Section Five

Module 21: Multi-Lingual and Cross-Lingual Communication Care

  • Which dialects of which languages do we need, and how should we use them?

  • After working with the material in this module, readers will be able to

    • select

Drawing on a range of multi-lingual and cross-lingual practices helps us provide every client with high-quality, individualized, and linguistically appropriate communication care that meets all their needs.

Be sure you understand the distinctions between “multi-” situations and “cross-” situations, and the constructs of universal needs and specific needs, from Module 15, before you try to read this module.

Multi-lingual, cross-lingual, bilingual, multi-dialectal, cross-dialectal, and all similar variations on communication care are often discussed as complex specialty areas suitable only for specific professionals with certain types of expertise. This assumption is reasonable, in part; there are definitely some situations that require specific expertise! Knowing certain languages, being familiar with specific materials, or having extensive experience working in two or more certain languages at once are all distinctly special and important abilities.

As we have emphasized throughout this website, however, we are not here to divide between “normal” communication care and “multi-lingual” communication care. None of your clients are so different from you that the only solution is to refer them to someone else, and none of them are so different from you that you must abandon all your “normal” clinical routines to use only “different” clinical routines. Yes, of course, there are details to know, but you are a speech, language, and communication professional! You already have most of the knowledge, skills, and abilities that you need to work successfully with all clients, regardless of which dialects of which languages you know or they know. And you are more than capable of learning the rest.

Instead of focusing on the “complexities” of working with interpreters, therefore, or getting ourselves too bogged down in “which language to use,” “which dialect to teach,” or questions about categorizing people as “simultaneous” versus “sequential” language learners, let’s start with our basic principles of being kind, accepting, supportive, and client-centered. Let’s remember that multi-lingual is a continuum and that most of us are multi-lingual to some degree. Our basic question, in this context, is simply how to create linguistically appropriate, multi-lingual and cross-lingual clinical services with and for all clients, including those that you might say use dialects or languages other than your own.

How can we do that?

Universal Approaches from Multi-Lingual and Multi-Modal Language Teaching

Start by thinking about truly multi-lingual speech and language learning situations, or language teaching designed for a group whose members have no language in common with each other or with the instructor. Have you ever been in such a situation?

One of my first such experiences occurred more than 40 years ago, when I was a student in community Norwegian classes in Norway. Because of the immigration patterns associated with the oil industry at the time, many of the people in my class were speakers of Arabic, Russian, Turkish, and other languages. Our teacher spoke some English, but she did not know all the group members’ other languages — and she did not need to know them, which is the larger point here, even though we as a group had no language in common other than the rudimentary Norwegian that we were beginning to learn.

Much more recently, I worked for a couple years, and I currently volunteer, in very similar kinds of classrooms: English-language classes for adults here in the U.S. Many of our learners speak Spanish, which our instructors also speak fairly well. But many of our learners speak Haitian Creole, Portuguese, Russian, Mandarin, Cantonese, Korean, or other languages that their fellow students do not know — and that their instructors do not know.

How do language instructors manage these situations, and what can we learn from them as we think about multi-lingual and cross-lingual speech-language pathology?

The primary answer is that they create classrooms that are happy, welcoming to every individual, communicatively redundant, designed to support the task of language learning, designed to support the people who are the language learners, and therefore effective and efficient with the task of helping people learn another language. Many language teachers have long done so by drawing on techniques that are now referred to as translanguaging (García et al., 2017, Vogel & García, 2017) and by combining a wide range of other teaching strategies, as summarized in Box 21.1.

Even if you will never serve as a language teacher for a large and multi-lingual group, try reading the ideas in Box 21.1 with the same mindset we used when we discussed culturally appropriate clinical methods: Some ideas that were developed for “multi-” situations or developed from a universal orientation turn out to be very useful both in “multi-” situations and also in the individualized “cross-” situations that tend to be more common as we work with individual clients.

Box 21.1. Common Strategies for Communication and Instruction in Multi-Lingual or Language-Universal Group Language Instruction,* to Read as Possibilities for Use in Multi-Lingual, Multi-Dialectal, Cross-Lingual, and Cross-Dialectal Communication Care Situations.

  • Use redundant multimodal expression, including print, pictures, and props.

  • Use emotion, facial expression, and gesture.

  • Provide context, content, and conclusions.

  • Mirror individual and group facial expressions, movements, and physical energy levels.

  • Use multiple repetitions of multiple examples.

  • Use silence.

  • Use small groups.

  • Use technologies.

  • Accept everything learners know, and use everything learners know.

  • Encourage learners to use everything they know, whether you know it or not.  

  • Remember why we are here.

*See the Oxford series of language instruction handbooks, especially Davies & Pierce, 2000, or Richards & Rodgers, 2010.

Do many of the ideas in Box 21.1 feel familiar? They should! You use and experience all of them, in many kinds of situations. “Use redundant multimodal expression,” for example, is why most presenters who are speaking to a group also show slides or provide a printed handout, in addition to speaking, and why bookcase-assembly instructions include both words and pictures. People in all situations also communicate with, and teach with, emotions, facial expressions, gestures, and props, not merely by standing and reciting words; taken only a step further, the same ideas become the use of theatre in language-learning classrooms.

You provide context, content, and then conclusions when you start any session or lesson by helping learners understand what the topic is and recognize their current knowledge about that topic before you introduce the new material. Effective clinicians and teachers across all disciplines also work to recognize and mirror facial expressions and other movements, and to attach communicative content and then language-specific forms to those expressions.

Within the inclusive, responsive, and intentionally diverse contexts these efforts create, we teach all learners by exposing them to many examples, including through individual, small-group, and whole-group work. Small groups activate the expertise of the whole group, by allowing interactions between group members that might not occur if the instructor attempted to control all interactions. Small-group and individual practice also help with allowing learners the time and space they need to create new connections for themselves, both metaphorically and neurophysiologically; remember that learning to produce language requires being given the tools and the time to work on producing language.

These notions also all blend into the ideas from the final set of suggestions in Box 21.1: use what people know, accept what people know, encourage learners to use everything they know, and remember why we are here. No one instructor can possibly know all the backgrounds, contexts, hints, explanations, and understandings that every learner brings or that the entire group brings. Effective multi-lingual (and cross-lingual) instruction uses this variety as we help people learn.

More specifically, most teachers in most multi-lingual learning situations use the wide variety of abilities that any multi-lingual or multi-dialectal group brings as they help students learn to use the language they are learning in the way that they will use it. This version of “remember why we are here” includes understanding that a person who knows one or more languages already and is working on learning another one will obviously never become a monolingual user of the later language; they will always use their plural languages in ways that will be influenced by their language history, their life history, and their current and unfolding circumstances.

As obvious as this acknowledgment of other people’s autonomy and experiences might sound, world-language teaching has traditionally wrestled with many questions related to this idea that might also sound familiar to you from our own profession. Are we teaching from a monolingual assumption, and teaching toward a monolingual ideal, somehow expecting that multi-lingual language users should sound and think the same way monolingual users do? Or are we teaching for intelligibility, comprehensibility, and functional use of a language, fully accepting and even relishing the ways each learner will make it her own?

One simple answer to all of these debates, once we have allowed that everyone is living their own life’s journey, involves recognizing that multi-lingual and multi-dialectal language teaching and language learning are always additive, interactive, individual, and dynamic, because people are additive, interactive, individual, and dynamic. From this point of view, the language teacher’s goal could not possibly be to turn the language learners into “mini-me” versions of the teacher; the goal must be to help each language learner learn to use their new language in the way that they will use it. Equally, it makes all the sense in the world to use any languages a learner already knows as one of many teaching strategies; carefully planned immersive language-learning experiences are enjoyable and effective, but refusing to make information available to learners in a form that they can access is not teaching (and makes very little sense, if we stand back and think about it; I fully recognize the higher-level complexities that characterize these issues, but, at a basic level, the point is that if you try to explain something to me in a language I do not know then I probably will not understand).

