Section Five
Module 21: Multi-Lingual and Cross-Lingual Communication Care
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Which dialects of which languages do we need, and how should we use them?
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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 all clients and 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 presented as complex specialty areas suitable only for our colleagues with specific types of expertise. As we have emphasized throughout this website, however, 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 “other” clinical routines. Yes, of course, there 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 too closely on such issues as the “complexities” of finding and working with interpreters, therefore, and instead of getting ourselves too bogged down in details such as “which language to use,” “which dialect to teach,” or how to categorize people as “simultaneous” versus “sequential” language learners, this module will focus on what you already know. From that base, we can add in the few necessary details while also thinking primarily about how to create client-centered, linguistically appropriate, multi-lingual and cross-lingual clinical services with all clients, especially but not solely those that you might say use dialects or languages other than your own.
Universal Approaches from Multi-Lingual and Multi-Modal Language Teaching
Let’s start by thinking about truly multi-lingual language-learning situations, or language teaching that is designed to work for a group that includes speakers of many languages who 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, the class combined a few of us who spoke English with many others who were speakers of Arabic, Russian, Turkish, and other languages. Our teacher spoke some English, but she did not know (or need to know, the larger point here) all the group members’ other languages, even though we as a group had no language in common other than the rudimentary Norwegian that we were beginning to learn.
I currently work, interestingly enough, in a very similar kind of classroom, this time in English-language classes for adults here in the U.S. Because of our geographic location, many of our learners speak Spanish, which our lead instructor also speaks 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 welcoming, happy, communicatively redundant, designed to support the task of language learning, designed to support the people who are language learners, and therefore effective and efficient with the task of helping people learn another language. They do so by drawing on a wide range of common and related multi-lingual teaching strategies, such as those summarized in Box 21.1. Even if you will never serve as a language teacher for a large and multi-lingual group, try reading these ideas with the same mindset we used as 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.
The first two ideas in Box 21.1 remind us that we can communicate to diverse groups by presenting our messages in more than one modality. In language classrooms, and almost anywhere else, most presenters who are speaking to a group also show slides or provide a printed handout, in addition to speaking, thus effectively combining spoken language with written language and other visual supports. If we are providing instructions using spoken words, we can also give people not only a printed version of our words but also a drawing, a set of pictures, or carefully sequenced examples to solve on their own. People in all situations also communicate with emotions, facial expressions, gestures, and props, not merely by standing and reciting words. As applied to teaching and learning for world languages, these ideas start with teaching greetings through welcoming pantomine with multiple repetitions, include showing people pictures as we help them learn vocabulary or morpheme patterns in a new language, and can become the use of theatre in language-learning classrooms. These ideas are probably familiar to you; they simply draw on and combine what we know about multi-modality in human communication.
The next two ideas in Box 21.1 focus on the organization of a learning session. The notion of providing learners or listeners with context, content, and then conclusions reflects several classic options; this is the same idea as structuring essays with introductions, body paragraphs, and conclusions, which is the same as organizing a speech by introducing what you are going to say, saying it, and then saying what you said. It is also why most teachers (and most clinicians) start most lessons by helping learners to understand what the topic is and to activate their current knowledge about that topic before introducing, working with, and then summarizing the new material.
Effective teachers for groups of language learners also work to recognize and mirror facial expressions and other movements, and to attach communicative content and then language-specific forms to those expressions. We can smile at people who are smiling, for example, regardless of which languages we know, while verbalizing “The game is fun” with beginners or initiating more complex conversations with more advanced learners about whatever has made them smile. We can work seriously for a moment with a person or a group that looks more serious, giving them the more serious words that they need in that situation, and we can shift to even more energetic approches if the group feels upbeat today. (We can also shift to more energetic approaches if the room has gone stale and needs a change, a different version of noticing what’s happening and noticing what learners need!).
Within the inclusive, responsive, and intentionally diverse contexts these efforts are creating, we teach multi-lingual learners by combining multiple repetitions, multiple examples, silence, small groups, and technologies. Multiple repetitions are key to all new learning and are especially important for adult language learning. Repetitions can and should be massed to support initial learning and also spaced to support generalization and maintenance. Mutiple repetitions and multiple examples allow learners to create the new connections that they need, and they also allow each learner to find at least one example that feels like a good match for them or that somehow sticks with them as a model. Silence, which is as important as repetitions, gives learners the space to work on creating new connections for themselves, both metaphorically and neurophysiologically; remember that learning to produce language requires being given the space to work on producing language.
Small-group work within large-group settings, as another option, allows for more and different repetitions and examples, and it also facilitates some helpful differentiated and individualized scaffolding. A learner who is ready to serve as the group leader can do so, a learner who is not ready to take a risk in front of the whole group can try in the safer context of the small group, and the person who needs to hear the repetitions can sit and listen.
Small groups also activate the expertise of the whole group, by allowing interactions between group members that might not occur if the instructor attempts to control all interactions. This notion blends 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. And as much as we will work to create inter-personal “cross-” connections with each of them, the group and its members will always have their own background knowledge, language use histories, and life goals. Multi-lingual (and cross-lingual) learning requires using this variety as we help them learn.
