a custodian at a local school to provide his family with enough income.  He has picked up a little English at work, but only Tagalog is spoken at home.

Since birth, Sonny has experienced chronic otitis media. Although he looks healthy, Sonny has had ear infections for several years.  When he was 2, a series of high fevers associated with the ear infections sent him to the hospital multiple times.  His parents do their best to care for him, but they are both under substantial stress with daily living.

After a doctor told the Santos family that part of Sonny’s medical problems were due to allergies, they relocated to a new apartment that has air-conditioning. In addition, to help with all the Sonny's problems, Mr. Santos has limited his smoking to outside on the patio.  The family has two dogs, which could be a problem, but they just couldn’t see getting rid of two loved members of their family. 

Sonny has taken a lot of medications for his middle ear symptoms, primarily antibiotics and decongestants. His parents have been taught about his condition and have been given a care plan.  They were told to call the clinic if at any time Sonny’s symptoms worsened or if his fever spiked above 101º.  Despite these actions, Sonny continues to experience middle ear infections with profusion at least once per month.

With Sonny continuing to have ear problems, His mother became skeptical that the medications weren't working.  Under the guidance of her mother, she took Sonny to a healer. At the healer’s advice, Mrs. Santos stopped giving Sonny all of the prescribed medications, and began giving him an herbal tea that she believed, along with prayer, would take Sonny's medical problems completely away.

Today in the Clinic

Sonny and his parents have come for a regularly scheduled visit to the clinic today to see if the new medications were helping to control Sonny’s symptoms.  This is the second visit since Sonny’s last hospitalization 6 months ago.   Mrs. Santos has not contacted anyone at the clinic about Sonny’s asthma getting worse, so the clinic assumes the best. 

During your testing, you find that Sonny has a moderate –to-severe mixed hearing loss in his left ear and a moderate sensorineural loss in his right ear. In addition, you determine that, in conversation, his use of English words is basically non-existent and his use of Tagalog is limited. His parents’ express serious concerns about the fact that Sonny is much slower in learning English than his older siblings and that this is affecting his ability to be successful in school.

Questions for you to answer about this case:

1. What speech and language characteristics do you expect to find in this child? Why?

- Delayed Speech, Language Impairment/Delay in both Tagalog and English, Limited Receptive Language,

- Why? - Otitis Media, ELL, Limited English Proficiency of Parents, Immigrant Parents, Poverty, Diverse Cultural Beliefs about Health and Healing, Language Delays Compared to his Siblings.

2. What tests will you use to assess his communication function?

Ideally Sonny will have been evaluated and fitted with a hearing device, but if not making sure to periodically check for understanding, speaking more loudly, facing Sonny and cueing him to watch the lips of the interpreter, anything to better facilitate hearing as to eliminate hearing interference from our language and articulation tests.

With the use of a Tagalog interpreter I would use

-PLS 4 (Preschool Language Scale 4)

-A teacher interview and rating of Sonny’s communication in school, including intelligibility rates.

-A Language Sample comparing Sonny’s sample to normally developing Tagalog speakers (Sonny’s siblings).

-The GFTA 2 (translating the test to Tagalog, even though it would make the reporting not standardized): Including words and or sounds for stimulability based off the phonetic inventory of Tagalog:

From:

3. What are some of the cultural and social factors might affect this family's approach to and experience with healthcare?

Some cultural and social factors affecting this family’s approach to healthcare in the U.S. is the language barrier (even with translators) they may not feel that they can effectively communicate with the doctors or staff. Another factor may be that the man of the household is the head of the family, so he may not be able to get off of work to attend the visit. The belief of what causes an illness for the most part in Pilipino culture relates back to spirits and/or punishment for something the individual has done. This belief can taint how the family may feel about if/how an illness should be treated. (Anderson, 1983)

4. Why might Mrs. Santos have chosen to consult a healer rather than call the clinic when Sonny was not getting better?

Mrs. Santos may have chosen to consult a healer rather than to have called the clinic when Sonny was not getting better, first of all because just that, Sonny was not getting better with the Western medicine given to him. Families rely extended family, mothers live with Grandmothers and turn to them for advice often, and Sonny’s mother’s mother told her to consult a healer. Filipinos have a strong belief in Timbang “Balance”, they believe in hangin ‘winds’ that enter the body most typically from hot or cold air. This wind that enters the body causes the body to be off balance, and balance must be restored mostly through prayer and teas. (Anderson, 1983) (Rigolioso, 2010) “Interestingly, when asked about faith healing, almost all agreed that faith healing and those who sought it were mainly people without education—“the lower classes,” as someone pointed out” taken from an article titled Caring in the Diaspora: Filipino Immigrants, Health Care, Healing, and Religion (Castillo, 2005). While this may be true, faith healing and the families perspective on it still needs to be respected and taken into consideration.