Did you see the many parallels and direct applications to all the situations you might encounter during group and individual communication care clinical services, as you were reading these ideas about teaching world languages to multi-lingual groups of learners? Did you also recognize that you already use most of the suggestions from Box 21.1 with everyone from preschool AAC clients to adults with aphasia? To be clear, in case this needs to be said, I do not mean to be implying in any way that language learners are childish; or that they have problems, disorders, or conditions; or that language teaching or language learning should be approached as therapy; or that therapy and teaching can be perfectly equated. At the same time, however, all variations on changing how a person knows and uses any one or more languages will always include some similar needs and some similar strategies, simply because all versions of learning and teaching for speech, language, and communication do have some things in common.

Whether you ever have or ever will teach a new language to a multi-lingual group of learners, in other words, the point of Box 21.1 is that you do have lots of multi-lingual and multi-modal expertise already — all of which you can draw on as you think about the multi-lingual situations you will encounter and also, perhaps more importantly, as you think about the many cross-linguistic therapeutic bridges you will build to your many individual clients.

Your Turn

Imagine working with a single older client who has aphasia, dysarthria, and dysphagia. Describe how you could use each of the possibilities listed in Box 21.1 as you communicate with, support, and teach the client and the family in each of the following scenarios, including the first one. (You might have an interpreter with you for the second client, and you should have an interpreter with you for the third client. For the purposes of this question, though, think beyond expecting the interpreter to communicate with your client for you. What else could you be doing, based on the ideas in Box 21.1, to enhance your multi-modal or multi-lingual communication and to support your efforts to help the people described in these three scenarios to learn whatever they are seeking to learn?)

  • You, the client, and her immediate family members all speak, understand, read, and write similar dialects of the same language.

  • You, the client, and her adult children all speak, understand, read, and write both English and Spanish, to varying degrees. English is your native and preferred language, and you describe your Spanish skills as those of an intermediate-to-advanced learner. The client prefers Spanish. The adult children communicate with their mother in Spanish, use a dynamic mix of blended Spanish and English with each other, and communicate with many other friends and colleagues in English.

  • You know English and also know bits of French, Spanish, and Italian. The client speaks primarily Korean, also knows some English and some French, and prefers Korean. The client and her adult children communicate with each other in Korean. In other settings, the adult children are equally proficient and equally comfortable in English and Korean. The adult children learned some French when the family lived in Quebec when they were young and remember bits of what they describe as happily childish French. The entire family remembers their time living in Quebec fondly.

One common occurrence in multi-lingual group classrooms, and in the associated hallways and cafeterias, is that learners may speak to each other in languages that instructors and other staff members do not know. Use the strategies summarized in Box 21.1 and the discussion in this section to imagine a range of supportive, human-centered, learner-centered extensions of this situation. (Why do you think some people get so upset when they overhear students or colleagues conversing in a language they do not know?)

The International Board on Books for Young People has provided these suggestions for sharing a wordless picturebook in a group that has no common language. What tips about working in multi-lingual communication care situations can you draw from these ideas?

Explore Marrero-Colón’s (2021) discussion of everything translanguaging might mean. How can these ideas help you in your communication-care practice with clients and colleagues who know more than one language?

Collaborating with Interpreters to Provide Cross-Lingual Communication Care

Let’s move now from thinking about multi-lingual situations with groups to thinking about cross-lingual situations with individuals. How do we build appropriate cross-cultural, cross-identity, and cross-linguistic therapeutic bridges to communicate with another person if their languages differ from ours?

There are lots of ways, and one of the best answers is that we connect with them as human beings, using our many bridge-building ideas from Module 19 and using the many multi-modal communication ideas from Box 21.1.

Another specific possibility involves working with professional interpreters, professional translators, and/or translated materials. Make sure you understand the classic terminology in Box 21.2, and then we can think about working with interpreters, working with translated materials, working with translators, and the many exciting technologies that are blurring the classic lines between interpretation and translation.

Box 21.2. Classic Terminology for Interpretation and Translation

  • Interpretation refers to changing spoken or signed language into another spoken or signed language in approximately “real time,” or as that language is being produced.

    Simultaneous interpretation or continuous interpretation means that the original speaker or signer does not stop. The interpreter hears the speaker’s message, understands it, reformulates it in the target language, and produces it in the target language, while also continuing to listen to whatever the speaker said next (and is now saying). The defining feature of simultaneous or continuous interpretation, therefore, is that the interpreter continuously converts the speaker’s message into the new language as the primary communicator continues to talk or sign (with the interpreter consistently a few words behind the original speaker, to allow for the interpreter’s processing and production time). An ASL interpreter during an uninterrupted public speech performs simultaneous interpretation, and the delegates at a U.N. meeting each listening on a headset to an interpretation of the speaker they are watching are experiencing simultaneous interpretation.

    Consecutive interpretation means that the original speaker or signer communicates in separated phrases or sentences, stopping after each segment to allow interpretation of that segment. Consecutive interpretation can include the exchange of single brief utterances, for which one complete conversational exchange takes four steps: Speaker 1 in Language 1, then Interpreter in Language 2, then Speaker 2 in Language 2, and then Interpreter in Language 1. Consecutive interpretation also occurs during extended presentations, explanations, or conversations with longer conversational turns; in these situations, the speaker produces somewhere between a phrase and a couple sentences, pauses to allow the interpreter to repeat, and then produces their next segment, with this process repeated a few times before the second primary member of the conversation answers. Consecutive interpretation for conversations might involve three people (the two primary communicators with one interpreter), or it might involve four people (the two primary communicators plus two interpreters, both of whom know both languages and each of whom speaks or signs for only one of the two primary communicators).

  • Translation refers to converting printed texts or other existing materials from one language to another, where both the original material and the resulting new material are permanent (written or recorded).

    Translation is assumed to occur off line and assumed to take time; the author of the original material and the receiver of the translated material are separated in time and space, not interacting directly. Examples of translation include starting with a book in French and creating a version of that book in Japanese, starting with a book in Korean and creating a video of that book in ASL, or starting with a video of someone telling a story in a spoken language that does not have a written form and creating a version of that story in written English.

  • Sight translation means converting from written language to spoken or signed language in real time. An interpreter or translator who is handed a document written in Language 1 and asked to “read it to” or “read it for” a person who needs Language 2 is performing sight translation. (The parallel with “sight reading” in music is intentional and meaningful, if you are familiar with sight reading. Sight translation is assumed to be less accurate and less nuanced than true off-line translation.)

Collaborating with Interpreters: Preliminary Considerations

Among the first things to know about collaborating with interpreters in clinical practice might be that they are wonderful colleagues and that you probably need more of them.

If you and the client cannot communicate easily about everything you need to communicate about, and if the challenges are related to the languages you are using (versus being solely related to the client’s communication disorder or cognitive abilities), work with an interpreter. If the client depends on a parent, spouse, guardian, or other caregiver, and if you cannot communicate easily with that person about everything you need to communicate about, work with an interpreter. As we have addressed in Module 4 and elsewhere, language access and language equity are required parts of our practice, for all clients. Think of having interpreters with you as a basic requirement, not as a special extra, until you are sure that you do not need them.

At the same time, be aware that “working with an interpreter” is another example of our principle that everything falls along a continuum. Working with an interpreter does not mean that every interaction you have with a client or a guardian/caregiver must necessarily always be only through the interpreter. Depending on the client’s language knowledge and preferences, the family’s, and your own, your professional collaboration with the interpreter will include that you will decide together which sessions or interactions require their presence and which do not (as we will address in more detail below).

Notice, also, that the interpreters you work with in your clinical settings should be trained professional people. The interpreter might be physically present in the room with you or might join you through a videoconference interpretation service, but your interpreters need to be real, live, trained and engaged human beings. We do not depend solely on machine translations, phone interpretation apps, or any such non-human electronics (more about this below, too). In addition, we cannot depend solely on the client’s family members or the other people who happen to work in schools or hospitals to serve as interpreters. Think of interpreters as among your professional colleagues, parallel in every way to the physical therapists, the CNAs, the mathematics coaches, and all the other experts who create the team of professionals at your hospital, clinic, or school. (It might be possible for a parent to lead a third-grade classroom for a moment, but we do not routinely expect parents or school-cafeteria employees to manage third-grade classrooms. The same principle holds for trained interpreters.)

