How do International Clinicians Assess for Developmental Language Disorder in Multilingual Children?
Published in the December 2024 issue of the ISHA Voice.
By Emily Frances Hunt and Wiebke Scharff Rethfeldt
ISHA’s Evidence-based Practice Committee invited the authors to provide this article for the membership.
Speech-language pathologists (SLPs) worldwide see increasing numbers of clients who speak a language or belong to a culture different from their own (Parveen & Santhanam, 2021), in part due to geopolitical changes (United Nations Department of Economic and Social Affairs Population Division, 2021) and changing linguistic diversity across generations of migrant families (Cox et al., 2021). Whilst multilingual (including bilingual) children are not a special clinical population, provision of culturally and linguistically appropriate services can be challenging for SLPs with limited experience of the child’s language and culture (Parveen & Santhanam, 2021). In addition, careful consideration of combination of differing language experiences between the child’s heritage (home) language and the dominant societal language may be more difficult for SLPs from monolingual backgrounds and training (Parveen & Santhanam, 2021).
One of the most common neurodevelopmental disorders seen by SLPs is Developmental Language Disorder (DLD), a diagnostic term referring to children with a language learning disorder that is not associated with a known biomedical condition (Bishop et al., 2017). DLD prevalence rates in multilingual populations are currently unavailable, as the research data on child language development is confounded by measurement instruments that were structured and standardized based on monolingual language acquisition patterns (De Cat & Melia, 2022; Nair et al., 2023; Scharff Rethfeldt, 2013). However, as the difficulty lies in language processing skills and not the number of languages spoken (Ebert, 2014; Ebert & Reilly, 2022), there is no reason to think that the prevalence rate of 6-8% observed in monolingual children (Calder et al., 2022; Norbury et al., 2016; Wu et al., 2023) would be significantly different in multilingual children.
Recommendations for assessment of multilingual children are available, published by a variety of national and international SLP associations (such as American Speech-Language-Hearing Association, 2004; IALP Multilingual Multicultural Committee, 2006; Royal College of Speech Language Therapists Specific Interest Group in Bilingualism, 2007). However, these guidelines largely reflect the experience of monolingual countries, based on research published more than a decade ago, from studies mostly conducted in Western, industrialized, Anglo-American countries. It remains unclear how international SLPs assess multilingual children for DLD, and how they apply the DLD diagnostic criteria.
The Multilingual-Multicultural Affairs Committee of the International Association of Communication Sciences and Disorders (IALP) created an online cross-sectional survey to collect data about how international clinicians assess multilingual children. The survey contained 70 questions, covering information about the participants’ demographics, education, clinical experience and clinical caseload; current assessment practices; opinions about DLD in multilingual children; and treatment services available to multilingual children. The survey was available in multiple languages, and open invitations to complete the survey were shared through social media and professional networks. The full results of the survey were published in April 2024 in Folia Phoniatrica et Logopaedica. This overview will discuss a selection of results answering three research questions:
1) How do clinicians diagnose DLD in multilingual children?
2) What methods do they use to assess societal and heritage language?
3) What are their opinions about access to SLP services for multilingual children?
Who responded to the survey?
This survey was not designed to elicit a representative sample of international clinicians working with multilingual children. However, the diversity of responses provided an interesting cross section of current practice, and allowed some exploration of regional similarities and differences. 354 clinicians from 44 countries completed the survey, with 90% of responses being from speech pathologists and 23% of responses from multilingual clinicians. Most participants were European (68%), clinicians working in a metropolitan/city setting (83% of responses), and working with four to six-year olds (94% of responses), with 26 responses from clinicians working in the USA. Approximately two thirds of the clinicians had obtained additional professional development in multilingual service provision, and 63% had more than 10 years of professional experience.
How do clinicians diagnose DLD in multilingual children?
Most clinicians were confident to differentiate between typically developing multilingual children, and multilingual children with language disorder, with 72% agreeing or strongly agreeing with this statement. Multilingual clinicians were significantly more confident than monolingual clinicians to make this distinction, as has been seen in other studies (Caesar & Kohler, 2007; Kritikos, 2003; Parveen & Santhanam, 2021).
Clinicians reported that assessing multilingual children’s language took 1.5-2 times as long as it took for monolingual children, reflecting the additional linguistic factors to be explored. Investment of sufficient time for accurate diagnosis is thought to improve the efficiency of service provision, as it ensures the child receives appropriate and relevant support for their communication difficulties.
Although 79% of clinicians agreed or strongly agreed that interpreters can be helpful to administer language tests, 30% sometimes use an interpreter for a different language to their own, and a further 39% never use an interpreter. Access to appropriate interpreters for speech and language assessment is an identified issue (Caesar & Kohler, 2007; Guiberson & Atkins, 2012), resulting in a diagnosis of language disorder being made based only on the child’s use of the societal language, rather on their full linguistic repertoire. This data was confirmed by 81% of the clinicians reporting assessing children only in one language.
What methods do clinicians use to assess societal and heritage language skills?
