February 18, 2003 Feature

Serving Multilingual Clients With Hearing Loss

How Linguistic Diversity Affects Audiologic Management

These are exciting times for audiologists serving clients from a myriad of cultural and linguistic backgrounds. Linguistic diversity, especially, affects audiologic management. Services are particularly affected when clients have limited English proficiency (LEP) because test materials are usually available in English only.

The great majority of audiologists in the United States—80%—are English speakers. However, the latest Census data indicate that almost 14% of U.S. residents do not speak English, creating a challenging clinical environment.

Although little information is available about the incidence of hearing loss among multilingual clients, a 2002 Gallaudet Research Institute survey reported that 8.9% of children who are deaf or hard of hearing are from homes where more than one language is spoken and 10.3% are from monolingual Spanish-speaking homes. Thus, audiologists need specialized clinical knowledge to provide equitable services for such clients.

The client’s linguistic profile, such as age, number of languages spoken, acquisition age for each language, and proficiency in each language, affects audiological management. Linguistic profiles can be quite variable. For example, a client reporting elective bilingualism has decided to learn a second language and typically has proficiency in both languages. Alternatively, a circumstantial bi/multilingual person has learned several languages because of necessity in the communication environment, and proficiency in each language may be variable.

Communicating with Multilingual Clients

Despite the language mismatch between client and audiologist, appropriate clinical communication is important. Sometimes, a rudimentary knowledge of the individual’s language is insufficient to ensure an accurate interaction. Audiologists should have the ability to adjust management when language barriers exist. For example, enlisting interpreters or speech-language pathology/audiology (SLP/A) assistants is often a worthwhile decision.

Interpreters are usually competent in the client’s language, facilitating information gathering, giving test instructions, and relaying evaluation feedback. Interpreters often share the client’s social, cultural, or ethnic background and facilitate trust, comfort, and acceptability in the clinical interaction. Interpreters or assistants are particularly helpful during pediatric play audiometry. With training, they can effectively condition young children to the task at hand, facilitating response accuracy and improved test reliability. During audiologic rehabilitation sessions, interpreters usually relay information because of the clinician-client language barrier. Adequate training of interpreters and SLP/A assistants is required for successful outcomes. Optimum use of interpreters occurs in a symbiotic relationship with the audiologist, where appropriate training is provided, and responsibilities, boundaries, and functional limits are outlined. Clinical interaction is also enhanced when audiologists demonstrate a basic understanding of the client’s language.

Speech Audiometry

Speech audiometry is most affected by multilingualism because tests are language-based. Although English test materials might not yield ideal outcomes for non-native speakers, they are still popular because of their availability, longevity, research support, and compatibility with the language of most audiologists.

In clinical practice with multilingual clients, we often observed that the measured speech recognition threshold (SRT) did not match the pure-tone average (PTA), and was seldom within the 5–6 dB clinical norm. SRT measurement is critical in diagnostic audiology, providing an overall indication of hearing threshold for speech, serving as a PTA reliability check, and providing a baseline for suprathreshold tests. Therefore, audiologists have sought alternatives, such as using a subset of a popular test or using tests in the client’s first language, when available.

For LEP clients, audiologists often modify the SRT test by reducing set size, and selecting only familiar words. Set-size reduction is popular due to convenience, reduced test time, and because it eliminates the need for alternate tests. However, research from Punch and Howard indicated that it reduces measurement accuracy, yielding lower SRT thresholds, which could lead to erroneous diagnostic conclusions.

Although language-specific tests have been developed, their validity and perceptual saliency are questionable. These tests are fairly new to audiology and lack clinical research support. The primary drawback of all non-English speech tests is limited use and applicability because audiologists are seldom proficient in the language of the test. In addition, language-specific tests are useful for only one linguistic group, and do not meet the needs of a multilingual community. Thus, they do not solve the immediate problems facing English-speaking audiologists.

Given the limitations of these modified practices, audiologists need an alternate SRT test with cross-linguistic appeal to accommodate clients from various linguistic backgrounds. The digit-SRT test may be an appropriate solution because research demonstrated its applicability in the United States for LEP, non-native speakers of English. The digit-SRT test is also being used in South Africa and its evaluation with other multilingual or non-native English speakers is encouraged.