Another key to working with interpreters involves approaching each clinical interaction as a collaborative task. Collaboration means that each person brings unique and necessary skills to the interaction, and the people involved then create something new and better than any of them could have created on their own. (Collaboration is more active and more creative than mere cooperation.)

  • An interpreted communication care session is a communication care session. As ASHA’s materials emphasize, your role is to be the communication therapist. You bring the expertise about disorders of speech, language, voice, and communication and about how to ameliorate the effects of disorders, and you will be largely in charge of the fundamental content, goals, shape, and timing of the session. You will complete all the documentation about the session (potentially with input from the interpreter).

  • The interpreter brings expertise about the two or more languages being used or taught in the session, expertise about moving between those particular languages, and expertise about the cultures that use those languages. The interpreter will work from their expertise about language form and use, allowing you and the client to exchange information and facilitating your attempts to help the client meet certain goals in linguistically and culturally appropriate ways. The interpreter might also take on the role of explaining the client’s communication abilities to you, perhaps by identifying pronunciation errors, syntax errors, or semantic errors that you do not have any other way of recognizing.

  • The client and family bring their abilities, needs, and expertise as the recipients of care and as the users of the language(s) they use, and they should be granted both the right to serve fully in those roles and also the right to not be expected to fulfill any other roles. We do not allow some clients the right to engage fully in making their own informed decisions about their own care (because we happen to know the same languages they know) and then make decisions for other clients to avoid potentially complex interpreted conversations. Similarly, we do not allow some clients to serve as the learner while we expect other clients to serve both as the learner and also as our language tutor. Asking clients or families about their culture, their family, their language use, and their needs is necessary; clients and families are the experts on their own lives, and we need to take the time to understand. Clients and families can also be excellent cultural brokers or language brokers for us, if they want to spend their time and energy explaining to us. The key is that the expectations we place on clients should be shaped by their needs, abilities, and desires, not shaped by the fact that we happen not to speak the languages they do. Clients should contribute essentially the same elements to their interpreted sessions that they would contribute if you did not need an interpreter, and they should be allowed to focus on their needs and their learning, not ours.

Collaborating with Interpreters: The BID Protocol

Interpreters are trained to expect and to use a “BID” protocol, referring to a three-step process that includes a pre-session Briefing, the Interaction itself, and a Debriefing. It’s a good system, and there are multiple materials available to help you understand each step.

To use the BID protocol, you and the interpreter will start your collaboration with a pre-session Briefing, during which you will discuss the overall shape of the session and provide each other with the information you both need. You will tell the interpreter about the client’s background and current abilities, share the content and the goals of the session, and share any specific vocabulary that will be critical to the session. You should also share any printed materials that you will be using with the interpreter ahead of the session (after having carefully selected your materials to be appropriate for this client and making sure that you will not be asking your interpreter to serve as a sight translator for you; see much more about these issues below).

Medical and educational interpreters tend to be familiar with the idea that our speech-language and communication-care clients will make errors; establish ahead of time how you would like the interpreter to transmit, ignore, or otherwise manage those errors. (During an intake interview about their medical history, for example, the fact that a client mispronounces a word is less important than the message they are trying to convey. During an articulation test or phonology learning session, however, the focus will be on the client’s specific productions of specific phonemes.) The interpreter will share with you any cultural- or language-specific knowledge they might have that could influence your session, help you learn to pronounce the client’s names correctly, teach you a couple greetings or politeness phrases in the client’s language, and tell you about their preferences for consecutive versus simultaneous interpretation. You both might also want to be sure you have access to materials such as comparative phonemic inventories for the two languages, if relevant.

  • Most interpretations between two spoken languages will use consecutive interpretation, and many interpretations between one signed language and one spoken language will use simultaneous interpretation. Check this detail with your interpreter during your Briefing, so you are both expecting the same thing for the session.

  • Your Briefing need not be long, especially as you develop an ongoing relationship with an interpreter. It’s not a complete case presentation. But take at least a minute: “Mrs. Herrero Díaz is 74 years old and was admitted last night after a left CVA. The nursing notes from overnight say that she has lived here in Wichita since 2002, she worked as an accountant, she speaks Mexican Spanish, and her speech is very limited. I’m suspecting aphasia and dysarthria, and I’m primarily concerned this morning with her swallowing safety. Are you familiar with dysphagia terminology, for talking about thickened liquids or a modified barium swallow study?”

During the pre-session Briefing, you and the interpreter will also work together to establish some basic plans about how to approach your session goals. In most situations, you will introduce the task to the client, give the instructions, control any pictures or other stimuli, give the client feedback or explanations about their performance, and provide any reinforcers or follow-ups. The interpreter will repeat your message for the client and repeat the client’s message for you. If you also need the interpreter to help you understand any errors the client is making, make a plan ahead of time for how this will be achieved. Recording and talking about it later is often the best strategy; your plan should minimize the amount of time that the client will be sitting waiting while you and the interpreter talk to each other about their abilities. (Again: The client’s experience during an interpreted session should be approximately the same as the experience of a client during a session conducted without an interpreter, if at all possible; most clients do not spend time during their communication care sessions waiting while two other people talk about them.)

Next, during the Interaction itself, you will look at and speak to the client (or family member). Arrange the people (and the potential computer or electronic tablet) in a triangle or a circle so everyone can see everyone. (If that is somehow not possible, sit or stand next to the interpreter or the iPad, so the client can easily see both of you.) Try to speak as you would to any other client, except where specific changes need to be made because of the interpreting situation.

  • Look at and speak to the client, who is the person you are speaking to. Watch the client while you are speaking, because they are the one you are speaking to; address them directly, using the same phrasing you would use to give information, instructions, or feedback to any other client. Watch the the client while the interpreter is speaking, to gather nonverbal cues from the client about their understanding. Watch the client while they are speaking, to observe the motoric and other elements of their language production, and even watch the client while the interpreter is repeating to you in your language. The client will probably look back and forth between you and the interpreter, which is completely fine

  • Use as little technical jargon as possible, and use a slightly slow speech rate if you are conveying complex information (just as you might with any other client).

  • If you are using consecutive interpretation between two spoken languages, divide your talking into short utterances, and pause after each utterance to allow the interpreter to repeat what you have said to the client in their language. This aspect is the primary difference between interpreted conversations and monolingual conversations, and it often means thinking of your conversational turn as requiring you to speak, wait, speak, wait, speak, and wait several times.

  • Do not interrupt either the client or the interpreter. Regardless of whether the conversational turn is changing, wait for the interpreter to finish before you speak again, even if you understood the client’s response as they spoke or signed it.

  • If you are using simultaneous interpretation between a signed language and a spoken language, you need not divide your speech into separate utterances, but do be aware of how long you have been speaking. Take a brief pause every so often to ensure that the interpreter is not too far behind you.

  • Assume and remember that the interpreter’s role is (and is only) to interpret everything you say and everything the client says. Avoid making any side comments to yourself or to the interpreter that you do not wish to be interpreted for the client, and do not ask the interpreter to summarize or to explain. Most professional interpreters will not engage in side conversations with you or with the client during the session; if it does occur, remind everyone kindly that “all three of us need to understand everything.” (One exception: The interpreter and the client will probably chat a bit in their shared language as they are being introduced or during any down-time before or after the session. That’s not a problem at all; that’s part of their building the relationship that they need. The interpreter’s professional training includes how to keep these exchanges brief and then return the client’s focus to you.)

  • If you are providing information or instructions, use lots of teach-back, and accept the responsibility for the client’s understanding (or misunderstanding). Ask the client, “Can you explain that in your own way, so I can be sure I explained it well enough?”

  • Depending on your knowledge and the client’s knowledge, end the session by discussing whether the interpreter will be needed for the next session. At this stage, you might engage in a true three-person conversation, drawing on the interpreter’s opinions and expertise. Be especially aware, also, if you do raise this question, to ask with humility, kindness, and genuine client-centered curiosity; the message should never be “Well, that was expensive, you can get by without an interpreter next time, can’t you?” or “That was slow and awkward, I would rather not have to deal with an interpreter next time.” For some clients, however, you will be able to use their abilities, your abilities in their preferred languages, ideas from Box 21.1, their family and friends, and the technologies we will address below to be able to conduct outstanding clinical sessions without an interpreter, especially for treatment sessions after your clinical routines have been established. Do not raise the question at all if it is obvious that you and this client will continue to need an interpreter.

