The answer to the question of who provides audiology and/or speech-language pathology services to bilingual clients varies depending on each client's linguistic abilities in his/her first and second language.
Bilingual clinicians who have the necessary clinical expertise to treat the client may not always be available. There are circumstances in which a clinician who does not have native or near-native proficiency in the target language is able to use the skills he or she does have to provide services to a client. In determining the appropriateness of this solution, the clinician considers both his or her own language proficiency in the target language and the language demands of the client and family.
When a bilingual speech-language pathologist (SLP) and/or audiologist is not available, using an interpreter is a viable option. For additional information related to working with interpreters in spoken and manually coded languages, please see the Practice Portal page on Collaborating With Interpreters.
As indicated in the Code of Ethics (ASHA, 2010), audiologists and SLPs are obligated to provide culturally and linguistically appropriate services to their clients and patients, regardless of the clinician's personal culture, practice setting, or caseload demographics. In providing services to bilingual individuals, SLPs consider how communication disorders or differences might be manifested, identified, or described in the client's/patient's cultural and linguistic community and integrate this knowledge into all areas of practice, including assessment, diagnosis, treatment, and treatment discharge.
Audiologists or SLPs who present themselves as bilingual for the purposes of providing clinical services must be able to speak their primary language and to speak (or sign) at least one other language with native or near-native proficiency in lexicon (vocabulary), semantics (meaning), phonology (pronunciation), morphology/syntax (grammar), and pragmatics (uses) during clinical management. In addition to linguistic proficiency, the audiologist or SLP must have the specific knowledge and skill sets necessary for the services to be delivered.
Bilingual audiologists must be able to independently provide comprehensive diagnostic and treatment/rehabilitative services for auditory, vestibular, and related impairments using the client's/patient's language and preferred mode of communication. They must also have the linguistic proficiency to
- select and interpret culturally and linguistically appropriate assessment materials, tools, and methods;
- instruct and assess the client/patient in direct clinical techniques using behavioral, physiologic, and developmental measures;
- administer and interpret standardized self-report measures of communication difficulties and of psychosocial and behavioral adjustment to auditory dysfunction.
Bilingual SLPs must be able to independently provide comprehensive diagnostic and treatment services for speech, language, cognitive, voice, and swallowing disorders using the client's/patient's language and preferred mode of communication. They must also have the linguistic proficiency to
- describe the process of normal speech and language acquisition—for both bilingual and monolingual speakers of that language, including how those processes are manifested in oral and written language (or manually coded languages when applicable);
- select, administer, and interpret formal and informal assessment procedures to distinguish between communication differences and communication disorders;
- apply intervention strategies for treatment of communication disorders in the language or mode of communication most appropriate for the needs of the individual.
Bilingual Service Provision Training Programs
ASHA does not accredit or approve specialty training programs for bilingual service providers, nor does ASHA review, evaluate, or rank such programs in any way; however, ASHA does maintain a list of those programs that offer formal training in addition to those that meet accreditation requirements. Placement on the list of this self-identified programs for bilingual service providers does not indicate any endorsement by ASHA, nor is this list meant to be exhaustive.
Laws and regulations for bilingual service providers in audiology and/or speech-language pathology vary from state to state. Differences may be reflected in a number of requirements, including proficiency in oral and/or written language, education, continuing education, titles used to identify bilingual service providers, and regulations or laws or lack thereof. Audiologists and SLPs should check with their state licensure boards and/or departments of education for the requirements for specific practice settings.
ASHA Principles of Ethics I, Rule C from ASHA's Code of Ethics 2010 states that "Individuals shall not discriminate in the delivery of professional services." Audiologists and SLPs who are not competent to provide services to bilingual clients still have professional responsibility for ensuring that a client receives appropriate services.
Principle of Ethics II, Rule B of ASHA's Code of Ethics (2010) states that "Individuals shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their level of education, training, and experience." With this in mind, clinicians must consider their own ability—including education, training, and experience—in determining the most appropriate means by which to provide services to bilingual clients. In all cases, the needs of the client are paramount.
