Embracing Diversity and Bridging Differences in Pediatric Occupational Therapy Practice

Guiding Questions and Key Terminology

Guiding Questions

• Why is it important for pediatric occupational therapy practitioners to show cultural humility in practice?
• What steps can occupational therapy practitioners take to develop cultural humility in practice?
• What does it mean to bridge differences?
• How can occupational therapy practitioners bridge differences in their work with others?

Key Terms

• Ableism: The notion that certain bodies are "normal," appropriate, and desirable, and that upholds as "natural" the inequitable opportunities and advantages that flow to those with usual bodies.
• Bias: Prejudicial attitudes toward and stereotypical beliefs about a particular social group or members therein.
• Bridging differences: A person's attempt to connect with another based on a recognition of their shared humanity and with the attitude of valuing the differences each brings to the interaction.
• Capabilities approach: A framework focusing on choices, opportunities, and quality of life beyond basic economics, considering whether a person's circumstances allow them to engage in valued experiences in chosen ways.
• Cultural competence: A traditional healthcare model focused on acquiring knowledge about other cultures, which contrasts with frameworks emphasizing power dynamic critique (cultural safety) and lifelong self-reflection (cultural humility).
• Cultural humility: The ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the person.
• Cultural sensitivity: Being aware of others' cultural beliefs and practices as well as one's cultural position relative to others, encompassing knowledge, consideration, understanding, respect, and tailoring.
• Cultural safety: An institutional and clinical stance wherein healthcare providers critique taken-for-granted systems and power differentials, focusing on the provider's culture rather than viewing the client as an "exotic other."
• Diversity: Unique attributes, values, and beliefs of an individual when compared with a group; describes a characteristic of a group rather than an individual.
• Equity: A principle ensuring everyone can access the same opportunities by acknowledging unequal starting places and providing tailored support to overcome barriers.
• Implicit bias: Unconscious beliefs, attitudes, and associations that influence perceptions, decisions, and actions without intentional awareness.
• Inclusion: The practice of recognizing diversity and specifically valuing the uniqueness of beliefs, values, and attributes of others in a way that creates belonging and engagement.
• Occupational justice: The fulfillment of the right for all people to engage in the occupations they need to survive, define as meaningful, and that contribute positively to their own well-being and the well-being of their communities.

Introduction to Demographic Realities and Healthcare Equity

Demographic Shift and Clinical Imperative

• According to the 2020 United States Census, the probability that two people chosen at random will be from different racial or ethnic groups increased to $61.1\%$ in 2020 (Jensen et al., 2021).
• This statistical reality makes it essential for occupational therapy practitioners, students, and educators to prepare for cross-cultural interactions with both clients and coworkers throughout their careers.
• While certain geographic regions remain less racially diverse, practitioners in all areas require robust skills to interact effectively with people different from themselves.

Scope of Human Diversity

• Diversity encompasses the broad array of human differences, including:
  • Ethnicity and race
  • Socioeconomic class
  • Ability (ableness)
  • Gender and sexual orientation
  • Age
  • Religious differences (Froehlich & Thornton-Marsh, 2021)
• Clients and practitioners bring all manner of unique attributes to the therapeutic process.
• Understanding these differences is vital for delivering client-centered care within healthcare and educational systems.

Systemic Inequity and Provider Bias

• Throughout history, human differences have frequently resulted in systemic inequity.
• Healthcare inequity is widespread and actively fueled by systemic biases (FitzGerald & Hurst, 2017; Hall et al., 2015; Hamed et al., 2022; Ricks et al., 2022).
• Empirical evidence confirms that these implicit and explicit biases exist among healthcare workers themselves (Hall et al., 2015).
• Practitioners must lean into differences, educate themselves, alter worldviews, and embrace diverse experiences to build effective therapeutic relationships.