Although not well understood, multilingualism influences suprathreshold speech performance. In our experience, multilingual clients had disproportionately poor test scores, conflicting with clinical expectations based on pure-tone tests. Linguistic background influences test performance in a unique manner; however, an overall unfamiliarity with test words accounts for some discrepancy.

Suprathreshold speech tests are often conducted in the presence of background noise to determine communication handicap and evaluate central auditory processing ability. Hearing loss and linguistic profile influence performance on these tests. For example, research reviewed by von Hapsburg and Pena indicated that bilingual individuals have poorer speech perception in noise compared to their monolingual counterparts, suggesting that adding a challenging auditory environment to a test of unfamiliar words negatively affected performance.

Alternate suprathreshold tests were formally developed in languages such as Spanish, French, and Arabic. However, these tests have limited practical use because audiologists predominantly speak English and the tests do not meet the needs of a multilingual clientele. In addition, von Hapsburg and Pena’s review of Spanish suprathreshold tests developed for monolingual listeners in the United States indicates that bilingual participants were used to evaluate these tests, making their validity questionable.

Choices and Intervention

When hearing loss is severe or profound, multilingualism becomes an important consideration in language acquisition. There is very little research on bilingual language acquisition or the effects of multilingualism on communication in children with hearing loss.

Communication choices for children with hearing loss typically contrast manual and oral systems, with multilingualism having variable effects on each. The choice of communication system might be altered in different ways depending on the philosophy of the parents, educators, and community. In general, oral schools in the United States and Canada serving children from bilingual homes emphasize a transitional approach to language acquisition. Families are encouraged to use the home language with the child while moving toward proficiency in English. Some schools begin early intervention in English, starting in parent-infant programs while mainstream schools encourage home language use and development until formal teaching begins. The empowerment method encourages parental involvement and the integration of language and culture in communication development.

Research by Levi et al. indicates that functional speech perception skills are not different between oral multilingual and monolingual children; however, multilingual children in total communication environments are at greater risk for slower development of speech perception skills than their monolingual peers. It appears that adding a third language in a total communication environment negatively influences development of speech perception. Because this is an important consideration for multilingual families making communication choices for their child with hearing loss, audiologists should impart this information during the counseling process.

In conclusion, increased awareness of the impact of multilingualism on audiology practice has stimulated research, but ultimately, the responsibility lies with individual audiologists to provide equitable and relevant care.

Ishara Ramkissoon, is a doctoral student at the University of Illinois at Urbana-Champaign. Her research interests include the effect of multilingualism on audiometry and the effects of aging on cortical auditory function and communication. She has worked as an audiologist in medical and community clinic facilities in the United States for 3 years and in South Africa for 7 years. Contact her by e-mail at ramkisso@students.uiuc.edu .

Farhana Khan, an audiologist and speech-language pathologist, is a lecturer and clinical tutor at the University of Durban-Westville, South Africa. Since 1989, she has practiced in hospitals and community clinics, primarily serving indigent, Black communities. Khan is on the national task team investigating auditory processing disorders and her interests include hearing aids and rehabilitation technology. Contact her by e-mail at farhana@pixie.udw.ac.za.

cite as: Ramkissoon, I.  & Khan, F. (2003, February 18). Serving Multilingual Clients With Hearing Loss : How Linguistic Diversity Affects Audiologic Management. The ASHA Leader.

A South African Experience

Our work experiences in Soweto and KwaZulu-Natal highlighted the effect of multilingualism on audiological practice. We trained as audiologists in apartheid South Africa during the 1980s when institutions followed the U.S. or British model of education and faculty were primarily White and spoke English or Afrikaans. Our training did not address issues of multiculturalism or multilingualism, and the importance of this omission was immediately evident when we accepted our first jobs at Baragwanath Hospital in 1989. Situated in Soweto, this hospital served mainly Black Africans and reflected the inequitable distribution of speech-language pathology and audiology services.

