Speech-language pathologists and audiologists strive to identify and implement the most ethical and appropriate services. However, clinical decision-making in intervention with English-language learners (ELLs) and their families can be challenging, as it may be complicated by personal, institutional, and societal interests.
Caesar and Kohler (2007) identify factors that influence service provision to ELLs, including the age of introduction to a given language, the context and community in which the language is used, and the child's approach to managing multiple languages during the development of language milestones. Current directives call for standardized assessment measures that have not, in many cases, been validated adequately on bilingual children with disabilities; there is potential, then, for a misrepresentation of the evaluation findings of these children's abilities that may result in over- or under-diagnosis.
The difficulty in providing informed assessments of bilingual children is magnified because many school-based SLPs are neither proficient in a second language nor adequately trained to provide nonbiased bilingual assessments. Further, families for whom English is not a first language may lack the facility or cultural confidence to question what they are told, or even to know what questions to ask. Ethical assessment raises several key questions that can guide us to equitable, consensus-building decisions as we seek to balance the perspectives of family, service providers, and the children served.
Current practices in speech-language pathology support decision-making that honors each family's priorities in identifying assessment and treatment options. Consideration is typically given to the full range of actions and whether they are obligatory or necessary; impermissible or never appropriate under any circumstance; or permissible with the potential for positive outcomes. The benefits and burdens of each action are then thoroughly explored within the contexts of the individual and the community (Chabon & Morris, 2004).
When faced with ethical questions about ELLs, the SLP must examine relevant evidence and clinical expertise, as well as the perspectives, values, and beliefs of the individuals involved (ASHA 2005b), and evaluate this information in relation to the ASHACode of Ethics (ASHA, 2010a). A systematic approach based in part on the organizational framework described by Chabon and Morris (2004) includes questions that can assist clinicians in responding to an ethical dilemma:
- What is the ethical question?
- What do we know?
- What do we need to know?
- Who are the people involved?
- What are the possible actions?
- What evidence, legal and ethical guidance, and/or personal, social, and professional insights support/contradict this action?
This framework is applied to the dilemma portrayed in the following scenario:
Rosita is 3 years, 8 months old. She came to the United States from Mexico six months ago with her parents and 1-year-old brother. Spanish is the language used at home. Five months ago she enrolled in a Head Start preschool where only a few staff members speak Spanish. Many of the students also are native Spanish-speakers. Three months after Rosita began preschool, her teacher referred her for a speech and language assessment. The SLP, who speaks only English, is in her first year at this preschool. She recently completed her clinical fellowship at a neighborhood school and her mentor has moved out of state. The preschool director, also a monolingual English speaker, spent most of his long career at an elementary school where most students spoke only English. The SLP knows that she should not proceed without an interpreter. The school uses the teaching assistant, whose son attends the preschool, to assist with as-needed interpretation. The assistant is not a trained interpreter and is not comfortable with her own English skills. The SLP has taken her concerns to the director who, although sympathetic to the situation, is fairly insistent that the SLP complete the evaluation.
What is the ethical question?
Is it obligatory, permissible, or impermissible for a monolingual SLP to conduct an evaluation of a child whose first language is not English? The answer to this question may appear relatively straightforward, and yet the process of evaluating an ELL is often rife with subjectivity and uncertainty.
What do we know?
The relevant facts include information about the school, SLP, school administrators, and the child and her family, all described above.
What do we need to know?
It would be helpful to know more information about:
- The child and parents' proficiency in and context of use for all languages spoken.
- Other key individuals in the child's sphere of influence (caretakers, extended family), the languages they speak (including any indigenous languages or dialects), and the proficiency with which they speak them.
- The reasons for the teacher's referral and any parent concerns about the child's communication skills.
- The SLP's education and training in serving culturally and linguistically diverse populations.
- The resources available in the community, school, and school district to assist the family and the SLP.
- The family's social support network.
- The teaching assistant's training in interpretation and in the testing process.
Who are the people involved?
This situation includes many stakeholders, including Rosita, her brother, and their parents; the SLP; the preschool director and classroom teacher; the teaching assistant; and the other children attending the school. Other SLPs, educators, and staff members employed in the community could be affected by the decision if the actions taken are interpreted as a reflection of common or acceptable practices.
What are the possible actions?
Assuming that consultation with the parents and teacher and observations of the child confirm the need for an evaluation, there are a number of possible responses. It is important to emphasize, however, that some responses are obligatory, some are permissible, and some are impermissible. The monolingual SLP could:
- Refuse to evaluate the child.
