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 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.