These ethical principles require that clinicians continue in lifelong learning to develop knowledge and skills required to provide culturally and linguistically appropriate services. See the Cultural Competence page and ASHA's Cultural and Linguistic Competence (2013) Issues in Ethics Statement for additional information.
Understanding the normal processes and phenomena of second-language acquisition is important to ensure accurate assessment of bilingual clients. While the experience of learning a second language is unique to each individual, common phenomenon during the second-language acquisition process are listed below. See additional resources and information on Learning More Than One Language.
Interference or transfer occurs when an error is made in a second language (L2) due to the direct influence of an L1 (primary language) structure. ELL children may manifest interference or transfer from their first language (L1) to English (L2). In children who are simultaneous bilinguals, transfer may occur between the two languages. Patterns that are the result of interference/transfer are not indicative of a disorder.
Adults who are learning English as a second language—or who acquired English after their language system was established in a different language—may demonstrate ongoing differences from standard English. The clinician considers if differences are influenced by the individual's native language and are typical error patterns seen in this population or are an indication of a change relative to baseline status (Anderson & Centeno, 2007).
A silent period may occur during the initial phase of second-language acquisition while an individual focuses on listening and comprehension of the new language. "Children acquiring second languages typically exhibit a 'silent period' during which acquired competence is built up via active listening" (Krashen, 1982/2009). The main characteristic of this stage is that, after some initial exposure to the language, the learner is able to understand much more than she or he can produce.
Codeswitching involves changing languages over phrases or sentences and is a normal phenomenon engaged in by many fluent bilingual speakers. In individuals who are simultaneous bilinguals, codeswitching does not occur randomly and is grammatically and socioculturally constrained. The vast majority of codeswitching demonstrated by bilingual children "is systematic and, specifically, conforms to the grammatical constraints of the two participating languages" (Paradis et al., 2011, p. 103). Adolescents and adults who are developing proficiency in a second language may demonstrate increased errors in codeswitching, as they lack the linguistic competence necessary for fluent codeswitching without errors. This is not to be considered indicative of a language disorder (Paradis et al., 2011).
Violations of typical codeswitching constraints in adolescents and adults who are fluent in multiple languages can be evident and may indicate cognitive and/or communication disorders. These errors are often noted due to deficits in executive function and decreased inhibition of the non-target language, dementia, aphasia, and other language disorders, among other deficits (Ansaldo & Marcotte, 2007).
As some individuals learn a second language, they lose skills and fluency in their primary language (L1) if this language is not reinforced and maintained. This is called subtractive bilingualism (Haynes, 2010). Lexicon and grammatical systems are the areas most affected by language loss (Anderson, 2004), and language loss can result in a simplified grammatical system and vocabulary gaps (Haynes, 2010). Linck et al. (2009) noted attrition and inhibition of L1 (primary language) during immersion in L2 (second language), even during the short term.
Clinicians should consider the prior level of proficiency in L1 (primary language), individual motivation, societal factors, and previous education and consistency in learning and instruction in L1 if language loss is observed. Errors may be related to the individual's language history. Attrition and attenuation (language loss) of first language (L1) proficiency may negatively influence overall language performance (Anderson, 2004; Linck, Kroll, & Sunderman, 2009).
Accent, Dialect, Phonetic Patterns
Accent and dialect influence phonetic patterns in individuals who are bilingual. Accent describes the way people sound or the pronunciation. Dialect describes "a rule-governed, systematic variation of a language" (Goldstein, 2000, p.9; Wolfram & Schilling-Estes, 1998) and includes accent as well as grammatical structures and semantics. Clinicians differentiate the influence of accent and dialect from communication disorders, including phonological disorders.
Phonology seems to be the most difficult linguistic area to master and accounts for the ongoing presence of an accent in otherwise very proficient speakers of a second language (Centeno, 2009).
In children, order of acquisition in one language may influence phoneme acquisition in another language. Additionally, accent may affect phoneme use and substitutions in each language. Dialect may influence development of morphosyntax, syntax, and semantics in development, as interference/transfer may be evident across the languages the child is learning (Yavas, 2007).
