Multilingual Service Delivery in Audiology and Speech-Language Pathology

This Practice Portal page focuses on audiology and speech-language pathology services for multilingual people across the life span. Visit Multilingual Service Providers for more information about audiologists, speech-language pathologists (SLPs), and assistants who use more than one language in service delivery.

Visit the Cultural Responsiveness and Collaborating With Interpreters, Transliterators, and Translators Practice Portal pages for more information about cultural and linguistic considerations.

See the Cultural and Linguistic Diversity (CLD) Evidence Map for summaries of the available research on this topic.

For information about assessment and treatment of specific communication, hearing, or swallowing disorders, refer to the relevant Clinical Topics in the Practice Portal.

A multilingual person can communicate in more than one language, has been exposed to more than one language, or may be learning English in addition to the language(s) they use (ASHA, 2023a). Multilingualism is a continuum of language skills. A person’s proficiency in any of the languages they use can change over time; across social settings, topics, and conversational partners; and additional variables (Bialystok, 2001; Grosjean, 1989).

Multilingualism is hard to define because of the differences among the people who understand and use more than one language. Differences can include the ages of acquisition, contexts for use, and levels of competence (Valdés, n.d.). As a result, terminology is evolving to describe a multilingual person and the languages they use. Some examples are as follows:

  • Multilingual learners—individuals who speak two or more languages. This is a more inclusive term because it also includes students who are fluent in English and are learning another language in a dual-language program (Najarro, 2023).
    • Dual language learners—individuals learning two languages simultaneously from infancy or who are learning a second language after the first language in early childhood.
    • English language learners (ELLs)—children and adults who are learning English as an additional language for social, educational, and/or employment purposes.
    • Emergent bilingual—a child who acquires another language through school (i.e., the language of instruction) and who is still able to function in their heritage language (García et al., 2008).
  • Limited English proficient—a term used for “English Learners” in the Individuals with Disabilities Education Act. Some administrative offices may still use this classification, but this term is not preferred. Many providers now focus on the strengths of learning another language instead of viewing it as a limitation.
  • Heritage language—language(s) that are different from the dominant language in a given social context (Kelleher, 2010).

Multilingual service delivery occurs in two ways:

  • Cross-linguistic—involves clinical practice with an individual who uses a different language than that of the clinician. For example, an SLP who uses English would be providing cross-linguistic services to a patient who uses Navajo while working with an interpreter.
  • Language-matched—an individual and a clinician share language(s) in service delivery. For example, an SLP who uses English and Navajo would be able to provide language-matched services to a patient who uses Navajo.

This Practice Portal page will use the terms “multilingual,” “multilingual service delivery,” and “heritage language” to encompass the varied experiences of using more than one language. Being multilingual is not a communication disorder, but it is a significant consideration when there are concerns regarding a hearing or communication disorder. Not appropriately responding to cultural and linguistic influences may lead to misdiagnosis, which can reinforce disproportionality in schools (e.g., over- or underrepresentation of a racial/ethnic group in special education) and disparities in health care (e.g., access to medical services).

Multilingualism in Populations Who Receive Audiology and Speech-Language Pathology Services

According to the 2022 American Community Survey, the majority (78.0%) of the U.S. population speaks only English, whereas 22% of the U.S. population speaks a language other than English at home. Of the estimated 69 million multilingual Americans, the most common spoken language (besides English) at home is Spanish (61%), followed by Chinese (5%), Tagalog (3%), Vietnamese (2%), Arabic (2%), and French (2%). On this same survey, 8.4% of Americans identified themselves as speaking English “less than very well” (U.S. Census Bureau, 2022).

For non-spoken, signed languages, estimates indicate that as many as 6.7 million adults—which includes hearing and hard of hearing individuals—report knowing and/or using a signed language (Mitchell & Young, 2023), of which an estimated 500,000 to 1 million individuals use a signed language at home (Mitchell & Young, 2023; Mitchell et al., 2006).

Based on ASHA’s National Outcomes Measurement System data, 4.7% of adult speech-language pathology patients who were discharged between 2018 and 2022 reported having a primary language besides English (ASHA, 2022). During the 2020–2021 school year, 11.78% of elementary and secondary students with disabilities who were served under an individualized education program (IEP) were also identified as English Learners (U.S. Department of Education, 2022).

Service Provision for Multilingual Populations

There is an increasing prevalence of multilingual people. The U.S. Department of Health and Human Services (HHS) created the National Culturally and Linguistically Appropriate Services Standards to improve the quality of care and promote health equity. The principal standard urges health care organizations to be responsive to diverse cultural health beliefs, languages used, healthy literacy, and additional communication needs.