The current client-practitioner profile reveals that 80% of the population and less than 1% of qualified speech-language pathology and audiology professionals are indigenous, Black African first-language speakers. More importantly, South Africa has 11 official languages and the typical client we encountered knew at least three languages. In fact, most clients were circumstantial multilinguals with linguistically diverse backgrounds. Thus, our traditional training and audiological practice was not always effective, or valid.

The first resource available to us was interpreters. Although those individuals had assisted with delivering audiology services for many years, they were not formally trained or certified. Their greatest contribution was facilitating the clinical interaction, as the audiologists were all English speakers. Interpreters effectively conditioned young children in play audiometry but the audiologist worked alone with adults, using basic knowledge of the client’s language.

In aural rehabilitation sessions, interpreters were the primary communicators with clients, essentially translating the clinician’s English into the client’s language. Although the use of interpreters seems ideal, interpreter bias often led to the omission, rephrasing, or paraphrasing of information. Thus, audiologists were often uncertain about intervention accuracy. Unfortunately, using interpreters undermined the development of trust in the clinical relationship, as clients often seemed more comfortable with the interpreter because of their shared linguistic and cultural background. Current training in South Africa encourages audiologists to know at least one African language. For example, students at the University of Durban-Westville (UDW) are required to take a class in Zulu, the regional majority African language.

Another resource available at Baragwanath Hospital was rudimentary word lists for speech audiometry. Previous audiologists and interpreters compiled these lists in Zulu, Xhosa, and Sotho. Being trained in the use of English tests only, these language-specific word lists were very useful because our multilingual clients had difficulty with the traditional tests. Limited knowledge of English and unfamiliarity with the test items compromised their performance. English-speaking audiologists with very basic knowledge of the client’s language used these word lists via monitored live voice testing to evaluate SRT and suprathreshold word recognition ability.

Subjectively, these lists appeared to have greater validity than the English tests; however, no formal research information was available about their development, validity, or reliability. In addition, the lists did not meet the U.S. criteria for the development of speech audiometric materials. For example, an important limitation of the Zulu SRT word lists is that they are monosyllabic test items, whereas research shows that speech threshold is optimally evaluated with bisyllabic items. The paucity of research on African languages makes audiologists in South Africa dependent on English-based principles to guide their selection of test materials.

Communication Choices

Multilingualism and cultural background complicate the selection of a communication method. To facilitate an informed choice, however, all communication options are presented through a skilled interpreter (informally trained) in an intensive family counseling session. In South Africa, options include the aural-oral (AO) or bilingual-bicultural (BLBC) communication approaches, with total communication (TC) being phased out. Hearing loss is typically identified at a late age, after the child has already been exposed to one or more Black African languages.

A family opting for the AO approach makes the final decision on a first language, but they are guided by the dictates of the school system. The English medium of instruction has been adopted in most schools, even those described as historically black institutions.

For a family choosing the BLBC philosophy, options include sign language (similar to American Sign Language), English, and one other African language. However, there is seldom a choice of languages due to restrictions of the school system. All schools for the deaf in KwaZulu-Natal have adopted the BLBC philosophy where the second language adopted after sign language is English. Family objections necessitate relocation or foregoing formal education because only a small number of schools cater to the needs of children who are deaf. For children who are hard of hearing, mainstream schools offer services only at the elementary school level.

Amplification options include hearing aids and are discussed parallel to communication choices. Cochlear implants are not the norm in South Africa, due to high cost and lack of implant centers in KwaZulu-Natal. Bilingual interpreters are used extensively during the hearing aid evaluation to facilitate realistic expectations.

In aural rehabilitation sessions, bilingual or manual interpreters facilitate meeting goals appropriate to the communication choice. Early intervention (EI) using either parent guidance and/or family-centered intervention is often offered to families that choose either the AO or BLBC philosophy. When the child enters school at age 3, the focus shifts from EI to direct intervention by a school-based clinician. At UDW, students are trained to provide services within an ecological (naturalistic) philosophy viewing the child as a whole, including family, environment, and linguistic background.

—Ishara Ramkissoon and Farhana Khan


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