More specifically, teachers in multi-lingual learning situations use the abilities and the variety that a multi-lingual or multi-dialectal group brings as we help them learn to use the language we are teaching them in the way that they will use it. This version of “remember why we are here” includes understanding, of course, that a person who knows one or more languages already and is working on learning another one will 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 circumstances.
As obvious as this acknowledgment of other people’s lives might sound, however, both world-language teaching and our own profession have struggled, through time, with many questions related to this idea. In language teaching, parts of the debates address whether we are teaching toward a monolingual ideal versus teaching for intelligibility, comprehensibility, or functional use of a language; in our profession, the debates question the ethics of work described as “accent reduction” or “accent modification” (as we will address in greater detail later in this module). One simple answer, once we allow 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. The language teacher’s goal is never to turn the language learners into “mini-me” versions of the teacher; the goal is to help language learners learn to use their new language in the way that the learners will use it.
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. 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 all 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 do encounter and also, perhaps more importantly, as you think about the many cross-linguistic therapeutic bridges you can build to your many individual clients.
Your Turn
Imagine working with a single older client who has aphasia, dysarthria, and dysphagia. Describe how you would use each of the possibilities listed in Box 21.1 and discussed in this section as you communicate with, support, and teach the client and the family in each of the following scenarios. (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 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 language, and you describe your Spanish skills as intermediate-to-advanced. 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 to use Korean during her sessions. The client and her adult children communicate with each other in Korean. 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 children’s 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, learner-centered responses to 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 communication care situations can you draw from these ideas?
Working with Interpreters, Translators, and Translated Materials
Let’s move now from thinking about multi-lingual situations to thinking about cross-lingual situations. How do we build appropriate cross-cultural, cross-identity, and cross-linguistic therapeutic bridges to communicate with another person if we do not share any of their languages?
Parts of the answer are cross-cultural (from Modules 15 - 20). Parts of the answer come from the multi-modal communication strategies and other ideas in Box 21.1, and there are also some specific cross-lingual clinical strategies and materials to be aware of (which we will discuss later in this module). Among the first decisions to be made, however, as you begin to work with a new client who uses languages different from the ones you use, are related to whether you should or will have access to interpreters, translators, and appropriate professionally translated and culturally-centered materials.
Start by making sure you understand the classic terminology in Box 21.2, and then we will address some details for working with interpreters, translators, sight translators, and translated materials in clinical settings.
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 the language or languages are being produced.
Simultaneous interpretation or continuous interpretation means that original speaker or signer does not stop. The interpreter simultaneously 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 includes the interpretation of conversations, for which one complete conversational exchange (utterance and response) 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. This situation 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 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 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 French 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 French.
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.)
Working with Interpreters
getting paid!
https://www.medicaid.gov/medicaid/financial-management/medicaid-administrative-claiming/translation-and-interpretation-services#:~:text=Claiming%20FMAP%20For%20Translation/Interpreter,all%20providers%20in%20the%20class.
Your Turn
You are again working with your clients with aphasia, dysarthria, and dysphagia from the previous Your Turn questions. Describe some allowable, useful, and helpful ways that you, they, and/or their families could incorporate realtime interpretation technologies or written language translation technologies into her care.
You, the client, and her immediate family members all speak similar dialects of the same language.
You, the client, and her adult children all know both English and Spanish. You describe your Spanish as “rudimentary” and are more comfortable in English. The client prefers Spanish. The adult children tend to respond to their mother in a fluid combination of mixed English and Spanish.
You know English and also know smaller to larger bits of French, Spanish, and Italian. The client speaks primarily Korean, also knows some English and some French, and prefers to use Korean during her sessions. The adult children are equally proficient and equally comfortable in English and Korean, and one of them studied Spanish in high school. The client and her adult children have always spoken Korean with each other.
Using Interpretation and Translation Technologies
Did you happen to notice that our discussions so far have 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 and translators we have just discussed.
First, obviously, multi-modal, multi-lingual, and cross-lingual technologies are amazing, useful, and include a wide range of options.
Language teachers can 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. Language 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’ preferences or abilities. 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 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, the technological possibilities have expanded these options in ways and to extents that we are changing our presumptions about interpreting spoken language versus translating written language. It has become routine in the ESL/ESOL program where I am currently, for example, for phone-assisted conversations to be conducted by one person speaking in Language 1 and the other person then reading their message in Language 2 (speech to text transliteration followed by machine-generated sight translation) or for a situation where one person types in Language 1 and the other person then hears the message aloud in Language 2 (machine-generated sight translation followed by text to speech conversion)nd. Apple’s “Live Translation” feature, for example, already 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 of two conversational partners speaking, reading, and/or listening in either or both of their two languages. The resulting conversation is intended to feel almost like consecutive interpretation (if both people are listening), and it actually involves fascinating behind-the-scenes or visible combinations of languages and technologie
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 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 and no, and there are several special and intertwined details to be sure we understand about professional ethics, legal requirements and regulations, accuracy of materials, and clients’ privacy rights. Let’s start with the bad news: there are some ethical concerns, legal limits, and related specific prohibitions that affect our use of automatic interpretation and translation technologies 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 make mistakes of nuance, interpretation, and emotion that trained human interpreters and trained human translators would never make; and 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 so on.