Any clinician can engage in multilingual service delivery. A clinician can (a) use their languages in service delivery as a language-matched multilingual service provider or (b) collaborate with a trained interpreter to provide cross-linguistic services. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators. When language-matched multilingual service providers are not available, the clinician considers their own language skills in the target language, assesses the language needs of the client and family, and uses available resources to support language access.

Roles and Responsibilities

Appropriate roles for audiologists and speech-language pathologists (SLPs) providing services to multilingual people are as follows (ASHA, 2023a):

Be culturally responsive.

  • Engage in culturally responsive and critically reflective practices, including the acknowledgment of systemic inequities and the impact on educational and health disparities. See ASHA’s resource on social determinants of health.
  • Obtain information on respective linguistic communities to appropriately consider the intersection of language and culture on the communication of clients and families. See ASHA’s resource on phonemic inventories and cultural and linguistic information across languages.
  • Establish foundational knowledge of speech and language features and processes of various languages to (a) inform clinical practice to mitigate cultural and linguistic bias in the assessment process and (b) effectively implement communication strategies and interviewing techniques (e.g., ethnographic interviews). See ASHA’s Practice Portal page on Cultural Responsiveness for more information about ethnographic interviewing.
  • Develop foundational knowledge of multilingualism, including (a) the influence of an individual’s heritage language on additional languages and (b) the factors that influence multilingual competence across the life span.
  • Examine how specific speech, language, and hearing conditions manifest in multilingual speakers—such as, but not limited to, the patterns of language in multilingual individuals experiencing neurological recovery or decline, the variation of stuttering across languages, and the increased difficulty processing speech in noise.

Support students, patients, clients, and their families.

  • Advocate for clients, families, and communities in the areas of communication, cognition, hearing, swallowing, and balance at the local, state, and national levels.
  • Collaborate with the client and their family in treatment planning; this includes determining the language(s) of intervention. Also, provide evidence-based interventions that support the language(s) and communication modalities that prioritize the client and family perspectives while also facilitating best outcomes. Implement strategies that help generalize treatment effects between languages and contexts.
  • Consider the use and limitations of technologies designed to assist communication across languages. Integrate multiple technologies to promote language access.
  • Advocate for the benefits of multilingualism to families who may have been told—or made to feel—that they should avoid using certain languages with their children and family members.
  • Communicate the patterns of language development and multilingualism, such as the difference between accent and dialect, features of second-language acquisition (e.g., language transfer, language attrition), and multilingual acquisition contexts (e.g., simultaneous, sequential).
  • Support the development and maintenance of heritage language comprehension and use for individuals who communicate by using augmentative and alternative communication or assistive technology. See ASHA’s Practice Portal pages on Augmentative and Alternative Communication (AAC) and Language and Communication of Deaf and Hard of Hearing Children.

Collaborate with other professionals.

Roles and Responsibilities for Speech-Language Pathology Assistants (SLPAs)

SLPA responsibilities related to cultural responsiveness and multilingual service delivery are as follows (ASHA, 2022):

  • Adjust communication style and expectations to meet the needs of clients, patients, and students from different cultural groups and to provide services in a culturally responsive manner.
  • Provide information to families and staff regarding the influence of first language on the development of communication and related skills in additional languages (under the direction of the supervising SLP).
  • Develop an understanding of the family dynamic and preferences from a cultural perspective to effectively engage in meetings surrounding intake, discussions of the therapy plan of care, and other communication scenarios surrounding practices for addressing communication concerns.
  • Engage in continuing education and training opportunities focusing on the assessment and intervention process when working with multilingual individuals.

For more information, see Scope of Practice for the Speech-Language Pathology Assistant (SLPA).

The ASHA Code of Ethics (ASHA, 2023b) indicates that audiologists and SLPs shall engage in only those aspects of the profession that are within their scope of professional practice and competence, considering their level of education, training, and experience. See the next section below for additional ethical considerations.

Ethical Considerations for Multilingual Service Delivery

As indicated in the ASHA Code of Ethics, 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. SLPs consider how communication disorders or differences might be manifested, identified, or described in the client’s/patient’s cultural and linguistic community and then integrate this knowledge into all areas of practice—including assessment, diagnosis, treatment, and treatment discharge.

Audiologists consider how language and cultural differences can impact communication with patients—including the ability to collect a complete patient history; communicate testing procedures and instructions; and effectively counsel the patient on test results, expectations, recommendations, and appropriate referrals.

It is the audiologist’s and the SLP’s responsibility to select testing materials that are linguistically and developmentally appropriate and to document any testing modifications and/or limitations.

Circumstances may call for the clinician to work with an interpreter to ensure that clinical services are provided in the language that is most appropriate for the patient and family. For additional information related to working with interpreters in spoken and manually coded languages, please see the Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.

It is the legal and ethical responsibility of the facility and its providers to offer reasonable and appropriate accommodations to facilitate access to clinical services. See the State and Federal Legislation section below for additional legal considerations.