5. Do you think that traditional Filipino gender roles might have some effect on this child and family’s experience with the health care system? Explain your answer.

Yes, traditional gender roles will have some effect on the family’s experience with the health care system. In Filipino culture traditionally the male works outside the home in some form of physical labor, while the female works in the home typically. She is responsible for the house and raising children, while he is responsible for providing for the family. This could have some impact on this family, as it is the father who speaks some English, but is the mother who will most likely attend any doctors visits. Women typically rely on an older child to help with the house and in taking care of an elderly family member who lives with them.

6. What is the predominant religion in the Philippines? How does this affect the Santos response to Sonny’s illness and their choice of treatments?

The predominant religion in the Philippines is Roman Catholic. However the break down according to the 2000 U.S. Census is: Roman Catholic 80.9%, Muslim 5%, Evangelical 2.8%, Iglesia ni Kristo 2.3%, Aglipayan 2%, other Christian 4.5%, other 1.8%, unspecified 0.6%, none 0.1% (2000 census).

While they may claim Roman Catholic as their religion that’s not without holding onto some traditional practices, “Animism or folk religion encompassing indigenous spiritual traditions from pre-colonial times still prevail even among baptized members of formal churches. Superstitious beliefs are widespread.” ()

7. How would it be possible to incorporate alternative folk remedies with mainstream western medicine in developing a treatment plan for Sonny?

From what the healer told Sonny’s mother, and what the doctors are prescribing Sonny, coupled with the family’s inability to take away contributing factors (the dogs) to Sonny’s health I think it would be best for Sonny if concessions could be made. Having the family gave Sonny prayer and tea, along with his medications from the doctors would be ideal. It would just be up to Sonny’s parents to incorporate both practices.

Faith healers could be incorporated into the discussion of the client. In the Doctor’s office or hospital the faith healers could serve as the person who combines both perspectives if they are willing. If not willing, a translator could inform the family of the medical advice from the doctor and the faith healer could perform their services as well.

8. What different perspectives on health care might be expressed by Mr. Santos, Mrs. Santos, and the primary physician? How would these perspectives have influenced Sonny’s treatment to this point?

Mr. & Mrs. Santos: May be more concerned with the spiritual cause of the illnesses seen in Sonny, they may try to alleviate the spiritual disruption that they believe to be the cause of Sonny’s symptoms. Their treatment thus far has been very symptom related, and they have just been given a medicine to ‘fix’ Sonny. The physicians may not have taken their perspective of a more spiritual etiology seriously or the Santos may not have been able to communicate that to the physician due to language barriers.

The Primary Physician: Chronic Otitus Media can lead to language delays (which we are seeing), while at the same time putting Sonny at risk for permanent hearing damage. The fevers and inconsistently taking medication are also compromising Sonny’s already disadvantaged system (allergies), which could lead to a host of other medical problems. The Santos’ attitude towards healthcare could show the doctor disrespect and that they don’t care, which could then color the remainder of the services provided by this physician and other physicians if the Santos’ developed a reputation amongst healthcare professionals.

9. What are 5 questions that you need to Mr. and Mrs. Santos? What is the rationale for asking these questions? Make sure that the questions are worded in a culturally appropriate manner that can elicit important information that can affect patient and family satisfaction with care.  

All questions will be asked in Tagalog through an interpreter.

1. What are your concerns or Sonny?

Rationale: Asking parents to express their concerns first is reported to give them a feeling of control over how their child is viewed and what their disorder is (if they feel there is a problem). It also sets the tone for the interview, letting the parents know what you’re there for them, not there to criticize or control how they raise their child.

2. When Sonny speaks Tagalog at home, does he sound like his peers?

Rationale: This question seeks to gather information on Sonny’s language compared to his siblings and peers. It also lets the parents know that Sonny will still be encouraged to speak and build his language in Tagalog, that he won’t be betraying his culture and background by learning English.