In an adult population, an accent may continue to influence phonetic patterns. Learning the appropriate phonetic patterns of a second language may become more difficult with age and the influence of a first language on speech in a second language may be more evident. The clinician considers if the phonetic patterns observed are consistent with second- or dual-language acquisition and with the baseline for the individual or if they are the result of a communication disorder (Bell-Berti, 2007).
Identifying a communication disorder in a bilingual individual requires careful consideration of the multitude of factors that influence communication skills. True communication disorders will be evident in all languages used by an individual; however, a skilled clinician will appropriately account for the process of language development, language loss, the impact of language dominance fluctuation, and the influence of dual language acquisition and use when differentiating between a disorder and a difference. Language dominance may fluctuate across a patient's/client's lifespan based on use and input and language history (Kohnert, 2012).
When differentiating between a difference and a disorder, clinicians consider the following.
Phonology—Linguistic development in bilingual children can manifest in patterns different from those observed in monolingual children and may include phonological patterns as the result of transfer or interference from another language (Goldstein & Gildersleeve-Neumann, 2012). Recognizing dialectal variations and the influence of accent is an essential component of phonological assessment.
Morphology—Grammatical structures are not constant across languages. Pronouns, verb conjugation and verb inflection structures, tense, etc. may not exist equally in each language spoken by a bilingual individual. Assessment considers the frequency and types of errors and morphological patterns observed in individuals in determining if they are the result of a disorder or of a difference resulting from bilingual language development.
Morphosyntax—Some research suggests that morphosyntactic language development in bilingual individuals may be similar to that of monolingual individuals in rate and order of acquisition (Bedore, Cooperson & Boerger, 2012). However, studies are limited and individual performance may vary based on a number of factors.
Syntax—Due to the variability of syntactic structures across languages, underlying syntactic deficits will likely manifest differently across languages. Difficulty in development of syntactic structure may also be influenced by the perceptual salience of morphemes and syntactic structures. Children with SLI are noted to demonstrate significant deficits for morphemes with limited perceptual salience (Restrepo & Guiterrez-Clellen, 2012). Additionally, grammatical structures in either language may be influenced by the other (Paradis et al., 2011). Consider if the patterns observed are due an underlying deficit, which may manifest differently across languages, or due to a difference, such as transfer of a grammatical structure from one language to another.
Semantics—Clients may learn specific words and/or categories of words in their home language and other words in the language used in academic environments (Paradis et al., 2011).
The clinician also considers the nature of language demands in a given interaction and the effects that contextual support, or lack thereof, may play in language proficiency. To explain this, Cummins (1984) distinguished between two types of language proficiencies:
- Basic interpersonal skills (BICS) are the context-embedded, everyday language that occurs between conversational partners, typically requiring 2 years under ideal conditions to acquire proficiency.
- Cognitive academic language proficiency (CALP) is the context-reduced language of academics, typically requiring 5 to 7 years under ideal conditions to develop a level commensurate with native speakers.
An individual may be fluent in conversational communication (BICS), yet continue to have difficulties with communication needs in an academic arena (CALP). Observing an individual's language skills in both areas is essential to develop a comprehensive understanding of his/her linguistic abilities.
See an informational video regarding bilingual language development.
Dynamic Assessment and Response to Intervention
Early intervening services are used to determine which children have intrinsic learning problems that cannot be explained on the basis of lack of experience with the tasks. Response to intervention (RTI) and dynamic assessment (DA) are early intervening approaches that can be used to decrease unnecessary referral to special education by determining if speech and language patterns are the result of a normal phenomenon of dual language acquisition or are the result of a communication disorder. Both approaches are highly focused on the intended outcomes, the individual's needs, and the data resulting from reliable screening measures (Hosp, n.d.).
The two primary goals of clinical service delivery for bilingual individuals are
- the accurate differential diagnosis between communication disorders and normal linguistic variations (from life experiences, including bilingual/multilingual backgrounds), and
- the design of intervention approaches and contexts that would provide the optimal stimulation to enhance linguistic recovery, minimize the extent of the functional impact of the disorder
(Centeno & Anslado, 2013).