The ASHA Code of Ethics (ASHA, 2023b) and the Issues in Ethics statement on Cultural and Linguistic Competence (ASHA, 2017) clarify the principles related to providing services to multilingual people. These principles include

  • the need to honor and hold paramount the welfare of individuals served professionally by promoting the use of heritage languages and service delivery in the languages used by multilingual persons.
  • interprofessional practice and/or proper referral to provide language access for cross-linguistic service delivery, if necessary.
  • the need for openness and flexibility in the selection, administration, and interpretation of diagnostic and/or treatment regimens and research decisions that address the unique, individual characteristics and cultural background of individuals and their families.
  • the prohibition of discrimination based on dimensions of diversity, including culture, language, dialect, and accent under national origin.

These ethical principles require that clinicians continue in lifelong learning to develop the competencies required for multilingual service delivery.

For additional information, see ASHA’s Practice Portal page on Cultural Responsiveness; ASHA’s Ad Hoc Committee on Bilingual Service Delivery Final Report on Competencies, Expectations, and Recommendations for Multilingual Service Delivery [PDF]; and the Issues in Ethics statement on Cultural and Linguistic Competence.

State and Federal Legislation

Several state and federal regulations have implications for the provision of audiology and speech-language pathology services to multilingual clients, patients, or students. Differences in state regulations may be reflected in several requirements, including education. See the ASHA State-by-State advocacy page for a summary of state requirements.

Title VI of the Civil Rights Act of 1964

Title VI of the Civil Rights Act of 1964 [PDF] prohibits discrimination in any federally funded program on the basis of race, color, or national origin (including heritage languages). 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 for Civil Rights, all providers who work for any agency funded by the HHS are required to provide language access services to patients who use languages besides spoken English.

See the U.S. Department of Health and Human Services Language Access Plan [PDF].

Affordable Care Act

Section 1557 of the Patient Protection and Affordable Care Act (2010) prohibits discrimination in covered health entities or activities. “Covered health entities” may include the following:

  • hospitals
  • health clinics
  • health insurance issuers
  • state Medicaid agencies
  • community health centers
  • physician’s practices
  • home health care agencies

Health entities must also take reasonable steps to provide meaningful access to people who use languages besides spoken English. Covered health programs or activities are also required to post taglines in at least the top 15 languages in their state. Taglines are brief messages in documents and websites that explain how people can obtain a translation of the document or request an interpreter to explain the document for them in their heritage language(s).

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 U.S.C. §§ 1701–1758). Congress has interpreted bilingual education as an action that a school district must take to teach non–English-speaking students how to speak English.

Individuals With Disabilities Education Act (IDEA)

IDEA was enacted to ensure that everyone, including children with disabilities, receives a free and appropriate public education. IDEA 2006, Part B, Final Regulations, supports nondiscriminatory service delivery by establishing the following:

  1. Assessment and other evaluation materials should not be racially or culturally discriminatory.
  2. Assessment and other evaluation materials are to be provided in the child’s heritage 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.
  3. The form in which evaluation materials are administered often varies from standard testing procedures to appropriately evaluate a multilingual student—including collaborating with an interpreter—and the assessment report reflects these adaptations. See the Assessment section for more information.
  4. A child must not be determined to have a disability based on the child’s emergent English language development or lack of appropriate instruction in reading or math.
  5. Parents are entitled to have an interpreter at the IEP meeting, if needed, to ensure cross-linguistic understanding and participation.
  6. When an IEP is developed for a child with emergent English development, the language needs of the child must be considered.

Federal regulations clearly define steps that states must take to address the problem of disproportionality in special education. Children who are ELLs and who are suspected of having a disability must be evaluated in a timely manner (Office for Civil Rights, 2015). The Office for Civil Rights (2015) clarified that ELLs with disabilities are entitled to a free and appropriate public education. This means that school districts are obligated to provide language assistance (e.g., English as a second language [ESL] services) and disability-related services (i.e., IEP, 504 plan).

See IDEA Part B Issue Brief: Culturally and Linguistically Diverse Students. See also the Department of Education’s resource for addressing English language learners with disabilities [PDF].

Every Student Succeeds Act (ESSA)

ESSA, Public Law 114-95, reauthorized the Elementary and Secondary Education Act and its long-standing commitment to equal opportunity for all students. ESSA, which replaced the No Child Left Behind Act, provides greater flexibility to state and local governments to create their own accountability systems, academic goals, reporting, and other requirements when implementing programs. ESSA ensures that all students are prepared for college and careers.

ESSA requires that states (a) include English language development/proficiency in their accountability frameworks, alongside statewide math and language arts assessments, and (b) report English proficiency progress by a growth measure for up to 4 years.