After the session, engage in at least a short Debriefing with the interpreter. This is your chance to talk about any impressions either of you had about the client’s understanding, ask the interpreter what you should do differently next time to make their job easier and to improve the services you can provide for future clients, and make any specific plans for follow-up that you might need (such as hiring the interpreter again separately to transcribe a language sample for you or to assist you with identifying the client’s speech or language errors or goals). The interpreter might also share their insights about decisions they had to make as they interpreted the client’s speech, language, or errors for you.

Does this all sound like a lot of work? It might be, but please allow me to emphasize again that our goal is not to approach clients who differ from us as if they were “more difficult” or as if we needed to focus on “navigating the complexities.” You are probably already familiar with collaborating with classroom teachers, physical therapists, family members, your speech-language supervisors, or your student-clinicians or interns. You might already routinely use small-group therapy sessions that require you to plan ahead and then to simultaneously manage several people’s abilities, needs, and contributions during a session. Collaborating with an interpreter is simply another version of these familiar variations. You are a speech-language communication care professional. You have the skills required to plan and to manage collaborative 3-person sessions.

And by the way: I have consistently found working with both ASL interpreters and spoken-language interpreters to be genuinely fun! We tend to have shared interests and shared goals that focus on languages, people, and communication. If your work setting uses real human interpreters who are physically present, they will probably become some of your favorite colleagues — and if your setting uses an online interpreter service, the people you will meet electronically on those systems will be experts at their job, usually with substantial experience and with positive, useful expertise about how to help people understand each other, which is their primary interest and their primary goal. Working with interpreters is a wonderful way to work, in other words — and it helps clients, which in another sense is really all that matters.

Your Turn

Do you recognize that you think of interpreted communications as intimidating, fun, tedious, scary, linguistically fascinating, or in some other emotional way? What about your life’s journey so far has led you to the assumptions you hold about interpreted communications? Would a 16 Questions matrix about interpreted communications lead you to any interesting recognitions about yourself? (Try imagining your client’s answers to a 16 Questions matrix about interpreted communication therapy sessions, or even use the 16 Questions matrix as a basis for a discussion with your client!)

Think again about the clients with aphasia, dysarthria, and dysphagia from the previous Your Turn questions. How could you collaborate with interpreters to provide them with the best possible care? What would the pre-session Briefing need to include, how might the Interaction proceed, and what would you want to Debrief with the interpreter afterward?

Are interpreters common in your work setting? If not, they probably need to be. If so, you might need even more of them or might be able to work with them in different ways. Would any of the following be appropriate new steps or changes for you, given where you are in your journey and given the details of your work setting?

  • As one of your basic questions during your job-search process, ask about how interpreters and translators are identified and included in this workplace.

  • When you write job advertisements to recruit new clinicians, highlight the routine presence of multiple trained interpreters as a feature of your workplace.

  • Ask that training about how interpreters and translators are scheduled and paid in this facility should be part of your onboarding training in your new position.

  • Include training about how to schedule, work with, and bill for the interpreters in your setting as a routine part of the onboarding training you provide to all new employees.

  • Ensure that ongoing education and professional-needs analyses about interpreters are a routine part of your department’s meeting agendas.

  • Provide routine in-service education to the other professionals in your setting (e.g., teachers or nurses), sharing your group’s expertise about working with interpreters.

  • Ask the interpreters in your setting about their suggestions for improving communication access in your building or facility.

One implication of the fact that interpreters are professionals is that they are paid for their expertise and for their services and are only expected to interpret while they are on the clock and are being paid. All institutions, facilities, school districts, and private practices must assume and plan for this expense. If you bill for your services as a practitioner, be sure you understand the details of how to bill for interpreters’ services in your state.

Many large hospital systems and interpreting businesses have posted some fun and informative internet videos about interpreting that you might enjoy. Try this explanation (I would break up the practitioner’s utterances a bit more, into shorter pieces), this summary and tips, or this (entertaining!) set of counterexamples and good examples.

If the population in your geographic area is such that you work with many clients and families who speak a language you do not know, and if you consider yourself to be a language and communication professional, how long is it reasonable for you to not learn that language? I realized much too late, after I had worked for many years with my amazing colleagues who communicated in ASL, that I could have spent those years learning much more ASL than I learned. I should have. I am currently working in a setting with many Spanish speakers, and I am actively (slowly, because my brain is old, but actively!) working to learn more Spanish. Remember that your journey through your life is ongoing, your career will span decades, and your skills should be continuing to expand. The fact that you need an interpreter today should not imply that you will need the same interpreter 3 or 5 or 10 years from now.

Translated Materials in Cross-Linguistic Clinical Practice

Professional translation, like professional interpretation, is a multifaceted discipline of its own. People who translate novels or adapt songs make a wide range of linguistic, artistic, and even personal decisions, and medical translation, legal translation, and many other pursuits represent their own specialty areas. I used the parallel of asking a parent to cover a third-grade classroom earlier, to explain why we do not ask a person to perform the professional task of serving as an interpreter if their primary qualification is that they happen to be physically present. For translation, the metaphor might be even more serious: We would never send a third-grade history textbook from Thailand to a random parent in Omaha and ask them to translate it into English so it can then be distributed for use as the history textbook for all third-graders in the U.S.

How, then, do we correctly get something translated, so we can use it correctly in our clinical work?

One answer, interestingly, is that we shouldn’t and we don’t!

Let’s think chronologically through several situations involving — or potentially involving — translated materials. Remember that you will probably have an interpreter with you, in many of these situations; if the client needs translated written materials, they often (but not necessarily) also need you to be collaborating with an interpreter for your conversations.

Providing Routine Business Operations Information

One of your first needs with many clients might be to provide them with scheduling and billing information, privacy-rights information, and similar written healthcare-operations or district-policy information in their preferred language. In most school systems, hospital networks, or other large practices, a higher level of the organization or district office will have already made this material easily available in the languages that are likely to be necessary in your community, because we are required to provide such material to all clients in their preferred languages. If you find yourself working with a client or a family that needs this sort of routine information in another language, my best advice is to assume that your managers know that this is an enterprise-level necessity; you should be able to simply pull or ask for a copy in whatever language you need.

If that turns out not to be true in your setting (perhaps because your very small practice is not required to follow lingustic access laws), then you will need to hire a professional to create a translated copy (just as you have hired a professional to serve as your spoken-language interpreter). One option is through the American Translators Association.

Seeking Translated Assessment Materials — Or, Getting Out of This Box!

Your next need, chronologically, might be some printed assessment materials in the client’s language or languages, a situation that could not be more different from the first one. In the case of billing practices, the content of the information is the same for all clients, and the reason you need it translated is so you can give the same material to every client. In clinical assessment, however, we start from the client’s abilities and needs, not from our own requirements or routines.

If we find ourselves asking “How do I get this test translated?” or “Where is the translated version of this assessment protocol?”, then, we might actually need to stop, back up, and ask a different question. The need for a translated version of a test might have emerged not because of the client’s abilities and needs but because I started my thinking with a text or material that is in the wrong language for the client. I would never, as a primarily-English-speaking clinician working with a primarily-English-speaking client, start with a language test that was developed in Russian and then try get it translated so I could use it in English. Equally, I do not, can not, and must not, as a primarily-English-speaking clinician working with a primarily-German-speaking or primarily-Korean speaking client, start with a phonology test that was developed in English and then try to get it translated to German or Korean. For assessment materials, in particular, the linguistic issues and the cultural issues are both obvious. Linguistically, the relevant phonemes are different, the relevant morphemes are different, the relevant syntactic requirements are different; everything about the languages differs. It is worse than meaningless to take “house” from the first page of an English articulation test, “translate” it to “casa,” ask a Spanish-speaking child to say it, and then somehow try to score that item as a measure of word-initial /h/ and word-final /s/.

What do we do instead? Explore Box 21.3.