The Assessment Process
When a clinician works with a bilingual individual, information related to language history is particularly relevant. Information gathered includes
- age and manner of acquisition of the language(s),
- dialect of the language used,
- language(s) used at home and at school/work,
- language(s) used within the family,
- length of exposure to each language,
- language of choice with peers,
- progress in receiving English as a second language (ESL) services or adult English language learning classes,
- contact with native speakers of L1 (primary language),
- language of academic instruction,
- academic performance in each language,
- age of immigration.
(Rimikis, Smiljanic, & Calandruccio, 2013)
A client interview is often included in patient intake and case history. See cultural competence for information related to ethnographic interviewing.
Use of parent surveys for young bilingual children can be an effective way to gather information about early language development (Thal, Jackson-Maldonado, & Acosta, 2000). Parent surveys used during a preliminary screening of a bilingual child have the potential to yield valid and reliable information (Guiberson & Rodriguez, 2010).
Bilingual clients/patients may benefit from visual modeling of commands to facilitate comprehension of tasks during oral-peripheral examination. Cultural and individual differences may influence how clients perceive tasks, such as a sticking out their tongues; therefore, it may be necessary to explain the reason for requested activities.
Criterion-referenced assessment tools can be used to identify and evaluate a client's strengths and weaknesses, as opposed to norm-referenced testing, which assesses an individual relative to a group. Standardized test scores are not valid for an individual who is not reflected in the normative sample for a given assessment; however, these assessments may still provide valuable descriptive information about a client's abilities and limitations in the language of the test (i.e., a test given in English will speak to a child's ability in English; a test given in Spanish will speak to a child's ability in Spanish). When possible, use culturally and linguistically adapted test equivalents in both languages to compare potential deficits.
Note that no test can be completely culture free. Most formal testing is unfamiliar to individuals who have not had exposure to the mainstream educational context and the culture of testing, which includes both nonverbal and verbal components. See cultural competence.
Accommodations and Modifications to Standardized Assessment Procedures
An accommodation, for the purpose of this page, refers to an adjustment or change to the environment or mode of client/patient response in order to facilitate access and interaction and to remove barriers to participation.
A modification, for the purpose of this page, refers to a change in material, content, or acceptable response.
Accommodations and modifications during the assessment process may be necessary to gain useful information about the client's abilities and limitations. However, some changes may invalidate the standardized score.
Examples of accommodations and modifications include
- rewording and providing additional test instructions other than those allowed when presenting test items,
- providing additional cues or repeating stimuli which may not be permitted on test or task items,
- allowing extra time for responses on timed subtests,
- skipping items that are inappropriate for the individual (e.g. items with which the client has had no experience),
- asking the individual for an explanation of correct or incorrect responses (when not standard procedure),
- using alternate scoring rubrics.
It is not appropriate to translate standardized assessments to reach a standard score. Problems that arise when tests are translated include
- language items often do not have a one-to-one translation;
- languages vary in their order of acquisition or vocabulary, morphology, and syntactic structures;
- languages vary in their syntactic structures and not all structures that are assessed on English tests exist in other languages;
- standardized scoring cannot be reported for translated tests;
- standardized assessments that are not normed on bilingual populations are to only be used as informal probes with no accompanying scores.
It is the responsibility of the clinician to document all accommodations and modifications made during the assessment process in any and all reporting of the client/patient.
Speech and Language Sample
Speech and language samples offer a window of opportunity to observe and analyze communicative skills as they are functionally used and may provide more insight than the typical standardized or criterion-referenced test. Single-word and connected-speech (conversation or narrative) samples should be obtained in all languages used by the client, through collaboration with an interpreter if necessary, to allow for an in-depth assessment of the individual's morphological, syntactic, phonological, and lexical systems. While a comparison of each of these areas across languages used can be informative, clinicians must keep in mind that skills across languages may not be easily comparable. Phonological acquisition will not be parallel across a bilingual child's two languages, especially when the two languages have vastly different phonemic systems (Goldstein & Fabiano, 2007). Morphological markers will look different across languages as will the syntactic complexity.