States must

  • clarify a standardized process for classifying English learners and for redesignating students as English proficient;
  • disaggregate English learners with a disability from English learners in general; and
  • report on students who have not attained English proficiency within 5 years of identification as an English learner.

The U.S. Department of Education developed regulations and other guidance to assist states, local districts, and schools with ESSA’s implementation. ASHA’s publication, Every Student Succeeds Act: Key Issues for ASHA Members [PDF], contains information about how ESSA affects audiologists and SLPs working in schools.

Executive Order 13166

HHS-issued guidance relating to Executive Order 13166 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). This guidance applies to any health care provider or entity that receives federal funding, including the following:

  • Medicare Part A
  • federally funded clinical trials
  • Children’s Health Insurance Program (CHIP)
  • Medicaid
  • other patient populations

Second-Language Acquisition

Understanding the typical processes and occurrences of acquiring additional language(s) after learning any first language(s) ensures accurate speech and language assessment of multilingual clients. The experience of learning a second language is unique to each person, but common experiences during the second-language acquisition process are listed below. See additional resources and information to share with families on Learning More Than One Language.

Timing of Acquisition

The nature of multilingualism depends on when a person learns the languages they use and how long they have been exposed to those languages.

Simultaneous bilingualism/multilingualism—the acquisition of two or more languages at the same time. Typically, all languages are introduced before the age of 3 years.

Sequential or successive bilingualism/multilingualism—the acquisition of an additional language that is introduced after the age of 3 years, at which time some level of relative proficiency has been established in the primary language. This term is also referred to as “successive multilingualism” or “second-language acquisition.”

Emergent bilingualism/multilingualism—the acquisition of another language through school (i.e., the language of instruction). Those with emergent bilingualism/multilingualism remain able to function in their heritage language (García et al., 2008).

Influence or Transfer

Influence or transfer occurs when the structure of a primary language (L1) directly influences an utterance made in a second language (L2). For example, children who are sequential ELLs may manifest influence or transfer from their first language (L1) to English (L2). In children who are simultaneous bilinguals, influence or transfer may occur between the two languages. Patterns that are the result of influence or transfer are not indicative of a disorder.

Adults who are learning English or who acquired English after their linguistic system was established may demonstrate ongoing differences from General American English as well as from the dialects they use in their community. The clinician considers whether differences (a) are influenced by the individual’s heritage language or (b) are an indication of a change relative to baseline status (Anderson & Centeno, 2007).

Silent Period

A silent period may occur during the initial phase of second-language acquisition while an individual focuses on listening and comprehending the new language (Elizalde-Utnick, 2007, as cited in Mayworm et al., 2015). The main characteristic of this developmental stage is that, after some initial exposure to the language, the learner can understand much more than they can produce.

Emphasis on the silent period can inaccurately normalize lowered teacher expectations and can delay identification of multilingual students with disabilities (Roberts, 2014). If the silent period is particularly prolonged, then the clinician may need to differentiate whether it is truly a silent period for second-language learning, whether it is selective mutism, or whether it is another cause (e.g., Preston, 2014). See ASHA’s Practice Portal page on Selective Mutism for more information.


Code-switching involves changing dialects or languages within utterances (known as intra-utterances) and across utterances (known as inter-utterances) based on the linguistic context and community around them (Roseberry-McKibbin, 2014). Many fluent multilingual speakers code-switch. In individuals who are simultaneous bilinguals, code-switching does not occur randomly. It is grammatically and socioculturally constrained.

Code-switching may be a cognitive strategy for multilingual people to easily access all the languages they know in order to provide alternate ways to convey meaning (Beatty-Martínez et al., 2020). Adolescents and adults who are developing proficiency in a second language may substitute grammatical structures and words from the first language for forms that they have not learned yet in the second language; however, this is not necessarily indicative of a language disorder (Roseberry-McKibbin, 2014).

Variation from typical code-switching constraints in adolescents and adults who are fluent in multiple languages may indicate cognitive and/or communication disorders. These errors are often noted due to deficits in executive function and decreased inhibition of the nontarget language, dementia, aphasia, and other language disorders (Ansaldo & Marcotte, 2007).


Because language is fluid and is shaped by communicative contexts, some modern scholars view language as a tool for people to make sense of the world and shape their knowledge and experiences. Traditional multilingual frameworks suggest that multilingual people pull language features from separate, socially constructed, named language systems—such as English, Spanish, and Vietnamese (Vogel & García, 2017).

Translanguaging proposes that multilingual speakers have a unified linguistic repertoire consisting of all of the linguistic features that a speaker uses based on different contexts without focusing on a single language (Otheguy et al., 2015). The notion of translanguaging challenges the hierarchical nature of socially constructed languages as well as the suppression of minoritized languages and peoples (Otheguy et al., 2015).