Box 21.3. Alternative Thoughts, Questions, and Options, or How to Get Out of the Box Labeled “I Need a Translated Version of This Text or Material”

  • Do I need a translated version of this material, or do I need other information about the structure and mutual influence of my client’s two or more languages, to support my use of informal assessments or spontaneous language therapies?

  • Why did I start my thought process with a document that is in the wrong language for this client? I need to approach their needs by starting with their abilities.

you see the basic point, here? Sometimes you will want and need a translated version of a written document. Good examples include privacy practices information for all clients that your hospital probably wrote originally in English, information about billing and financial responsibilities for all clients, and clinical materials that will meet a client’s specific needs or abilities. Sometimes, however, our percieved “need” for a translated version of assessment materials or clinical materials reflects our own clinical habits (“I like the ABC Test, so let’s start there”) instead of reflecting our clients’ needs. The answer to “I need a translated version of this material” might often be “Wait. No, I don’t. I need to start my entire clinical thought process with activities and materials that are meaningful to this client.”

Clinical Care with Materials in Multiple Languages, with Materials in Languages You Do Not Know, with Translated Materials, and with Universal Materials

That said: You will, yes, often need to work with materials in languages other than your primary languages. Cross-lingual clinical care means working with clients who use a single language that differs from your single language, clients who use two languages that you do not know, clients with whom you share two but not all three languages, and many other variations. Our goal is to provide them with all the written materials they need in all their languages.

 

 

Your Turn

Translation is a major topic of interest for multi-national business. Try exploring resources like this post about sales software for international businesses, this post about creating educational software with a global mindset, or this post about how the Heineken brand approached global sports advertising. Their overall goal of making more money from more customers differs from our overall goal of helping clients and families, but what do you see that they are doing right, as they seek to make sure that all their potential customers undertand their message?

Using Interpretation and Translation Technologies

Did you happen to notice that our discussions so far have almost completely skipped over the idea of using technologies in multi-lingual and cross-lingual communication, which was listed as a possibility in Box 21.1? I did that on purpose, but let’s return to the idea now, using the information about human interpreters, translators, and translated or universal materials we have just discussed.

First, obviously, multi-modal, multi-lingual, and cross-lingual technologies are amazing, useful, and include a wide range of options.

Think back to the multi-lingual language-learning situations from the beginning of this module. Technologies allow teachers in this sort of setting to quickly search online during class for a word or a phrase in the target language that students are not understanding and show them several pictures of it. In the opposite direction, teachers can search online for words from students’ languages that students are using, find the translation in the teacher’s language, and use that information to structure lessons based on the students’ interests. Students next to each other in a language-learning classroom can complete the same language-learning lesson on the same language-learning software while each receiving automatic feedback and explanations in their different native languages. Most of us have gotten used to using Google Translate and other companies’ similar tools, at least while traveling (or, for those of us who happen to work in ESL/ESOL programs, to help students understand details or complexities). Software of various sorts provides us with instant translations of printed written materials, captions for TV shows and videos in the language we want, and webpages that almost magically appear to have been written in the language we want.

Most recently, technological possibilities have expanded these options in fascinating ways that are actually changing our presumptions and definitions about interpreting spoken language versus translating written language. We emphasized above that interpreting has classically been referred to as related to live spoken or signed language, whereas translation has classically referred to texts (or videos of non-written languages). Current technologies in our phones, however, have created some wonderful and useful variations that did not exist only a few years ago.

It has become routine in the ESL/ESOL program where I am currently working, for example, for phone-assisted conversations to consist of one person speaking in Language 1, the phone creating a speech-to-text transcription and then an instant machine-generated sight translation of that text, and the other person then reading Speaker 1’s written message but in Language 2. Alternatively, one person can type in Language 1 and then, after only the briefest of pauses for some technological magic to be completed, the other person hears the message aloud in Language 2 (i.e., machine-generated sight translation followed by text-to-speech conversion). Apple’s “Live Translation” feature combines speech-to-text transliteration, text-to-speech conversion, and machine translation from one written language to another in ways that allow all possible combinations between two conversational partners speaking, reading, and/or listening in either or both of their two languages, if both conversational partners have the necessary hardware and software. The resulting conversation is intended to feel almost like simultaneous interpretation (if both people are listening), and it actually involves fascinating behind-the-scenes and visible combinations of languages and technologies.

If your daily life includes primarily monolingual English-language conversations, in fact, you might be surprised by how often and how expertly many people in the U.S. routinely use interpretation and translation technologies to communicate. (Remember those 20% of people in the U.S. who use languages other than English?) Conversations conducted through Google Translate or Apple’s equivalents are a bit slower than unimodal, unilingual conversations, and they may require a bit more patience on both people’s parts, but the technology is there and serves many wonderful purposes for many people, both in language-learning classrooms and in day-to-day life.

Can we adapt these technological possibilities into our communication care clinical sessions? Yes, we can, and we should — but also no, we cannot depend on technologies instead of collaborating with human interpreters and translators. There are several special and intertwined details here, related to professional ethics, legal requirements and regulations, accuracy of materials, and clients’ privacy rights.

Let’s start with the bad news: there are several ethical concerns, legal limits, and related specific prohibitions that affect our use of automatic technologies for interpretation and translation in our clinical work.

Concerns and Prohibitions with Cross-Lingual Technologies

Two of the most important issues for our use of cross-lingual technologies include that our work must always be conducted at the highest level of professional ethics and that our work must always meet the federal civil rights requirements discussed in Module 3 and Module 4.

As ASHA’s artificial-intelligence materials emphasize, we are ethically bound to provide competent care and accurate information to other people and to maintain complete and accurate records of the clinical services we provide. In addition, civil rights law requires us not only to avoid discriminating in our care provision but also to be proactive about ensuring that all people from all cultures and language backgrounds, and with all personal identities and a wide range of physical and neurocognitive abilities, have equitable opportunities to access the full benefits of our services. To help both providers and recipients of services understand these requirements, many details about what constititutes a qualified interpreter and a qualified translator have been specified in federal requirements (and are easily accessible in the Federal Register: 89 F.R. 37522).

With respect to the related issue of accuracy, the problem is that real-time interpretation software, translation apps, and all similar automatic technologies do not meet the federal requirements defining qualified interpreters or translators. One reason is simply that apps and technologies make too many mistakes. We cannot count on automatic interpretation or translation because these technologies make mistakes of nuance, interpretation, and emotion that trained human interpreters and trained human translators would never make and because they make different mistakes from those that all fallible human beings might make. Moreover, the interpretation and translation systems available to English-language users in the U.S. from U.S.-based technology companies are still known to make more errors with non-European languages than they do with European languages, a situation that creates communication access disparities not only for non-English speakers as compared with English speakers in the U.S. but also across subgroups of non-English speakers (i.e., interpretation and translation apps will provide a more accurate representation of English-speaking clinician’s message to her Spanish-speaking clients than to her Bengali- or Swahili-speaking clients, an unacceptable difference in quality of care based on the clients’ language backgrounds). Newer AI models have, if anything, made this situation worse, not better, given their known ability to produce output that is not only incorrect in simple ways that human users might be able recognize and solve but also incorrect in ways that appear to make sense but are utterly and completely fabricated.

A final, related, and equally important reason to avoid most publicly available interpretation software, translation apps, and similar technologies in clinical and educational settings is that they are owned by companies that have no right whatsoever to access our patients’, clients’, and students’ personal health information (PHI) or educational records. In short, we cannot use common commercial technologies as interpreters or translators for any personal, private, confidential, sensitive, or otherwise privileged information because to do so would be a HIPAA violation. (There are ways to limit Google’s, Apple’s, and related companies’ access to or storage of interpretation and translation records, but the companies themselves make it quite clear that they tend to keep and use the information and that they do not recommend the use of their products for medical interpretation.)

Despite these and other reasons for not using interpretation and translation apps or software in clinical practice, however, many ASHA publications and other working groups are actively recommending the wider use of AI and other technologies for interpretation and translation (see, among many others, this ASHA video, Kong’s 2025 recommendations, Azevedo et al.’s 2024 review, and Birol et al.’s 2025 review).

How can this be happening, or what can these authors reasonably be recommending, if automatic or app-based interpretation and translation may be unethical, illegal, inaccurate, and in violation of HIPAA?