- Conduct the evaluation in English.
- Conduct the evaluation with the support of a bilingual speaker (the teaching assistant).
- Conduct the evaluation with the support of a trained interpreter.
- Arrange for a bilingual SLP to participate in or conduct the evaluation.
What evidence, legal and ethical guidance, and/or personal, social, and professional insights inform each action?
Ethical and Legal Issues
The ASHA Code of Ethics (2010a; specifically Principles of Ethics I, Rules A and B) prescribes that services be provided competently with all available resources, including referral when appropriate. Principle of Ethics 1, Rule C, prohibits discrimination on the basis of race or ethnicity, a provision that eliminates the option of refusing treatment without ensuring that the child receives proper services.
This provision is further specified in an Issues in Ethics Statement on Cultural Competence, which notes, "When a clinician is not proficient in the language used by the client and family, a suitable interpreter [should] be used" (ASHA, 2005a, p.2). It also states, "Bilingual skill (understanding and speaking the language) does not equate to bicultural skill (understanding and respecting the culture)," and that both of these skills are required for service to be culturally competent.
The need to consider a child's native language in assessment is clearly mandated in the Individuals with Disabilities Education Improvement Act (IDEA, 2006). This reauthorization strengthened the language regarding equitable assessment. It states in part that testing and evaluation materials and procedures should not be racial or cultural discriminators and that "Such materials or procedures shall be provided and administered in the child's native language or mode of communication, unless it is clearly not feasible to do so, and no single procedure shall be the sole criterion for determining an appropriate educational program for a child" (20 U.S.C. §1412 (6)(B)).
The Standards for Educational and Psychological Tests (1999) also support the need for a test to be administered in the test-taker's most proficient language. However, despite strong ethical and legal guidance, in actual practice these principles may be breached rather than observed. Further, laws and ethical principles are inherently general, and this lack of specificity may explain in part why practice patterns do not always reflect legislative, research, and practice guidelines (Whitmire, as cited in Caesar & Kohler, 2007).
Guidance From the Literature
Spinelli (2008), citing several earlier studies, asserts that an evaluator should speak the language of the student, assess in both English and the student's native language, and use a trained interpreter as needed to assist in test administration. Considering that a significant percentage of SLPs are either monolingual or not proficient enough in languages other than English to provide services to ELLs (Caesar & Kohler, 2007), there are several steps described in the literature to guide SLPs in equitable evaluations of ELLs (Crowley, 2006; Flanagan, Ortiz, & Alfonso, 2007): They need to know how culture and language affect assessment and intervention; they can use trained interpreters/translators to communicate in the child's native language; and they can request the assistance of a bilingual SLP.
Ortiz (2008) writes, "Linguistic competence is reflected in two distinct ways: the ability to communicate effectively in an individual's native language (eliminating the need for an interpreter) and possession of a knowledge base related to first- and second-language development and instruction methodology and pedagogy" (p. 665). Therefore, although the ability to speak a child's native language is desirable, it may not be necessary for equitable assessment if the SLP knows how the languages contrast, understands the issues involved in bilingual assessment, and uses trained interpreters.
With the advent of P.L. 94-142 (now IDEA) in 1975, parent participation has become central to the provision of special education services. Nonetheless, it has been difficult for some service providers to shift from a tradition in which the professional provides information and makes the decisions to a practice that involves reciprocal planning, dialogue, and informed consent with family members (DeGangi et al., 1994; Gutierrez & Sameroff, 1990; Lieberman, 1990). Non-English-speaking parents are often given lengthy documents written in English that contain the procedural safeguards outlining their rights. Fitzgerald and Watkins (2006) reviewed parental rights documents from 50 states and reported that 20%–50% were written at a college reading level or higher. Thus, even when the information is translated, it is often too complex for some parents to comprehend fully.
This problem may be exacerbated by conflicting visions of and expectations for the child, predetermined decisions about best placements, and other factors, such as interpreters who leave the meeting before it is finished. One educator who met with Spanish-speaking parents from an early intervention program summarized the parents' frustration: "They don't know their children's rights beyond the limited therapies they [the children] have received" (S. Ramirez, personal communication, May 24, 2010).