Translanguaging is speaker focused. It refers to both the fluctuation between languages and the deployment of features that make up the speakers’ complete language repertoire (García & Wei, 2014). Code-switching, however, is more listener focused, as speakers often change codes to adapt to the needs or preferences of their communication partner. Some people may even make assumptions about the speaker’s overall level of competence, based on their fluctuation between languages. However, all communicators use language in different ways; thus, translanguaging is a common occurrence in the communication of users of multiple languages.

SLPs can adopt a translanguaging approach to assessment practices that allow multilingual individuals to express themselves using their full linguistic repertoires. This helps the SLP gain an accurate picture of the individual’s communication skills to inform recommendations. For example, a multilingual client, patient, or student can use both Mandarin and English during a speech and language evaluation (e.g., ethnographic interviewing, storytelling). This approach (a) values the rich experiences and languages that clients bring to clinical interaction and society and (b) supports the development of their communication skills in the way the client chooses (see Hernández et al., 2023, for a detailed scenario). To learn more about ways in which teachers are embracing translanguaging to support multilingual learners in the classroom, see WIDA’s resource, Translanguaging: Teaching at the Intersection of Language and Social Justice [PDF].

Language Loss/Attrition

As some individuals learn a second language, they lose skills in their heritage language if this language is not reinforced and maintained in the individual’s environment (e.g., English-only instruction). 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). Attrition and inhibition of the heritage language during immersion in L2 may occur, even during the short term (Linck et al., 2009).

Clinicians consider the prior level of the client’s proficiency in the heritage language, individual motivation, societal factors, and previous education and consistency in learning and instruction in the heritage language if language loss is observed. Errors may be related to the individual’s language history. Heritage language attrition and attenuation (language loss) of first-language proficiency may negatively influence overall language performance (Anderson, 2004; Linck et al., 2009).

Dialect, Accent, and Phonetic Patterns

Dialect and accent influence phonetic patterns in multilingual individuals. Dialect describes “a rule-governed, systematic variation of a language” (Goldstein, 2000, p. 9; Wolfram & Schilling-Estes, 1998). Accent describes the way people sound or the pronunciation used. Dialect includes accent as well as grammatical structures and semantics. For example, there are a variety of American accents across the different American English dialects. Clinicians differentiate the features of accent and dialect from communication disorders, including phonological disorders. See ASHA’s technical report on American English dialects.

In children, the 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 the development of morphosyntax, syntax, and semantics as influence/transfer may appear across the languages that 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-language acquisition and with the baseline for the individual or if they are the result of a communication disorder (Bell-Berti, 2007).

See ASHA’s resource on phonemic inventories and cultural and linguistic information across languages.

Identifying Communication Disorders in People Who Use More Than One Language

Identifying a communication disorder in a multilingual person requires careful consideration of the multitude of factors that influence communication skills. Signs of a communication disorder are seen across all the languages that a multilingual person uses, but symptoms usually differ across languages. Language dominance may change across a client’s life span based on how much they use a language, how much language input they receive, and their language history (Kohnert, 2012).

Clinicians consider how diverse linguistic systems influence the following:

Phonology—Linguistic development in multilingual children can manifest in patterns different from those observed in monolingual children and may include phonological patterns as the result of transfer or influence 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. Structures such as pronouns, verb conjugation, verb inflection, tense may not exist equally in each language used by a multilingual individual. Assessment considers the individual’s linguistic community as well as the frequency and types of observed morphological patterns to determine if patterns are the result of a disorder.

Morphosyntax—Some research suggests that morphosyntactic language development in multilingual individuals may be similar to that of monolingual individuals in rate and order of acquisition (Bedore et al., 2012). Cross-linguistic influence of morphosyntax from the dominant language into the heritage language may occur (Van Dijk et al., 2022).

Syntax—Due to the variability of syntactic structures across languages, underlying syntactic deficits will likely manifest differently across languages. Difficulty in the development of syntactic structure may also be influenced by the perceptual salience of morphemes and syntactic structures. Children with spoken language disorders are noted to demonstrate significant deficits for morphemes with limited perceptual salience (Restrepo & Gutiérrez-Clellen, 2012). Additionally, grammatical structures in either language may be influenced by the other (Paradis et al., 2011). The clinician considers if the patterns observed are due to 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 heritage language and other words in the language used in different 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. Cummins (1984) distinguished between two types of language proficiencies:

An individual may be fluent in conversational communication (BICS) yet continue to have difficulties with communication in an academic setting (CALP). Observing an individual’s language skills in both areas is essential for a clinician to develop a comprehensive understanding of that person’s linguistic abilities.

See an informational video about bilingual language development.