It’s an important question, precisely because of the many benefits and opportunities that we started by recognizing! Interpretation and translation technologies create many wonderful opportunities for all language instructors and supports for all language learners. If we use creative technologies with some clients but not with others, we are actually running the risk of allowing our legitimate concerns about technology to lead us to inadvertently discriminate against our clients who speak languages other than our own, because our choices would be by denying them access to the wonderful, creative possibilities of technology-supported communication and learning.

The key here, as for most complex questions, will be to recognize the distinctions, the details, and the “it depends.”

We can not and do not depend on commerical or automatic interpretations or translation technologies when accuracy is crucial. We can not and do not allow these technologies to make our professional decisions for us, and we can not and do not use automatic interpretations or translation technologies in any way when clients’ PHI or other sensitive educational or other information will be discussed directly or could be revealed by the content of the conversation. Limitations and prohibitions include, but probably are not limited to, the following.

  • Do not use these technologies to obtain informed consent, or to discuss or obtain any other permissions for assessment or intervention.

  • Do not use these technologies as part of any diagnostic, therapeutic, or other interviews or conversations that would contain PHI.

  • Do not use these technologies for decision-making or shared-decision-making conversations about diagnoses, treatment plans, or long-term management plans.

  • Do not use these technologies as the sole means of creating assessment materials or translating assessment materials.

  • Do not use these technologies as the sole means of providing models, instructions, or feedback to clients.

  • Do not use these technologies as the basis for any clinical decisions about clients’ abilities in high-stakes tasks or in placement assessments, or as the basis for any diagnosis or management decision.

  • Do not use these technologies in any other complex situation where accuracy is crucial, including emergency situations.

I would also say, more generally, to trust your knowledge of professional ethics. The ASHA Code of Ethics was written before AI was envisaged and was not written with Google Translate in mind, but its wording and its requirements obviously apply anyway: we provide all services competently (not through a machine that we know makes many mistakes), we protect confidentiality, we provide accurate information to clients and to the public, and we make all our decisions while holding our clients’ welfare paramount in our minds.

When and How to Enjoy Using Cross-Lingual Technologies

Despite these many serious problems, warnings, and concerns, on the other hand, let’s not lose sight of the amazing opportunities that interpretation and translation technologies can provide!

We can and do use technologies in multi-lingual and cross-lingual communication care situations in all of the following ways.

  • to develop first drafts of written translated materials that will then be reviewed by humans with relevant knowledge

  • to support scheduling and other logistics that can be confirmed by reference to a printed or electronic calendar, map, or other relevant visual resource

  • through the use of medical-communication apps or AAC-type technical systems that offer users choices among preset phrases, when those apps or systems can be trusted to have been developed appropriately

  • to provide supplementary models to clients of speech, voice, or language targets

  • as part of providing information or instructions to facilitate a client’s recall or carryover of learned clinical strategies and techniques, when they have previously demonstrated their understanding of those strategies or techniques

  • to provide initial or supplementary feedback to clients, in low-stakes learning situations and when the clinician does also provide professional interpretations and feedback

  • and, most importantly, in day-to-day clinical learning sessions, as part of your creative, client-centered, therapeutic bridges and clinical work!

What do these last two possibilities mean?

They mean, basically, that if none of the ethical or other concerns from the lists of prohibitions are in play; and if you are working with a client during a session on a previously established goal or communicating with a family outside a session; and if you are using some variation of an interaction within which you present some information or some stimuli, the client makes some expressive or receptive response, and you then provide them with some further information or some feedback, either with or without a human interpreter present — then yes, absolutely, interpretation and translation technologies can definitely be an important and fun part of your work.

Try re-reading some of the ideas from the beginning of this module, and try thinking about how you can incorporate technologies in client-centered ways. Clinicians, clients, and family members might use automatic interpretations or translations to find pictures, to learn words or learn about topics that matter to each other, to develop individually or culturally appropriate examples for discussion, to provide extra models of speech or language targets, to provide initial automatic feedback about clients’ productions, or to support a client or a family in any number of other ways. We do not depend on interpretation or translation technologies to do our professional work for us, and we do not allow these technologies to introduce errors or to expose PHI, but in many other ways the many wonderful and expanding technological options are absolutely a fun and useful part of how we can interact in multi-lingual and cross-lingual situations with a wide range of people who use a wide range of languages.

Your Turn

Think again about the clients we have been discussing who have aphasia, dysarthria, and dysphagia. Which technologies might be useful in your clinical sessions or in your discussions with the clients’ family members?

If you are not familiar with conversations conducted through Google Translate or another automatic translation app or service, try some. If you know more than one language, or if you can find a partner who knows another language, pretend that one of you does not know English and use an automatic translation app to have a conversation with a specific goal (giving directions from where you are to the bus station, or explaining how billing works in your facility, or choosing a movie to see this weekend and arranging where to meet when). If everyone around you knows only English, pick any other language and pretend: You speak in English, your phone translates to Mandarin, and your conversational partner translates it back to English. What do you notice about these conversations?

Google Translate and Apple’s automatic translation technologies include only limited numbers of languages. As a business decision, they focus on more common languages. Find the demographic data about the languages spoken by people at home in your community, in your school district, or among your hospital system’s patient population. Are all these languages available in the translation technologies? How does your answer influence your work?

I know!

Sorry.

I’m still working on this page.

•working with a (mono-, bi-, or multilingual) child when you and the child have no language(s) in common

•working with a bi-/multilingual child – focusing on Spanish-English families in the U.S.

•working with an English-speaking child whose dialect differs from yours or from a dialect that is privileged in their school or community – focusing on AAE and other race-adjacent issues in Georgia schools

•Administer the Intelligibility in Context Scale (ICS) in a language you do not know through an interpreter

•https://www.csu.edu.au/research/multilingual-speech/home

•Administer a single-word articulation test in a language you do not know without an interpreter

https://phonodevelopment.sites.olt.ubc.ca/

•administer and interpret a dynamic assessment for a made-up rule (Dr. Brown’s protocol is on eLC)

•explain dynamic assessment to a Spanish-speaking parent using prepared bilingual sentences

•https://sites.google.com/pdx.edu/multicsd/spanish-english-podcasts?authuser=0

Speech Assessment for Children Who Do Not Speak the Same Language(s)

as the Speech-Language Pathologist

(based heavily on McLeod, Verden, et al., 2017, AJSLP – an international view of assessing motoric speech production abilities and phonological patterns when the clinician does not speak any of the child’s languages, with an emphasis here on English-speaking SLPs)

1.

Actively Manage Current Referrals

·      you are not required to follow every referral with a complete direct assessment

o   the Intelligibility in Context Scale, a conversation about specific concerns, and/or a plan for future checks might be all that is needed

§  https://www.csu.edu.au/research/multilingual-speech/ics

2. Assessment Steps for a Child, when a complete assessment is warranted and the primary concerns are related to speech production (versus language-based concerns)

Use bilingual and translated materials, have a translator to work with, have an interpreter to work with, and/or use the child’s caregiver as your model.

Case History and Language History

·      Obtain information about the child’s overall developmental and medical history

·      Obtain caregivers’ general views about the onset, cause, or meaning of the child’s speech abilities or speech problems; obtain general information about the caregivers’ or the extended family’s short-term and long-term speech-related goals for the child

·      Obtain a comprehensive language-exposure and language-use history from caregivers (which languages has the child heard, from whom, when; which languages did or does the child speak, with whom, when).

Caregiver Report of Current Speech and Language Abilities and Concerns

·      receptive language abilities (all languages, all domains, spoken and written)

·      expressive language abilities (all languages, all domains, spoken and written)

·      speech abilities (all languages; artic/phonology, voice, fluency)

·      intelligibility (have caregiver complete ICS for all languages the child uses)

o   https://www.csu.edu.au/research/multilingual-speech/ics

Assess Child’s Speech-Sound Production in Single Words

Transcribe while listening so you can ask for repetitions; record also for later analyses

If possible, use single-word task materials that have been prepared in the language you know and in the child’s other language(s)

o   http://www.csu.edu.au/research/multilingual-speech/speech-assessments

o   https://phonodevelopment.sites.olt.ubc.ca/

If you cannot find appropriate materials, find a phonetic inventory for the language and find phonotactic constraint and syllable structure information for the language, then assess using sounds and nonsense syllables.