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!
e of m.
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
in the context of medical-communication apps or AAC-type systems that offer users choices among preset phrases, when those apps or systmes 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 (including if the professional’s interpretation and feedback are provided with the assistance of a human interpreter, a different situation we will address soon)
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 our 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 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. Clinicians and clients 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.
Work
https://pubs.asha.org/doi/full/10.1044/2024_PERSP-23-00143
Langdon & Saenz 2016 https://doi.org/10.1044/persp1.SIG16.15
https://www.nilc.org/articles/trump-administrations-attempts-to-dismantle-language-access-do-not-erase-civil-rights-law/
new review, effects of interpreters
https://www.sciencedirect.com/science/article/pii/S2666623523000120#sec0006
Uphold federal guidelines for ensuring language access in health care and educational settings.
Identify the appropriate spoken and/or signed language(s) of service for patient and their care partners—including the preferred language for meetings, clinical interactions, and written documentation.
Recognize that not all spoken or manually coded languages have a written form.
Use plain language principles to ensure that all messages, especially written information, are clear and concise (Alani et al., 2024). See ASHA’s resources on health literacy and communication access.
Advocate for access to—and sustainable funds for—an interpreter, a transliterator, or a translator.
Seek an interpreter, a transliterator, or a translator who has knowledge, skills, and relevant experience. See the Selecting an Interpreter, Transliterator, or Translator section of this document for more information.
Seek information on the features and developmental characteristics, when available, of the language(s) and/or dialect(s) that are spoken or signed by the patient or care partner.
Obtain information on the linguistic community to identify significant cultural and linguistic influences.
Establish collaborative relationships with cultural or linguistic brokers, interpreters, transliterators, and translators to maximize the effectiveness of services by doing the following tasks:
Providing the goals and intent of the session to the interpreter, transliterator, or translator.
Scheduling additional time in each session to allow for a briefing, an interaction, and a debriefing.
Making advance arrangements to ensure appropriate physical accommodations (e.g., space, lighting, noise) necessary for a successful collaboration. Physical accommodations may include placement of phone, computer, and/or video screen to ensure visibility and audibility during remote sessions.
Arranging for the translation of documents written in unfamiliar languages—to ensure that clinicians know the content of the documents. Note that translation of written material from one language to another may alter the document’s intent and overall readability.
Verify the cultural appropriateness of assessment and treatment materials, and review potential bias, as applicable. Clinicians also review prompts in assessment materials for linguistic influences of an additional language and consult with language assistance providers to review phonetic information and potential syntactic influences.
Evaluate and integrate technologies to promote language access, as appropriate.
Maintain appropriate professional relationships among the clinician; the patient and care partner; and the interpreter, transliterator, or translator (ASHA, 2023b).
Your Turn
Think again about the clients we have been discussing who have aphasia, dysarthria, and dysphagia. Describe how you could work with an interpreter to communicate with, support, and teach the client and the family in each of the following scenarios.
You, the client, and her adult children all know both English and Spanish. You describe your Spanish as “rudimentary” and are more comfortable in English. The client prefers Spanish. The adult children tend to respond to their mother in a fluid combination of mixed English and Spanish.
You know English and also know smaller to larger bits of French, Spanish, and Italian. The client speaks primarily Korean, also knows some English and some French, and prefers to use Korean during her sessions. The adult children are equally proficient and equally comfortable in English and Korean, and one of them studied Spanish in high school. The client and her adult children have always spoken Korean with each other.
You know English and Korean. The client knows Farsi. The client’s grown children know Farsi and French.
One common occurrence in multi-lingual group classrooms is that learners may speak to each other in a language that the instructor does not know. Use the strategies summarized in Box 21.1 and the discussion in this section to imagine a range of supportive, learner-centered responses to 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 communication care situations can you draw from these ideas?
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. Visibility, Preparation, and Caseload Management
Make Interpreters Routine
· ask about the systems in place for identifying interpreters and translators as part of your job-search process
· ask for training about how interpreters and translators are scheduled as part of your on-boarding in a new position
· ask for interpreter/translator plans to be on department meeting agendas
· include interpreter/translator costs in your budget for your private practice
Establish Routine Working Relationships with Interpreters and Translators
· if you are in private practice, communicate with existing companies/individuals in your community routinely
· depending on your work setting, establish a list of trained individuals, or individuals who are willing to seek training, from within your school or from relevant community groups who could accept occasional hourly work assignments
Actively Manage Potential Future Referrals in the School/Community
· educate relevant groups in your setting to maximize necessary referrals, reduce overreferrals of typical bi-/multilingual children, and reduce underreferrals of children who have speech disorders
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.
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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/
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.
•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)
w
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