Core Frameworks of Diversity, Equity, Inclusion, and Justice

Defining DEI in Occupational Therapy

• The American Occupational Therapy Association (AOTA) commits to diversity, equity, and inclusion (DEI) through child- and family-centered practice (AOTA, 2020a).
• Diversity: Describes group characteristics defined by unique attributes, values, and beliefs compared across group members (Kornhaber, 2016; Taff & Blash, 2017).
• Equity: Ensures all individuals can access identical opportunities (World Health Organization [WHO], 2023).
  • Equity is distinct from equality.
  • Equality assumes that everyone benefits from identical support.
  • Equity acknowledges that starting places are unequal due to individual differences and social structures; it delivers tailored support to grant equal access.
• Inclusion: Values individual uniqueness specifically to foster active belonging and occupational engagement (Taff & Blash, 2017).

Pediatric Applications of DEI

• Supporting access to chosen occupations in educational and community environments:
  • Providing adapted seating, positioning devices, writing tools, or assistive technology so children with diverse abilities learn alongside peers.
  • Designing inclusive extracurriculars (e.g., dance classes modifying skill sequences so all children participate, learn steps, and practice teamwork).
  • Constructing inclusive playgrounds featuring adapted swings, access ramps, and quiet sensory spaces.
• Establishing safe social-emotional spaces where children from diverse backgrounds express themselves openly without fear.

Mitigating Bias in Clinical Practice

• Explicit bias involves intentional, conscious attitudes, whereas implicit bias operates automatically and unconsciously (Hagiwara et al., 2020).
• Implicit bias is resistant to basic changes, requiring active, continuous methods to unlearn (Greenwald & Lai, 2020; Mason, 2020; Vuletich & Payne, 2019).
• Unconscious biases undermine the therapeutic relationship.
• Practice strategies for mitigation:
  • Learn routines, culture, environment, and expectations directly from each family.
  • Maintain curiosity without making hasty assumptions.
  • Design custom interventions grounded in family-expressed priorities rather than stereotypes or conventions.
  • Communicate compassionately and ask probing questions during stressful family events.

Cultural Stances: Humility, Sensitivity, Safety, and Decolonization

Cultural Humility

• Defined as maintaining an interpersonal stance open to the client regarding aspects of cultural identity most important to them (Hook et al., 2013).
• Core actionable requirements (Agner, 2020; McGee-Avila, 2018):
  1. Ongoing self-evaluation and self-reflection.
  2. Continuous learning and bias acknowledgment.
  3. Openness to personal and professional change.
  4. Recognition of power differentials in therapeutic relationships.
  5. Partnering with clients and communities to dismantle institutional bias and inequity.

Case Example 4.1: Practicing Cultural Humility

• Scenario: Malcolm, an occupational therapy practitioner, prepares for an initial session with a female immigrant client from an unfamiliar country and culture.
• Malcolm's Action Steps:
  • Journals and reflects on personal assumptions and biases regarding the client's home country.
  • Analyzes gender concepts and considers how the client views the power differential of having a male therapist; plans actions to diminish this differential.
  • Prepares communication expressing his intent to establish an egalitarian partnership and respect her worldview.
  • Examines potential cultural differences and universal human commonalities.
  • Researches gender power dynamics and touch norms (e.g., prohibitions on cross-gender physical contact) while committing to asking the client directly rather than assuming compliance with literature.
  • Invites the client to define her identity first upon meeting and listens more than speaking.
  • Listens to her narrative for systemic access barriers and partners with her to resolve them.
• Clinical Outcome: Discovers via an interpreter that the client has diabetes and limited physical activity. Her inactivity stems from living conditions lacking safe exercise spaces. Malcolm partners with her to establish physical activity routines aligned with her selected choices.