Clinical Service Delivery

Speech-Language Pathology

The two primary goals of speech-language service delivery for multilingual individuals are as follows (Centeno & Ansaldo, 2013):

  • accurate differential diagnosis between communication disorders and linguistic variations due to second-language acquisition
  • intervention approaches and contexts that provide the optimal stimulation to enhance linguistic recovery and minimize the extent of the functional impact of the disorder

For more information about care of multilingual people with specific disorders or conditions (e.g., aphasia, dysphagia, spoken language disorders), visit the Clinical Topics page on the Practice Portal.


In some settings, such as schools, a speech-language and hearing screening may be conducted to determine whether there is a need for further assessment. Screening activities do not result in diagnosis. Screening multilingual individuals may include the following:

  • a hearing screening to rule out hearing loss as a possible contributing factor to communication difficulties
  • information from the individual, families, care partners, service providers, and other people who can speak about communication development, use, and concerns
  • informal measures tailored to the population being screened
  • formal screening measures with demonstrated evidence of adequate sensitivity and specificity (report scores only if appropriate)
  • language and work samples, observations in various settings, and dynamic assessment (DA) across languages to probe areas of concern and to observe varieties of languages used (e.g., Puerto Rican Spanish, African American English, etc.)
  • collecting progress-monitoring data from multi-tiered systems of support (MTSS)/response to intervention (RTI) services and (if applicable) examining RTI criteria that have not been met

If screening results indicate further testing, clinicians conduct a comprehensive and linguistically appropriate assessment.


See the Assessment–Linguistic Diversity section of the Cultural and Linguistic Diversity (CLD) Evidence Map for pertinent scientific evidence, expert opinion, and client and care partner perspective.

A comprehensive assessment of communication skills is culturally relevant and functional. It involves the collaborative efforts of families/care partners, cultural brokers, interpreters, and other professionals as needed.

Case History

A clinician gathers relevant language history—including, but not limited to, the following (Rimikis et al., 2013):

  • age and manner of acquisition of the language(s)
  • number of languages spoken
  • dialect of the language(s) 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
  • language of choice with health providers
  • progress in receiving English as a second language (ESL) services or adult English language learning classes, if applicable
  • contact with speakers of their language(s)
  • language of academic instruction
  • academic performance or literacy skills in each language

A client interview is often included when gathering case history. See ASHA’s Practice Portal page on Cultural Responsiveness for information related to ethnographic interviewing.


Parent surveys for young bilingual children can be an effective way to gather information about early language development (Thal et al., 2000). Parent surveys used during a preliminary screening of a bilingual child have the potential to yield valid and reliable information (Guiberson & Rodríguez, 2010).

Questionnaires provide valuable information about a client’s or care partner’s concerns, language preferences, observations, communication practices, quality of life, and/or goals of treatment. Questionnaires can also provide insight into the individual’s previous level of mastery in each language, which can be helpful when working with adult patients with neurological injury or decline (Centeno, 2010). As a language-matched multilingual service provider or while working with an interpreter, clinicians use questionnaires in the languages their clients use. Clinicians may modify the questionnaires as needed to account for cultural and linguistic aspects relevant to the client and collect qualitative information. If using a translated questionnaire with scoring options, ensure that the instrument has been validated for use with that specific population. For example, some questionnaires— such as the Voice Handicap Index (e.g., Seifpanahi et al., 2015)—have been translated, modified, and validated for use with multilingual populations.

Oral Mechanism Examination

Multilingual clients and patients may benefit from visual modeling of commands to helpthem comprehend tasks during oral mechanism examination. Cultural and individual differences may influence how clients perceive certain tasks that clinicians request them to do, such as sticking out their tongues; hence, the clinician may need to explain the reason for certain requested activities.

Assessment Tools

Criterion-referenced assessment tools identify and evaluate a client’s strengths and weaknesses, whereas norm-referenced measures assess an individual relative to a group. Standardized test scores are not valid and are not reported for an individual who is not reflected in the normative sample for a given assessment; however, these assessments may still provide valuable descriptive information in the documentation about a client’s abilities and limitations in the language of the test (i.e., a test given in English will speak to a person’s ability in English; a test given in Spanish will speak to a person’s ability in Spanish). When possible, use culturally and linguistically adapted test equivalents in both languages to compare potential areas of need.

No test can be completely free from cultural bias. 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 ASHA’s Practice Portal page on Cultural Responsiveness.

Accommodations and Modifications to Standardized Assessment Procedures

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. In this case, the standardized score is not reported.

An accommodation refers to an adjustment or change to the environment or mode of client response to facilitate access and interaction and to remove barriers to participation. A modification refers to a change in material, content, or acceptable response.