Speech perception testing measures how well an individual is able to understand speech and predicts how well he or she will perform in everyday listening environments. Speech reception thresholds and word recognition ability should be evaluated using culturally and linguistically appropriate recorded test materials that reflect the background of the client. Best practices utilize pre-recorded materials to ensure consistency across trials (Mendel & Owen, 2011). Monitored live voice testing may be used, given a client's unique needs, such as age or ability. Careful consideration of accent, dialect, and linguistic background is given for the speaker used in live voice testing.
Age of acquisition (of the second language) has been shown to influence speech perception results. Shi and Sánchez (2010) found that patients who acquired a second language at 10 years of age or later performed more favorably on speech perception testing in their dominant language. The researchers recommended that patients who acquired a second language between the ages 7 and 10 years be evaluated in both languages. Mayo, Florentine, and Buus (1997) found that patients who acquired a second language before the age of 6 (i.e., early bilinguals) were better able to process speech in noise than patients who acquired a second language after the age of 14 (i.e., late bilinguals).
Questionnaires have been developed to indirectly measure speech perception abilities by asking questions related to the benefits of treatment in the patient's everyday listening environment. These tools must be translated appropriately into the patient's first language.
Digit pairs have been shown to be appropriate stimuli for speech recognition threshold (SRT) testing in non-native speakers of English. As with spondees, listeners must be familiar with this closed set of stimuli (Ramkissoon, Proctor, Lansing, & Bilger, 2002).
While research with this population has been limited, children who are ELLs perform more poorly in noisy classroom conditions than children whose native language is English (Crandell & Smaldino, 1996). When tested in their second language, even fluent bilingual speakers who acquired a second language at an early age (i.e., before the age of 6 years) have poorer speech recognition ability in noise than monolingual speakers (Rogers, Lister, Febo, Besing, & Abrams, 2006). Implications of this research include recognition of the importance of effective classroom acoustics and the suggestion that hearing loss due to aging may have an even greater negative impact on speech understanding of bilingual speakers.
Selecting the language of intervention is dependent on unique factors for each individual, including
- language history and relative experience with each language,
- frequency of use for each language,
- proficiency in each language, including how well the individual understands and produces each language,
- environment, including where and with whom the child uses each language,
- family considerations and goals.
(Goldstein & Fabiano, 2007)
To account for the nature of bilingual language development, Kohnert and Derr (2012) and Kohnert, Yim, Nett, Fong Kan, and Duran (2005) proposed two main approaches to providing intervention to bilingual children. These approaches are models based on underlying research on language (including phonological) development in bilingual children. Relative to pediatric populations, there is a paucity of research for intervention in bilingual adults.
The bilingual approach supports beginning with goals in which one treats constructs common to both languages or errors or error patterns exhibited with relatively equal frequency in both languages (Yavas & Goldstein, 1998) and focuses on increasing language skills common to both languages. The initial treatment determination is the goal and not the language of intervention.
The cross-linguistic approach focuses on the linguistic skills unique to each language and is used to address errors and deficits noted in a specific language. This approach is often necessary—and may be used in conjunction with the bilingual approach—to address differences in the linguistic structures of the two languages. For example, aspirated affricates exist in Hmong, but not in English, and can only be remediated in the one language. Additionally, SLPs might use a cross-linguistic framework based on types of errors and/or error rates (Yavas & Goldstein, 1998). For example, final consonant deletion is more common in the English of Spanish-English bilingual children than in their Spanish (Goldstein & Fabiano, 2007).
In bilingual children, it is suspected that acquiring a "certain level of proficiency in L1 (primary language) should achieve comparable levels of proficiency in L2 (second language)" (Gutierrez-Clellen, 1999, p. 292). Treating targets common to both languages may be most beneficial in some populations before expanding to target features exclusive to just one language.