Cultural Sensitivity

• Defined as awareness of client cultural beliefs/practices alongside one's cultural position relative to others (Agner, 2020; Foronda et al., 2015; Resnicow et al., 1999).
• Five Essential Components (Foronda et al., 2015):
  1. Knowledge: Understanding cultural values and differences.
  2. Consideration: Applying cultural knowledge in clinical delivery while avoiding stereotyping.
  3. Understanding: Grasping the meaning and impact of client cultural values.
  4. Respect: Appreciating cultural differences inherently.
  5. Tailoring: Modifying perspectives and adapting therapeutic approaches based on client needs.

Case Example 4.2: Cultural Sensitivity in Systemic Advocacy

• Scenario: Bijon works in a community pediatric clinic located in an affluent neighborhood. Clinic policy schedules all evaluations on Mondays from $9\text{--}5:00\text{ p.m.}$ within a rigid $40\text{-hour}$ workweek.
• Access Issue: A single mother of three calls stating she cannot attend Monday daytime appointments without losing hourly wages and jeopardizing her employment, having exhausted her paid time off.
• Action Taken: Bijon identifies that the clinic policy creates systemic inequality favoring dual-income/higher-SES families while excluding hourly working parents. He advocates to management to adjust scheduling, successfully establishing evening and weekend clinic hours to guarantee equitable access.

Cultural Safety

• Extends beyond cultural humility or competence by requiring healthcare providers to critique taken-for-granted institutional structures rather than seeking competence in client cultures (Curtis et al., 2019).
• Focuses explicitly on provider culture and organizational power structures, transferring power to clients to achieve healthcare equity.

Case Example 4.3: Implementing Cultural Safety in Health Systems

• Scenario: Shae, an OT in a Neonatal Intensive Care Unit (NICU), participates in an organization-wide cultural safety accountability initiative.
• Systemic Actions Implemented:
  1. Policy Revision: Allowed Indigenous women to observe cultural birth practices (e.g., retaining placenta, holding traditional welcoming ceremonies).
  2. Inclusive Space: Established dedicated prayer and reflection spaces outside the traditional hospital chapel.
  3. Pharmaceutical Adaptation: Provided verified halal and kosher alternatives for necessary medications.
• Individual Practice Adaptation: Shae revised her OT clinical interview tools, eliminating ethnocentric phrasing and adding questions to explore family cultural practices without misinterpreting preferences.

Decolonization of Health Care

• Involves empowering Indigenous communities, fostering community control, and dismantling Western assumptions regarding human occupation (Mulumba et al., 2021; Ramugondo, 2018).
• Historical Context & Critiques:
  • Occupational therapy originated in Western society; its theories, assessments, terminology, and research literature reflect dominant Western norms and systemic racism (Hammell, 2020a, 2020b; Hammell & Beagan, 2017; Lavalley & Johnson, 2020).
  • Standardized pediatric assessments normed on North American cohorts fail to reflect global cultural diversity in play, feeding, dressing, and bathing.
  • Dominance of English in scientific literature ($87.9\%$ of US OTs are White non-Hispanic) perpetuates global bias (Hammell, 2018; US Bureau of Labor Statistics, 2022).

Box 4.1: Decolonization Research in Healthcare Systems

• Study Details: Eni et al. (2021) evaluated healthcare perspectives across Manitoba First Nation communities in Canada, conducting $183$ interviews and focus groups across $8$ communities.
• Four Core Themes Emerged:
  1. First Nation Control: Desiring autonomous control over healthcare systems with reduced government interference.
  2. Traditional Medicine & Healing: Reviving traditional medicine and engaging in healing practices without institutional ridicule.
  3. Meaningful Community Participation: Guaranteeing community voices in governance, open dialogue, and shared decision-making.
  4. Diminishing Colonization Impacts: Ensuring consistent healthcare resources while reconnecting with land-based practices.