Examples of accommodations and modifications are as follows:

  • rewording and providing additional test instructions other than those allowed when presenting test items
  • providing additional cues or repeating stimuli that 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 without proper validation studies to reach a standard score because the standardized assessment’s psychometrics, such as content validity, may be weakened (Roger & Code, 2011). The following problems may arise when tests are translated (Goldstein, 2000):

  • 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 scores are not required if they are not appropriate for the client, but items may be used as informal probes. It is the clinician’s responsibility to document all accommodations and modifications made during the assessment process in all reporting of the client or patient.

Speech and Language Samples

Language sample analysis is a valuable part of an evaluation for both multilingual children and adults. 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. This assessment approach also enables clinicians to monitor and report progress of functional communication skills over time. For instance, clinicians can share information (a) with clients to show the gains they have made or (b) with payers to justify ongoing medical necessity and reimbursement for services.

The clinician obtains single-word and connected-speech (conversation or narrative) samples 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. Although a comparison of each of these areas across languages can be informative, skills across languages may not be easily comparable. For example, 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.

See also ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.

Dynamic Assessment

Dynamic assessment (DA) is another alternative to standardized testing. DA usually uses a test–teach–retest evaluation method to help identify a person’s current skills and their ability to learn and transfer learned concepts or skills (Kapantzoglou et al., 2012). A person’s inability to make modifications by learning a new skill may indicate a language disorder. Unlike standardized assessments, DA does not rely on monolingual norms and can provide a more accurate picture of a person’s language abilities (see, e.g., Laurie & Pesco, 2023).

Another approach in DA is graduated prompting, which uses a hierarchy of scripted prompts to get a sense of how much support a child needs for an accurate response (Gutiérrez-Clellen & Peña, 2001). Graduated prompting can be done in one session, so it is suitable for screening and assessment (Patterson et al., 2013).

See ASHA’s resource on dynamic assessment for more information. See also the Linguistic Diversity section of the Cultural and Linguistic Diversity (CLD) Evidence Map.

Treatment Considerations in Speech-Language Pathology

See the Treatment–Linguistic Diversity section of the Cultural and Linguistic Diversity (CLD) Evidence Map for pertinent scientific evidence, expert opinion, and client and care partner perspective.

The unique factors that inform the language of intervention are as follows (Goldstein & Fabiano, 2007):

  • 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 client uses each language (e.g., community, school, work)
  • family considerations and goals

For conditions not directly related to communication, such as swallowing and balance, clinicians use the client’s preferred language(s) based on home and work needs. This ensures cross-linguistic understanding and full participation in all aspects of service delivery.

Kohnert and Derr (2012) and Kohnert et al. (2005) proposed two approaches to providing intervention to multilingual children: the bilingual approach and the cross-linguistic approach. These approaches account for the nature of language (including phonological) development in multilingual children. Relative to pediatric populations, there is a paucity of research for intervention in bilingual adults.

The bilingual approach begins with goals in which one treats constructs common to both languages 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 goal is to determine initial treatment—not to determine language of intervention.

The cross-linguistic approach focuses on the linguistic skills unique to each language and addresses areas of need 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. SLPs might also use a cross-linguistic framework based on types of errors and/or error rates (Yavas & Goldstein, 1998). For instance, in Spanish–English bilingual children, final-consonant deletion is more common in their English than in their Spanish (Goldstein & Fabiano, 2007).

Treating targets common to both languages may be beneficial for some populations, such as bilingual children with developmental language disorder (Payesteh & Pham, 2022). Cognates are an example of targets common in both languages. Cognates are words in two languages that share similar form and meaning, such as “music” in English and “musique” in French. Clinicians may also be able to incorporate heritage languages into treatment by (a) providing carryover activities that can be conducted in multiple languages with families and care partners, (b) using multilingual materials, (c) labeling objects in the therapy space in multiple languages, (d) collaborating with family and community members to create multilingual resources and materials, and (e) learning key words in your clients’ heritage languages.



It is the audiologist’s responsibility to be mindful of how multilingualism impacts speech testing performance, which then impacts candidacy, expectations, and outcomes. The audiologist’s familiarity or comfort with multilingual patients must not interfere with the patient’s access to care, technology, or information.

Evaluating Speech Perception

A patient’s experience and exposure to the language used in testing significantly impacts audiologic findings, outcomes, and candidacy. Speech audiometry allows clinicians the opportunity to collect various pieces of information about how a patient detects, tolerates, and understands speech.

Speech audiometry that is collected to evaluate sensitivity and/or to cross-check pure-tone thresholds can be reliably gathered when sufficient instructions are given or while working with an interpreter. Speech audiometry, which evaluates how a person can understand speech, requires language-specific speech materials and an audiologist with the linguistic capacity to score the test.