·      Collaborate with your interpreter ahead of time to check for inappropriate combinations (!)

Assess Child’s Speech-Sound Production, Voice, and Fluency from Connected Speech

If you have single-word testing materials with target transcriptions, ask the child to make up sentences that use 2-3 of those words (through the interpreter, use “Tell me which one is bigger than the other one,” or use a carrier phrase that can be interpreted, such as “Here is a red ___”). Transcribe the child’s production of the words you can identify in the sentence-level context.

Listen for voice and fluency issues as the child converses with a caregiver.

·      Substantial research has shown that voice quality ratings and measures of stuttered speech can be completed in unfamiliar languages.

Assess oral mechanism and hearing using typical procedures. Assess expressive and receptive language abilities using language-sampling or language-testing procedures, if needed.

3. Stimulability Testing

If phonemic accuracy is a concern, complete stimulability testing by re-using the translated items.

If voice or fluency are of concern, complete stimulability testing by modeling the possible change (e.g., higher pitch or reduced loudness for voice; rhythmic, smoothed, or slower speech for fluency).

4. Linguistic Analyses

Complete independent analyses (phonetic inventory) and relational analyses (articulatory and phonological pattern differences from adult model) of the child’s speech-sound productions.

If the child is bi-/multilingual, use linguistic information to develop at least three categories of phonemes: L1, L2, and L1+L2 (potentially L3, L2+L3, L1+L2+L3)

·      Analyze those phonemes that are used in both/all languages separately from those used in only one language.

·      Do not interpret transfer between languages as errors in initial analyses.

Summarize voice quality ratings or speech fluency data. Describe voice or fluency impressions.

5. Further Input from Caregivers

Discuss your initial findings (not interpretation or recommendations yet) with caregivers. Ask specifically if the data you have developed seem to be addressing the original concern.

·      Caregivers are the experts about their language and about their children.

·      The SLP is the expert about identifying, assessing, and treating speech disorders.

·      Caregivers decide to pursue or not pursue intervention for their child.

6. Develop Possible Recommendations; then Present, Discuss, Suggest, or Seek Recommendations for Intervention

After discussing the data with the caregivers and listening to their interpretations and requests, develop at least one set of possible interpretations and recommendations.

Depending on the cultural norms, then work with the caregivers in a range of ways to suggest your recommendations as one possible interpretation, present your recommendations, and/or seek their suggestions for their child based on your data.

-------------------------------------------

Our in-class example task: Articulation testing in Bulgarian

http://www.csu.edu.au/research/multilingual-speech/ics

http://phonodevelopment.sites.olt.ubc.ca/bulgarian-word-list-in-order-with-translation_2012/

http://phonodevelopment.sites.olt.ubc.ca/bulgarian_phonologytest_ignatova_marinovatodd_bernhardt_stemberger_oct15_englishversion/

Speech and Language Assessment and Diagnostic Decision-Making

for Bi-/Multilingual Children

based heavily on Castilla-Earls et al., 2020, AJSLP

(emphasis on possible language disorders in Spanish-English bilingual children in the U.S.,

and assuming that you as the SLP are comfortable in Spanish, English, or both;

if the family is monolingual and you do not share that language,

you’ll work with an interpreter and/or a translator)

1. Language Abilities and Concerns: Questionnaires and Interviews

·      importance of parent concern (Restrepo and colleagues, 1990s)

·      ask about all four modalities, and ask about each language plus the combination:

o   “Describe your child’s talking in Spanish”

o   “...listening and understanding in Spanish”

o   “...reading in Spanish”

o   “...writing in Spanish”

o   then repeat for “in English” and for “when they are mixing some Spanish and some English”

§  if the parent does not know about the child’s use of English, do a similar interview with a teacher or another relevant adult

·      ask parents to describe child’s speech and language behaviors in these areas; follow up by asking if that behavior concerns the parents and why

·      use your expertise to begin considering if that behavior seems problematic to you

·      ask “Do other people understand your child?” (Intelligibility in Context Scale)

2. Bilingual Speech and Language Sample Analysis

·      Speech-sample analyses of in all languages and in all combinations the child uses

o   phonetic inventories, syllable structure inventories/constraints

·      Language-sample analysis in all languages and in all combinations the child uses

o   narrative structure, syntax, morphology, semantics

3. Evaluation of Learning Potential

·      Dynamic Assessment with you

·      MTSS/RTI with the team

4. Consider standardized tests last and only if they would be helpful

·      Use a standardized test only if an appropriate test exists that will provide a reliable and valid answer to a remaining question that you still have and need answered about this child after evaluating all the information from Steps 1-3.

Treating Phonological Disorders in Bi/Multilingual Children

Goldstein and Fabiano, 2007, ASHA Leader

[emphasis is on children who unquestionably have articulation and/or phonological disorders and who are also bilingual]

Basic principle: Design phonological treatment programs with longterm goals of intelligibility and age-appropriate or adult-like competence for the languages the client uses.

Basic principle: Select specific treatment targets by assessing the child’s specific speech production profile and the child’s needs as a speaker, then select the language or languages of intervention for those targets.

The questions are not “Which language do I treat?” or “What language do I treat in?”

The questions are “What targets does this child need my help with, to improve their communication abilities in their environments?” and

“How can I best treat those targets?”

The Bilingual Target-Selection Approach

·      this approach suggests that we would begin with, or focus on, the targets, goals, or structures that exist in both languages and that the child uses incorrectly in both languages (i.e., choose targets from the overlapping center of the Venn diagram)

·      the bilingual approach means addressing targets that are used in both languages, but a bilingual target-selection approach does not require treating a bilingual target in both languages or by using one or the other of the languages

§  This is one of the situations where transfer from one language to another does occur, so measure in both and in any mix the child uses

will usually be combined with

The Cross-Linguistic or Language-Specific Target-Selection Approach

·      a language-specific approach recognizes that languages differ; thus, the emphasis here is that we would begin with, or focus on, targets, goals, or structures that exist only in one language, regardless of the other language, when their occurrence in the one language interferes with the child’s intelligibility in that language (and when the child’s productions cannot be explained as acceptable transfer from the other language)

·      similarly, we might focus on targets/goals/structures that occur in both languages but are more common for the child in one language or are more salient/important in one language

·      in practice, we often address language-specific targets in the one relevant language

  • …will produce /s/ correctly in at least 80% of single words…

  • …will produce the grapheme “s” as the phoneme /s/ or /f/ in at least 80% of single words and produce the grapheme “s” as the phoneme /k/ in no more than 10% of single words…

  • …will produce words typically written in most American Englishes using the grapheme “s” in ways that are similar to the ways members of his immediate family produce them…

•Hamilton (2020):

•The goal of individual SLP therapy is to increase the ability of children with disorders to use speech and language effectively.

•If the child's native dialect is X, it is not the SLP’s job to turn that child into a speaker of  Y.

•In addition to providing treatment for children with disorders, SLPs should collaborate with teachers to develop culturally and linguistically responsive teaching practices for the school, so that all children can access the MAE curriculum while maintaining their cultural-linguistic identities.

•https://doi.org/10.1044/leader.FTR1.25012020.46

with an individual child:
ignoring dialect will result in inaccurately low test scores

with an individual child:
but also do not accept any feature from a list of possibilities as if it were necessarily dialectal for any single child

•Unmodified scoring of children who speak AAE results in very low specificity (i.e., counting dialectal features as "errors" overidentifies too many children as having disorders, because of how our tests are made) but •Hendricks and Adolf (2018) modified CELF-5 scoring to count any response that could have been a feature of AAE as if it were a correct/acceptable response for that child...  the result was that both sensitivity AND specificity were poor!

•Hamilton (2020):

•The goal of individual SLP therapy is to increase the ability of children with disorders to use speech and language effectively.

•If the child's native dialect is X, it is not the SLP’s job to turn that child into a speaker of Y.