Occupational Justice vs. Capabilities Approach

• Occupational Justice: Framework advocating for the fulfillment of occupational rights for all people (WFOT, 2019).
• Capabilities Approach: Proposed as a superior alternative to occupational justice by international scholars (Gasper, 2002; Hammell, 2020a, 2020b, 2023; Nussbaum, 2009; Sen, 1993).
  • Focuses on real choice, opportunities, well-being, and capabilities (what one is enabled to be and do) rather than raw achievement (Kellock, 2020; Robeyns, 2005).
  • Aligns with international human rights by evaluating whether societal circumstances permit people to use their abilities in valued ways (Entwistle & Watt, 2013; Mousavi et al., 2015).
• Occupation, Capability, and Wellbeing Framework for Occupational Therapy (OCWFOT): Formulated by Hammell (2020a, 2020b, 2023) to promote strengths-based practice, focusing on client-prioritized occupations and advocating for community access rights.

Workplace Barriers and Microaggressions

Categories of Microaggressions

• Microaggressions are subtle, brief daily indignities—verbal, behavioral, or environmental—that communicate hostile or derogatory slights toward marginalized groups (Cambridge Dictionary; Sue et al., 2007).

Microaggressions
├── Microinvalidations (Insidious dismissals of lived reality)
├── Microinsults (Insensitive remarks expressing hidden bias)
└── Microassaults (Explicit, deliberate discriminatory actions/jokes)

• Microinvalidations: Exclude, negate, or nullify the psychological thoughts, feelings, or experiential reality of a target group (e.g., asking an elementary fine motor writing group "What were you for Halloween?", assuming universal celebration).
• Microinsults: Demean a person's identity through insensitive comments (e.g., telling a student with dyslexia "This text is probably too hard for you, just try to keep up," or questioning a staff member wearing a hijab).
• Microassaults: Explicit, intentional discriminatory statements or actions (e.g., telling a new employee to leave their purse in the car trunk when visiting an inner-city school).

Workplace Resolution Strategies

Case Example 4.4: Addressing Workplace Microaggressions

• Scenario: Tamara, a Black female occupational therapy practitioner, relocates to another state for her first professional role.
• Experienced Microaggressions: Coworker inquiries ("Are you the first in your family with a master's?", "How did you get into such a great school?"), supervisor case assignment ("I am giving you this case because the family is Black and you can relate to them"), and lunchroom group questioning ("Tamara, why do Black people always do that?").
• Resolution Strategy (Washington, 2022 framework evaluating timing, relationship, and topic awareness):
  • Tamara scheduled a 1-on-1 meeting with her supervisor.
  • Used structured communication: "I know you intended to be supportive of me, but the way I received it was that I do not belong in the profession, or for some reason Black people are not as qualified."
• Outcome: The supervisor apologized, contacted Human Resources, and arranged an inservice training session led by an outside facilitator. The team established inclusive environment goals and offered direct apologies.

Strategies for Bridging Differences in Pediatric Practice

Definition and Core Concepts

• Bridging differences means connecting with others based on shared humanity while valuing individual differences (Mendoza-Denton & Briscoe-Smith, 2023).
• It does not require total agreement, compromise, or friendship, but demands that neither party views the other as less worthy of health or happiness.
• Requires approaching interactions with modesty and recognizing that no single group holds a monopoly on truth.

Eight Essential Skills for Bridging Differences

1. Recognize common humanity.
2. Focus on understanding (not persuading) others.
3. Attempt to find common ground.
4. Engage in inner personal work.
5. Demonstrate modesty and humility.
6. Make small shifts in thoughts and actions, consistently.
7. Take risks and accept vulnerability.
8. Recognize times when one should NOT attempt bridging (e.g., situations involving prior trauma, personal safety risks, violence, or rushed conditions).

Case Example 4.5: Bridging Differences in Early Intervention

• Scenario: Mourad, a $15\text{-month-old}$ child from Sudan diagnosed with right hemiplegia, is referred to early intervention. His family immigrated $3\text{ months}$ prior and resides in temporary housing.
• Practitioner Implementation Steps:
  • Bias Neutralization: Educated self on Sudanese culture, processed personal assumptions, and reflected on prior positive experiences with Sudanese colleagues.
  • Active Listening: Listened to the mother's concerns regarding motor function, temporary housing, and her older child's public school integration.
  • Shared Values: Identified shared parental aspirations for child health, school success, and future opportunities.
  • Common Goals: Provided school system resources, defined terms clearly during therapy, monitored facial expressions for understanding, and connected the family to parent support networks.