3. How often do you understand Sonny on the first try?

Rationale: Sonny’s intelligibility at home in his most relaxed environment will give us a picture of how deeply his speech delays are impacting his quality of life. How his familial relationships may be affected, and opening up the floor for the parents to express their concern or frustrations with Sonny’s speech.

4. Does Sonny receive any instruction at school in Tagalog, or does he receive any help with his English?

Rationale: This question can give the clinician better insight into Sonny’s academic resources or if he receives any. If Sonny can’t access the curriculum, then we need to investigate the services and instruct the parents to request referrals and assessments to get Sonny help in accessing the curriculum.

5. How does Sonny interact with his peers at school?

Rationale: This gives us insight into how affected Sonny’s social life is by his communicative abilities. If Sonny has trouble making friends, this can also be factored into school services and he may need to see the school psychologist.

10. What information would you provide Sonny’s teacher about communicating effectively with him and his family?

Sonny’s teacher needs information on hearing loss, Tagalog, and Pilipino culture and family structure.

Instructing Sonny’s teacher in what to look for when Sonny doesn’t understand, make sure he can hear the instructions.

Suggest to Sonny’s teacher wear a microphone and project her instructions to the entire class, or wear a personal FM device with a receiver at Sonny’s seat so he can hear her amplified voice. Sonny’s seating should also be preferential, closest to where the teacher gives most of the instruction.

We could provide Sonny’s teacher with the normal sounds of Tagalog, and maybe some key words for her to include in her classroom. Labeling things in Tagaloga and English can give Sonny better access and exposure to language in print form.

Make sure that the teacher understands that Mom will be the most involved in Sonny’s education. The family structure of most Pilipino families is the father working, the mother at home, with help from a grandmother or older sibling.

She could incorporate some Pilipino cultural activities into her curriculum to make Sonny feel more welcomed and accepted.

11. Use the information that you have obtained to answer items 1-10 to develop the following:

a. Long-term speech-language goals – include rationale

i. Sonny will improve his use and intelligibility of English.

Rationale: Sonny attends a school where the academic language is English, to access the curriculum he will be expected to speak, read and write in English.

ii. Sonny will continue to develop his grammatical and pragmatic use of Tagalog.

Rationale: For ELL individuals it has been proven that the second language develops only to the level of the primary language. Sonny needs to read and write in Tagalog to better improve his learning and functionality of English.

b. Short-term speech-language goals – include rationale

i. Sonny will ask questions to check for understanding 80% of the time.

Rationale: Since Sonny has a hearing loss and is an ELL individual making sure he understands what is being asked of him is crucial for any further development in school and therapy.

ii. Sonny will produce the /f/ English phoneme with 80% accuracy at the sound level, moving to the word and sentence level.

Rationale: The /f/ phoneme is not in the Tagalog phonemic inventory, and therefore will need to be taught with articulator placement and auditory bombardment, and minimal pairs contrast. The /f/ phoneme is age appropriate for Sonny’s adjusted chronological age as an ELL student.

c. Related services that are needed – include rationale

-Audiology – Fitting of an assistive device

-ESL to help Sonny access the curriculum and develop his English

-Resource – to help Sonny gain an understanding of the elementary academic concepts he may be missing due to his language and hearing impairments.

-Psychology – to help Sonny adjust to a different culture and to learn socially acceptable ways to make friends and conduct himself in a school setting.

d. Estimated long term out comes

The prognosis for Sonny’s overall academic achievement is guarded due to cultural resistance from the family to help Sonny access the materials he needs to succeed. Sonny’s delay is at a crucial time for starting elementary school when children his age are performing at or above the level expected of them. If Sonny is fitted with an amplification device his prognosis may change, but due to parental resources and interest this may not be an option for Sonny.

References

Anderson. (1983). Health and illness in Pilipino immigrants. Cross Cultural Medicine , 139(6), 811-819. Retrieved from

Barringer , S. (n.d.). Countries and their cultures: The philippines . Retrieved from

Castillo, M. V. (2005). Caring in the diaspora filipino immigrants, health care, healing, and religion.Harvard, Retrieved from

Pollack , B. J. (1997). Educating children who are deaf or hard of hearing: Additional learning problems. Retrieved from

Sarte, M. (2010). Long live matriarchy. Retrieved from

Zuraw, K. (2010). A model of lexical variation and the grammar with application to tagalog nasal substitution. National Language Linguistic Theroy, 28, 417-472. Retrieved from

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