When determining a plan for speech testing, an audiologist considers that speech materials are language specific; are grouped with items that are selected for familiarity, phonetic dissimilarity, and homogeneous audibility; and are representative of the language (Hudgins et al., 1947). Often, the audiologist providing services to the multilingual patient is not fluent in the patient’s preferred language. This creates a difficult problem of what type of speech testing can be performed and how the speech testing is to be administered, scored, and interpreted. A limited number of reliable tools and recommendations address this growing challenge. A lack of multilingual providers and researchers within the profession of audiology may be contributing to this challenge; however, this area of research could make a significant contribution to how providers meet the needs of diverse populations.

Patients benefit when audiologists are aware of alternative tests that can be used to meet the needs of multilingual communities. Digit pairs may be appropriate stimuli for speech recognition threshold testing in multilingual speakers of English. As with spondees, listeners must be familiar with this closed set of stimuli (Ramkissoon et al., 2002).

Self-report assessment tools can offer an opportunity to gather information on how an individual with hearing loss is functioning in everyday conditions and how hearing loss is impacting a person’s daily function. Questionnaires allow the provider to gather information about the patient’s perception of their hearing and to quantify perceived benefit from intervention. If appropriate, these can be translated into the language that the patient uses most or can be administered by working with an interpreter or a translator. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.

Special Considerations: School Settings

Multi-Tiered Systems of Support (MTSS) and Response to Intervention (RTI)

Multi-Tiered Systems of Support (MTSS) is a broad approach that includes Response to Intervention (RTI services that are provided to students who are struggling to meet grade-level expectations. This three-tiered approach focuses on universal screening, high-quality instruction, research-based interventions matched to individual student needs, and ongoing progress monitoring.

RTI informs decisions about general education, compensatory services, and special education services. An RTI process cannot be used to delay or deny an evaluation for eligibility under IDEA (see the U.S. Department of Education memo [PDF]).

Audiologists and SLPs may have integral roles in the RTI process. For example, audiologists may rely on work samples, observations in and out of the classroom, and reports from teachers and parents to understand how a multilingual student with hearing loss is functioning. The audiologist ensures that students have access to auditory information in learning and social environments. The audiologist also informs the student’s care partners about the hearing assistive technologies or environmental modifications provided to support them. The audiologist and the SLP will work with an interpreter and a translator to help inform care partners if needed. Adjustments are made to the environmental modifications and/or technologies based on the reports of how the student is functioning. The audiologist, the SLP, and teachers continue encouraging families to keep using their heritage languages.

SLPs may assist with administering screening measures and selecting and delivering targeted interventions to individual students to determine if their struggles are the result of a communication disorder or the process of dual language acquisition. It is important to identify students who can succeed with modified instructional supports and those who may need special education services.

For additional information on academic instruction for ELLs, see Effective Literacy and English Language Instruction for English Learners in the Elementary Grades and Helping English Language Learners Succeed with a Multi-Tiered System of Support (MTSS).

Common Core State Standards and Accommodations

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) [PDF] 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).

English Language Development Standards

To successfully participate in school, multilingual learners must simultaneously acquire English language competence and achieve academically across content areas according to ESSA. ESSA maintains the requirement (from the No Child Left Behind Act) to include accountability measures toward English language proficiency/development for multilingual learners and allows states to adjust their approach and implementation of those requirements to provide an equitable education for multilingual learners. For example, states who are members of the WIDA Consortium use WIDA’s English language development standards. Other states, such as California, New York, and Texas, have their own language proficiency/development standards. To learn more about your state, see Colorín Colorado’s ELL Resources by State.

Providers Who Speak More Than One Language

Multilingual service providers are audiologists, SLPs, and audiology assistants or SLPAs who use one or more languages in professional and/or clinical service delivery (ASHA, 2023a). In 2022, 8.3% of certified ASHA members identify themselves as multilingual service providers, reporting the ability to provide services across 86 spoken languages plus American Sign Language, other sign languages, and Manually Coded English (ASHA, 2023c).

See Multilingual Service Providers for detailed information about providing language-matched audiology and speech-language pathology services.

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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Multilingual Service Delivery in Audiology and Speech-Language Pathology page:

  • Mariam Abdelaziz, PhD, CCC-SLP
  • Raquel Anderson, PhD, CCC-SLP
  • Lauren Calandruccio, PhD, CCC-A
  • José Centeno, PhD, CCC-SLP
  • Myriam De La Asuncion, AuD, CCC-A
  • Maria Diana Gonzales, PhD, CCC-SLP
  • Mark Guiberson, PhD, CCC-SLP
  • Henriette Langdon, EdD, CCC-SLP
  • Nihdi Mahendra, PhD, CCC-SLP
  • Ishara Ramkissoon, PhD, CCC-A
  • Luis F. Riquelme, PhD, CCC-SLP, BCS-S
  • Celeste Roseberry-McKibbin, PhD, CCC-SLP
  • Melissa White, MA, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Multilingual service delivery in audiology and speech-language pathology [Practice Portal].

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.

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