Demographic Reality and Developmental Trajectories

• AOTA Code of Ethics and Policy Statements explicitly condemn systemic racism and require inclusive, equitable practice (AOTA, 2020a, 2020b, 2021).
• Given that $87.9\%$ of US occupational therapists identify as White non-Hispanic, unexamined white worldviews risk reproducing dominant power relations and heteronormative or ableist assumptions (Whiteford, 2019).
• Ableism: Viewing traditional body types as "normal" and treating variations as flaws or defects (Hammell, 2023).
• Early Disparities: Non-White children aged $0\text{ to }3\text{ years}$ suffer significantly lower developmental screening, monitoring, and early identification rates alongside higher poverty rates (Barger et al., 2022; Chaudry & Wimer, 2016; Wexler et al., 2022).
• Developmental Impact: Delays in early identification alter life-course developmental trajectories across cognitive, gross motor, fine motor, self-care, play, language, and social-emotional domains (Agorastos et al., 2019; Halfon & Hochstein, 2002; Luyster et al., 2011; Thomas, 2016).

Worldview Expansion: Self-Reflection, Education, and Action Steps

Mechanics of Self-Reflection

• Stereotypes trigger inaccurate beliefs and subtle behavioral shifts.
• Teacher expectancy research confirms that adult expectations significantly impact student performance outcomes over time (Jussim & Harber, 2005; Lorenz, 2021; Rosenthal & Jacobson, 1968; Wineburg, 1987).
• Implicit stereotypes documented in systemic research alter sentencing decisions by judges, hiring choices by employers, force usage by police officers, and treatment access in healthcare (Hall et al., 2015; Kinsella & Whiteford, 2008; Madeira et al., 2022; Moskowitz et al., 2012; Zestcott et al., 2021).

Actionable Activities to Challenge Worldview

Practical Communication and Program Design

• Humanizing the Individual: Shift focus from group identity to individual characteristics by asking non-stereotypical questions (e.g., asking about favorite vegetables or morning/night schedule preferences, while avoiding music questions that evoke group stereotypes) (Mendoza-Denton & Briscoe-Smith, 2023).
• Cross-Group Friendships: Developing direct cross-group contacts reduces prejudice and fosters systemic social change (Hewstone & Greenland, 2000; MacInnis & Hodson, 2019; Reimer & Sengupta, 2022).
• Language Modifications: Replace "patient" with "client", eliminate clinical jargon, and recognize that terms like "occupation" evoke war trauma among refugees (Creek, 2020; Magalhaes & Galheigo, 2010; Mahoney & Kiraly-Alvarez, 2019).
• Programmatic Design: Co-design community programs directly with families (e.g., ballpark sensory rooms for autism, inclusive dance for Down syndrome, camp-based constraint-induced movement therapy, adaptive sports, and Latino immigrant healthy lifestyle programs) (Suarez-Balcazar et al., 2018, 2022).

Guidelines for Communicating with Children and Families

• Assume good intentions and approach all families as wanting the best for their children.
• Invite families to share hopes, dreams, traditions, and struggles frequently.
• Respect diverse family structures and recognize how identity shapes professional interactions.
• Bring openness, reflect on personal values, and view diversity as a strength.
• Use respectful tones, ask questions politely, speak honestly, and maintain comfort with silence during processing.