•

•Question referrals that you know are unnecessary; educate your colleagues

•If you are working with an individual child, use the basic techniques you know and from today:

•Talk to parents and teachers about how the child communicates in that child’s world; use dynamic assessment; analyze speech and language samples using thoughtful applications of what a true disorder would include for this child; ignore tests that were designed for other purposes or for other children; use bilingual (Venn diagram) or dialect-specific target selection criteria thoughtfully; recognize when individual SLP therapy is the correct tool and when the child needs something else

•Hamilton (2020):

•The goal of individual SLP therapy is to increase the ability of children with disorders to use speech and language effectively.

•If the child's native dialect is X, it is not the SLP’s job to turn that child into a speaker of Y.

•

•But in schools, we are also required to consider the adverse educational impact of the child’s abilities – and using speech and language effectively in schools includes using spoken and written language as tools for learning.

•Washington, Branum-Martin, Sun and Lee-James (2018): Children with the highest dialect density… in first grade may still be producing densities as high as 70% in fifth grade.  These are the children at greatest risk for reading problems.

https://sites.google.com/ttsd.k12.or.us/2022-ortii-conf-recordings

Craig et al AAE An examination of the relationship dialect shifting reading outcomes

the ability to shift between AAE and “GAE” predicts reading

•Use the DELV, because distance from MAE can matter to educational outcomes

•Language sample

•Listen to caregivers

•Dynamic assessment

•

•Similarly: Washington suggests options that could include teaching children to actively mediate spoken AAE and written MAE

•Here's one example of how to do it – What would the SLP's role be in this school? https://oraal.uoregon.edu/society

In addition to providing treatment for children with disorders, SLPs should collaborate with teachers to develop culturally and linguistically responsive teaching practices for the school, so that all children can access the MAE curriculum while maintaining their cultural-linguistic identities."

•But, next level…

•“Culturally sustaining pedagogies must extend the previous visions of asset pedagogies by demanding explicitly pluralist outcomes that are not centered on White middle-class, monolingual/monocultural norms and notions of educational achievement” (Alim & Parris, 2017, p. 12, in Paris & Alim, 2017).

•In other words: Question the premise! But this is also where Anne has to fall back into cultural humility… I simply do not know what is right for other people.  All I can do is encourage you to be informed and intentional with your individual clients and as you work with your school as a whole.

Stockman’s own voice!

https://www.youtube.com/watch?v=OKCLDIeu1C8&list=PLRXcSAl_dA7arRMrE0qdxLuzGChY1LgY2&index=14

•Today we are adding, to our one large pile of options:

•acquired and degenerative disorders in speech, language, and swallowing

•thinking in terms of language-independent and language-dependent communication needs

•thinking about finding and using academic, research, and international professional resources for when you need information

•thinking about what "treatment" and "management" might mean

•“Language-independent” speech/voice characteristics occur regardless of language because of basic neuromotor flaccidity, spasticity, hypokinesis, or hyperkinesis

•reduced breath support

•breathy/hoarse/quiet voice

•hypernasality

•articulatory imprecision

•relative preservation of vowels in mild-moderate disorders

•relative preservation of prosody and phonemic tone in mild-moderate disorders

•reduced intelligibility overall, with accompanying reductions in activities/participation

•“Language-dependent” speech/voice characteristics are expressed differently across languages or reflect the fact that sometimes the language does matter

•languages that use clicks: weakening/distortion of clicks

•languages with phonemic tones: mostly preserved but do be ready for variation here

•languages with syllable-timed (vs. stress-timed) structures may not conform to English-based views of "excess and equal stress"

•The assessment and treatment skills you are learning for the dysarthrias in English will get you a long way in other languages, because the dysarthric speech itself stems from human neuromotor constraints

•focus on intelligibility to the listeners who matter (education for listeners and for speaker)

•address physical support for speech at all levels (respiration, phonation, resonance, articulation)

•be aware of the articulatory and tonal phonemes of the client’s language(s)

•look up tone patterns or the stress/timing patterns of the language if you don't know (e.g., Cantonese tones: https://phonodevelopment.sites.olt.ubc.ca/activities-2/chinese/chinese-12/ )

larger, louder, slower, exaggerated, regardless of language (LSVT research)

•One of Anne's linguistic-nerd favorite books (UGA Library has it online):

•Miller, N., & Lowit, A. (2014). Motor speech disorders : A cross-language perspective. Multilingual Matters.

•LSVT research articles, including

•Moya-Galé, G., Goudarzi, A., Bayés, À., McAuliffe, M., Bulté, B., & Levy, E. S. (2018). The effects of intensive speech treatment on conversational intelligibility in Spanish speakers with Parkinson's disease. American Journal of Speech-Language Pathology, 27(1), 154-165.

•Google Scholar: "linguistic features of" the language you need

•Some parts of aphasia are language independent – What do you notice and understand from her, even if you don't speak Spanish?

•http://www.aphasia-international.com/2015/12/06/videos-about-aphasia-spain/

•But language/aphasia differs from speech/dysarthria because

•the brain mixes the languages!

•So the general recommendation for assessing a client with aphasia is to use the same sorts of language history assessments and language use assessments that we discussed for children, but what is the problem going to be?

•International/multilingual materials intended for families and patients 

•http://www.aphasia-international.com/languages/

•International/multilingual research and other materials intended for professionals

•ASHA keeps a list of international equivalents: https://www.asha.org/members/international/intl_assoc/

•or search for a journal name in relevant country: e.g., the Brazilian equivalent of AJSLP

•

Kiran et al AJSLP rehab bilingual aphasia

•Bilingual participants who showed

•improvement on treated items: 14/17

•within-lang generalization to untrained semantically related items: 10/14

•across-lang generalization to translations of trained items: 5/14

•across-lang generalization to translations of untrained semantically related items: 6/14

•combines several of today's themes:

•motoric nature of swallowing is universal (language independent)

•similar recommendations exist worldwide

•but the personal/social/cultural experience of eating is obviously culturally dependent, and it is also definitely influenced by the client's entire "community of care"

•start by asking the patient and the family what your patient eats or used to eat, and what their assumptions are about who should cook for the patient and help them eat

•diet history, parallel to a language-use history

•then google it (“foods in Peru”) if you need more information

•cultural assumptions that a woman will feed her husband? that a man must feed himself? that an elderly parent will feed the middle-aged patient? that the nurse should? who is the community of care?

•then model and explain diet texture recommendations to the patient and to the family as modifications of the patient’s own preferred foods, using the IDDSI pyramid in all of the family’s languages, and using the individual and cultural information you have about the family

Use pyramids in all of the family's languages to explain which foods they have named are safe (if any), to explain why some foods they named are unsafe, and to explain how to modify those foods to make them safe

Model dysphagia posture, exercises, manuevers

(we’ll do a breakout room challenge here, depending on how time is going)

Practice with the patient’s real foods (if food is part of your activity).

Provide pictures and have client or family write the explanations for themselves.  Actively encourage their use of all of the family’s languages in their notes.

Also: Look for materials in the languages you need, and start a multilingual collection, if your hospital doesn’t have one already (e.g., Spanish dysphagia words and phrases)

https://pubs.asha.org/doi/full/10.1044/2025_AJSLP-24-00398

I know!

Sorry.

I’m still working on this page.

https://www.theinformedslp.com/review/BilingualMultilingual-language-assessment-Start-here

https://bilinguistics.com/

Use the child’s languages. Use the language the child understands to explain the language the child is learning.

“The literature in bilingual education of the last two decades suggests that children who are learning two languages may benefit from a bilingual approach in intervention. None of the studies designed to prove the contrary have been able to show that an English-only approach is superior. The research clearly shows that mediation in the native language does not slow development or learning of a second language. There is no evidence that a bilingual approach in intervention would “confuse” or tax the learning abilities of children with disabilities. There is great variability in second-language acquisition and the language-learning processes involved are not well understood.”

“The research presented in this paper has several implications for clinicians working with bilingual children. First, it suggests that children’s language performance and achievement can be maximized when the language of instruction matches the child’s language(s), and when L1 is used as an organizational language framework to facilitate second-language learning.”

Gutiérrez-Clellen, 1999

https://doi.org/10.1044/1058-0360.0804.291

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