Evaluating
bilingual patients can be tricky, especially given limited
availability of bilingual tests and materials. But even with only a
few resources, SLPs can get a pretty good picture of a bilingual
patient's skill-set using the process presented below. Before we go
into details, let's define some words:
Bilingual
person, or "a bilingual": a person who is exposed to
more than one language. They may speak both languages, or they may
only speak one fluently. They may be "better" at one
language than the other. (For simplicity's sake, I also use this
word to refer to multilinguals, who speak three or more
languages.)
Monolingual
person, or "a monolingual": a person who is exposed to
one language and only understands and/or speaks that language. The
language can be Asante Twi, Portuguese, Quechua, etc.
Bilingual
test: a test in two languages. The languages can be Spanish and
English, Farsi and Urdu, etc.
Monolingual
test: a test in one language. The language can be English,
Spanish, Greek, etc.
Dominant
language: this refers to the
language the patient feels more confident using. Not all patients
have a clear dominant language. Some patients have different language profiles in different domains (e.g. expressive and receptive
language).
Home Language: the language spoken at home OTHER than the
majority/official language spoken in public and professional places.
Because I treat in the United States, I will refer to the majority
language as "English" and all other languages as "Home
Language."
OK, now that we're on the same page about terminology, let's get to
testing.
How to test a bilingual patient
Bilinguals are a heterogeneous group not well represented in
mainstream standardized tests. Let me first describe my ideal
bilingual speech evaluation: An SLP who fluently speaks the same
language(s) as the patient gives them a standardized test that probes
for language skills in both languages and has a normed sample
containing only bilinguals who speak the same language(s) as the
patient.
Unfortunately, the above scenario isn't always feasible. Sometimes
the SLP only speaks one of the patient's languages, or there aren't
tests published that include the language of the patient, or the
tests in that patient's language are only normed on monolingual
speakers (more on this later), or there is some other unexpected
complication, like an intense fear of teddy bears or a need for more
pain medication.
Here is my process for a bilingual evaluation. It works in ideal and
not-so-ideal scenarios. I am always looking to improve my methods as
newer testing materials are published, best practice is improved,
etc.
Step 1: Determine the level of bilingualism.
During my medical history interview, I ask the family of every
patient if there is another language spoken at home, whether their
last name is Liu, Rodriguez, or Jones. If the answer is YES, I
determine how often the patient is exposed to and uses each language.
If the patient only hears their German grandmother speaking on the
phone once a month, I proceed to monolingual testing. If the patient
converses in German with their family daily, I use the following
bilingual evaluation process. I then ask about the patient's
dominant language. If they don't have one, the order of languages
tested in below isn't important.
IMPORTANT: If the patient and I do not share a fluent language, I
refer them to a Speech Therapist who can speak at least one of their
languages. If there isn't one available, I go straight to step 3.
Step 2: Test in the dominant language (or in the language that I
share with the patient, if I can only fluently speak one of their
languages).
If this involves using a monolingual test with monolingual
standardized scores, I take that into consideration. Since bilingual
language development looks different than that of monolinguals, a standardized score comparing them to monolinguals is not comparing them to true peers (again, more
on this later).
I also take a language sample to analyze grammatical accuracy, length
of utterances, etc. Ideally, I want to compare the patient's
language sample measures to that of children from the same bilingual
background using a database comparison (Personally, I have experience
with SALT). If I don't have access to a database, I can still
take inventory on their grammatical development and collect baselines
for Mean Length of Utterance (MLU), Number of Different Words (NDW),
etc. I can also determine which grammatical "errors" are
due to language influence from the other language and which are true
errors.
Step 3: Test in the other language (if I speak it fluently or
have an interpreter), or perform an interview with a family member
regarding the patient's language skills.
Again, if this involves using a monolingual test with monolingual
standardized scores, or if an interpreter has had to translate the
test, I note that. And I take a language sample.
Or, if I can't speak this language
fluently and don't have access to an interpreter, an interview
with the family about the patient's language skills and deficits can
help me to use my clinical judgement to determine the diagnosis (or
lack thereof) and establish goals to train the family to work with
the patient.
Step 4: Determine diagnosis
In the case of a patient with developmental concerns: a child
presents with a disorder IF and ONLY IF they present with deficits in
BOTH LANGUAGES in at least one domain of language (e.g. Syntax,
receptive language, phonology, etc.) Otherwise, they do not present
with a disorder, but rather a language difference, which is best
addressed by ESL teachers. A clinical note: parental concern is one
of the most likely predictors of language impairment in bilingual
children; parents often have a good instinct about their children's communication skills. (For more information, see this study by Restrepo.)
For a patient with an acquired brain injury or dementia, I use all
the information given in their medical history, as well as their
symptoms in each language to determine the diagnosis (e.g. Broca's
Aphasia, Primary Progressive Aphasia, Cognitive Communication
Disorder, etc.).
Step 5: Write goals
Ideally, I write general goals targeting both languages AND
language-specific goals addressing unique points of breakdown within
each language. However, I ONLY write language-specific goals in
languages I can speak (English and Spanish). Otherwise, I provide
extra family training so the patient can work on the Home Language
informally at home with their family.
This is my process for a smooth, least-biased evaluation for a
bilingual patient. I hope this can help you in your practice too!
Feel free to share this tutorial with anyone you know who might use
it. It's therapists like you who make a big difference for our
bilingual patients!