Case Example 4.6: Careful Communication in Transition Planning

• Scenario: Taz, a $14\text{-year-old}$ student with a learning disability, undergoes transition planning.
• Context: Taz's family has limited financial resources and values immediate local retail employment, whereas the practitioner holds advanced degrees and values higher education.
• Therapeutic Strategy: The practitioner engaged in self-reflection to suppress personal educational bias. Through active listening and structured communication, the therapist aligned interventions with Taz's goal of working at a local store, utilizing his verbal strengths, creativity, and peer motivations.

Clinical Environment and Interaction Protocols

• Verbal & Vocal Modulation: Use clear, calm, short sentences without infantilizing. Match energy levels to context (e.g., subdued energy for sensitive intake, energetic tone for play).
• Eye Contact & Positioning: Respect cultural norms regarding eye contact. Half-kneel or sit at eye level with children; avoid approaching clients with trauma histories unexpectedly from behind or side.
• Visual Environment: Wear solid, dark-colored clothing when treating children with Cortical Visual Impairment (CVI) or Traumatic Brain Injury (TBI) to prevent visual overstimulation caused by patterns or stripes.

Working with Interpreters and Translation Technology

• Interpersonal Protocols: Speak directly to the client/child rather than the interpreter. Seat the interpreter beside or slightly behind the client.
• Translation Technology: Document both the translated output and original text side-by-side in records.
  • Example Email: "Zonja F, për shkak të stuhisë së borës duhet ta ndryshoj vizitën e sotme me të enjten në orën 15.00. A do të funksionojë kjo për ju? Nëse jo, ju lutem më njoftoni. Faleminderit, OT Mary." / "Ms. F, due to the snowstorm I need to change today's visit to Thursday at 3:00 p.m. Will this work for you? If not, please let me know. Thanks, OT Mary."
• Assessment Constraints: Establish ground rules before clinical testing (interpreters must not physically redirect children, add extra prompts, or hand out unstandardized test items). If an interpreter alters or repeats standardized directions, standardized scoring is invalidated and data must be reported informally.

Managing Interpersonal Missteps and Institutional Advocacy

Four-Step Error Correction Process

Error Correction Process
├── 1. Acknowledge the error (Label specific action with a verb)
├── 2. Apologize sincerely (Be succinct; avoid defensiveness)
├── 3. Ask how to rectifying (Transfer power to the client)
└── 4. Affirm commitment (Change future behavior directly)

1. Acknowledge the error: Label the specific action clearly using precise verbs (misgendered, mislabeled, mistook, misunderstood, assumed).
2. Apologize sincerely or make amends: Keep apologies succinct and direct without defensive excuses (avoid statements like "No one told me").
3. Ask how to rectify: Grant power to the offended party by asking "How can I fix this?" or "What would be a better way?"
4. Affirm and commit to non-repetition: Demonstrate remorse by modifying future behavior.
   • Clinical Scenario: A practitioner misgenders a teenage client who states, "Hey! I'm not a boy!"
   • Correct Response: "I'm sorry, I didn't mean to misgender you. What pronouns do you prefer?"
   • Client: "I go by Taylor, I use they/them pronouns."
   • Practitioner Affirmation: "Thanks for letting me know that. That was my error, I won't do it again."

Avoiding Overgeneralization and Systemic Advocacy

• Avoid assuming that all members of a specific cultural group share identical practices (e.g., assuming all Jewish clients strictly observe Saturday Sabbath prohibitions against clinic attendance).
• Seek supervision, mentorship, and support from workplace inclusivity teams or HR.
• Act as institutional agents of change by advocating for systemic funding, accessibility grants, and community-based equipment loan programs (O'Brien, 1990).

Summary of Key Takeaways

• Establish therapeutic relationships with diverse children and families through cultural humility, self-evaluation, and active system-level advocacy.
• Bridge differences by finding shared human values while respecting unique cultural worldviews and identity structures.
• Address microaggressions in the workplace using structured communication, self-reflection, and institutional support.
• Adapt clinical environments, communication methods, and assessment procedures when working alongside interpreters to ensure equitable, client-centered pediatric care.