Personal and Professional Insights
SLPs play a significant role in evaluation of and intervention with ELLs. ASHA policy on providing culturally and linguistically appropriate services (2004) states that intervention and assessment must focus on a child's abilities in both languages and be aligned with a family's expectations, values, and goals as well as those of the larger cultural and linguistic community. Additional guiding principles illuminate that "these practices are predicated on the belief that families provide a lifelong context for a child's development and growth" (ASHA, 2008, p. 2).
Equitable assessment requires information regarding a child's level of proficiency in English and the native language, and the background knowledge and skills required by the tests. A clinician, whether mono- or multilingual, must ensure that assessment incorporates multiple sources of information, including educational and medical records, interviews with family members and educators, observations in multiple settings, and assessment of the child in a variety of communicative contexts (Kohnert, 2008).
In an effort to alleviate the disproportionate numbers of minority students who are inappropriately referred for special education services, SLPs are called upon to consider not only linguistic data, but also socioeconomic and cultural factors, access to and quality of prior education, and differences between school and home languages in providing accurate evaluation of potential communication disorders in ELLs (ASHA, 2010b).
Possible Consequences of Each Action
Failure to conduct the assessment may have negative ramifications for the child if she is truly struggling with language, as well as for the clinician who might be viewed as insubordinate for refusing to comply with the employer's request. Conducting the evaluation in English only or in Spanish by an untrained Spanish "interpreter" who is unfamiliar with the testing process or uncertain about her own English skills may result in inappropriate assessment practices and incorrect diagnoses. A child who receives unnecessary services may be labeled inappropriately, creating unwarranted concerns for the child and family.
Review of the law and ethical principles illustrates that it is impermissible for the SLP to refuse to evaluate the child, to evaluate the child in English only, or to evaluate the child without appropriate support. The SLP is obligated to provide culturally and linguistically appropriate services and to educate fellow staff members about their need to conduct evaluations in both languages. The SLP should seek the assistance of a professional interpreter, or, if one is not available, an individual who has an appropriate level of training.
Regardless of her language expertise, the SLP is responsible for locating suitable testing materials and for discussing with the interpreter whether the test items are culturally and linguistically germane. If there are no standardized assessments available in the child's home language, the SLP is responsible for designing alternative procedures that meet the child's needs and for discussing assessment questions to determine linguistic equivalency and cross-cultural applicability (Langdon & Cheng, 2002).
This process begins with identifying standards that are systematic and equitable. It is also important to connect with the child's culture and world experience in designing treatment materials (including relevant visuals, structured vocabulary to represent main ideas, periodic reviews of key concepts, concrete referents).
Given the linguistic background of the children at the school, the SLP might consider reasonable options available to improve her own preparation for working with other non-English-speaking children.
The example given illustrates a systematic approach to ethical decision-making that can be used to determine whether, in providing services to ELLs, it would be obligatory, permissible, or impermissible for SLPs to:
- Address educational disparities, including ease of access, availability of services and resources, lack of information due to potential language barriers, perceptions about eligibility for services, and lack of bilingual service providers.
- Over-identify, over-diagnose, or misdiagnose communication disorders.
- Under-identify or adhere to a "wait to fail" philosophy.
- Use, fail to use, or misuse interpreters.
- Treat bilingual children when the SLPs are monolingual.
- Hire a bilingual SLP primarily or exclusively because of his or her language background and with limited consideration of the requisite knowledge and skills for working with ELLs.
- Offer training programs to prospective SLPs and other service providers that include little or no information about working with bilingual children.
- Use a non-SLP to assist with service delivery because he or she speaks the child's language.
- Deny children a response-to-intervention alternative to special education referral due to funding differences.
- Use research evidence collected primarily on monolingual children to support practice decisions with bilingual children.
- Work with children who come from families without legal status (this question may involve issues related to barriers to access and need to report).
- Teach English versus facilitate language development.
- Recognize the need to teach in the language of instruction. (Is the language of instruction in intervention the language used in the home? Why is the language of instruction given priority over the family language?)
- Refer bilingual children to a school where it is unlikely that they will interact with bilingual teachers, assistants, or children.
A number of mitigating factors may influence responses to these queries and ultimately influence decisions. We hope that raising these ethical challenges, considering the questions they generate, and providing an example of a decision-making process will help SLPs to identify best practices in situations that involve stakeholders who speak different languages and who may have different cultural values and goals.
There may not be an optimal balance in determining how best to respond to these questions, much less what that response might be. The decisions we make, however, can demonstrate our commitment to those we serve and ultimately inform our ethics, refine our science, and enhance our practices.