The Common Core State Standards is a state-led initiative designed to establish a single set of educational standards in English language arts and mathematics for students in Kindergarten through 12th grade. Two consortia of states are developing common assessments—the Partnership for Assessment of Readiness for College and Career (PARCC) and the Smarter Balanced Assessment Consortium (SBAC). Both consortia offer guidance for districts and decision-making teams to ensure that all assessments yield valid results for students, including students who are English language learners (ELL).
A number of state and federal regulations have implications for the provision of audiology and speech-language pathology services to bilingual clients/patients. Differences in state regulations may be reflected in a number of requirements, including education. See ASHA's state-by-state page for a summary of state requirements.
Equal Educational Opportunities Act of 1974
The Equal Educational Opportunities Act of 1974 states, "All children enrolled in public schools are entitled to equal educational opportunity without regard to race, color, sex, or national origin." No state can deny students the right to equal education by "failure by an educational agency to take 'appropriate action' to overcome language barriers that impede equal participation by its students in its instructional programs" (20 USC Sec. 1701vê1758). Congress has interpreted bilingual education as an action a school district must take to teach non-English-speaking students how to speak English.
Individuals with Disabilities Education Act (IDEA)
The Individual with Disabilities Education Act (IDEA) was enacted to ensure that everyone, including children with disabilities, receives a free appropriate public education. IDEA 2006, Part B, Final Regulations supports nondiscriminatory service delivery by establishing the following:
- assessment and other evaluation materials should not be racially or culturally discriminatory;
- assessment and other evaluation materials are to be provided in the child's native language or other mode of communication and in the form most likely to yield accurate information on what the child knows and can do academically, developmentally, and functionally, unless it is clearly not feasible to do so;
- the form in which evaluation materials are administered may vary from standard testing procedures when necessary in order to appropriately evaluate a student;
- a child must not be determined to have a disability if the determinant factor is lack of appropriate instruction in reading or math or limited English proficiency;
- parents are entitled to an interpreter at the individualized education program (IEP) meeting if needed to ensure that the parents understand the proceedings;
- when an IEP is developed for a child with limited English proficiency, the language needs of the child must be considered.
In addition, regulations clearly define steps that states must take to address the problem of disproportionality in special education. See IDEA Part B Issue Brief: Culturally and Linguistically Diverse Students.
No Child Left Behind Act of 2001
Title III of the No Child Left Behind Act of 2001 (NCLB) was established to ensure that ELL students (referred to as limited English proficient in NCLB legislation) attain English language proficiency, attain high levels of academic achievement in English, and meet the same state academic content and academic achievement standards that all children are expected to meet. Under NCLB, schools must show adequate yearly progress (AYP) in ensuring that all students achieve academic proficiency in order to close the achievement gap.
In October 2006, the U.S. Department of Education released final interpretations of Title III that clarified that no ELL student, even those recently arrived or those with disabilities, is exempt from annual English language proficiency assessments. The only exemption is for an ELL student who has attended school in the United States for less than 12 months; in this case, he or she may be exempt from one administration of a state's content assessment in reading/language arts. Although no other exemptions are allowed, the final regulations noted that, for those ELL students with a disability, the school must provide appropriate accommodations. See NCLB fact sheet on english language learners [PDF].
Title VI of the 1964 Civil Rights Act
Title VI of the 1964 Civil Rights Act prohibits discrimination in any federally funded program on the basis of race, color, or national origin. This includes any public or private facility—such as a hospital, clinic, nursing home, public school, university, or Head Start program—that receives federal financial assistance (e.g., grants, training, use of equipment, and other assistance). According to the Office of Civil Rights, all providers who work for any agency funded by the U.S. Department of Health and Human Services (HHS) are required to provide language access services to patients who do not speak English well.
Executive Order 13166
Guidance relating to Executive Order 13166 and issued by HHS indicates that "health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner, during all hours of operation" (Youdelman, 2008, para. 6). The guidance provided applies to any health care provider or entity that receives federal funding, including
- Medicare Part A,
- federally funded clinical trials,
- Children's Health Insurance Program (CHIP),
- other patient populations.