For both societal and heritage language assessments, clinicians mainly relied upon child observation, parent questionnaires, and informal assessment (e.g. narrative production and spontaneous speech). These methods have value in exploring the way the child uses language to communicate in different situations, and the perspective of the child’s caregivers (Boerma & Blom, 2017; Paradis et al., 2013). There was a statistically significant difference in the way that monolingual and multilingual clinicians assess societal and heritage languages. Multilingual clinicians used significantly fewer standardised assessments, and significantly more dynamic assessment and criterion-referenced assessments when assessing the societal language. When assessing the heritage language they also used significantly more dynamic assessment, teacher report and experimental tasks than monolingual clinicians. Whilst the survey did not ask why monolingual and multilingual clinicians assessed language differently it is possible these differences may be due to the clinician’s personal knowledge of typical patterns of multilingual language use, or perhaps a shared knowledge of the child’s heritage language allows a greater range of tasks to be performed.
What are clinicians’ opinions on the access to speech pathology services for multilingual children?
The most common reasons for referral to SLP services were similar in most regions, including concerns by a parent, teacher or doctor; or a lack of progress compared to peers. Whilst 73% of clinicians thought that multilingual and monolingual children have equivalent access to speech language pathology services in their community, 18% disagreed, and a further 8% did not know. The common access barriers to SLP assessment for multilingual children were cost, a lack of resources, a lack of multilingual clinicians, low knowledge about typical multilingual development, and availability of services. Barriers specifically identified by North American clinicians included a lack of multilingual SLPs, but also parents of multilingual children not being aware of the option of SLP services, and language difficulties being attributed to multilingualism instead of a possible language disorder. These knowledge barriers are noteworthy targets for community education and training, given that the child’s parents, teachers and doctors require knowledge of typical multilingual language development, and available services, to refer a child for assessment.
Conclusions
The survey found that where a child lives has a significant impact on the way that their clinicians provide services. Clinicians are largely confident to diagnose DLD in multilingual children, and this confidence is possibly underwritten by professional development, clinical experience, and personal knowledge of multiple languages. Clinicians more frequently assess societal language than heritage language, but most clinicians do not rely on standardised tests normed on monolingual children to assess the languages of a multilingual child, consistent with advice in the literature. Specific barriers to access SLP services vary by region, requiring locally designed solutions to address.
For further information about the study, including additional results:
Scharff Rethfeldt, W., McNeilly, L., Laasonen, M., Meir, N., Abutbul-Oz, H., Smolander, S., Niegia Garcia Goulart, B., & Hunt, E. F. (2023). Assessment of Developmental Language Disorder in multilingual children: Results from an international survey. Folia Phoniatrica et Logopaedica, 1-24. https://doi.org/10.1159/000533139
References
American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of speech-language pathology. https://www.asha.org/siteassets/publications/pp2004-00191.pdf
Bishop, D. V. M., Snowling, M. J., Thompson, P. A., & Greenhalgh, T. (2017). Phase 2 of catalise: A multinational and multidisciplinary delphi consensus study of problems with language development: Terminology. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.12721
Boerma, T., & Blom, E. (2017). Assessment of bilingual children: What if testing both languages is not possible? Journal of Communication Disorders, 66, 65-76.
Caesar, L. G., & Kohler, P. D. (2007). The state of school-based bilingual assessment: Actual practice versus recommended guidelines. Language, Speech & Hearing Services in Schools, 38, 190-200.
Calder, S. D., Brennan‐Jones, C. G., Robinson, M., Whitehouse, A., & Hill, E. (2022). The prevalence of and potential risk factors for Developmental Language Disorder at 10 years in the Raine Study. Journal of Paediatrics and Child Health, 58(11), 2044-2050.
Cox, R. B., Jr., deSouza, D. K., Bao, J., Lin, H., Sahbaz, S., Greder, K. A., Larzelere, R. E., Washburn, I. J., Leon-Cartagena, M., & Arredondo-Lopez, A. (2021). Shared Language Erosion: Rethinking Immigrant Family Communication and Impacts on Youth Development. Children, 8(4). https://doi.org/10.3390/children8040256
De Cat, C., & Melia, T. (2022). What does the sentence structure component of the CELF-IV index, in monolinguals and bilinguals? Journal of Child Language, 49, 423-450.
Ebert, K. D. (2014). Role of auditory non‐verbal working memory in sentence repetition for bilingual children with primary language impairment. International Journal of Language and Communication Disorders, 49(5), 631-636. https://doi.org/10.1111/1460-6984.12090
Ebert, K. D., & Reilly, M. (2022). Predictors of language proficiency in school-age Spanish-English bilingual children with and without developmental language disorder. Biling (Camb Engl), 25(2), 296-306. https://doi.org/10.1017/s1366728921000985
Guiberson, M., & Atkins, J. (2012). Speech-language pathologists’ preparation, practices, and perspectives on serving culturally and linguistically diverse children. Communication Disorders Quarterly, 33(3), 169-180. https://doi.org/10.1177/1525740110384132
IALP Multilingual Multicultural Committee. (2006). Recommendations for working with bilingual children. Folia Phoniatrica et Logopaedica, 58(6), 458-464. https://doi.org/https://doi.org/10.1159/000096570
Kritikos, E. P. (2003). Speech-language pathologists' beliefs about language assessment of bilingual/bicultural individuals. American Journal of Speech - Language Pathology, 12(1), 73-91.
Nair, V. K. K., Farah, W., & Cushing, I. (2023). A critical analysis of standardized testing in speech and language therapy. Language, Speech & Hearing Services in Schools, 1-13.
Norbury, C. F., Gooch, D., Wray, C., Baird, G., Charman, T., Simonoff, E., Vamvakas, G., & Pickles, A. (2016). The impact of nonverbal ability on prevalence and clinical presentation of language disorder: Evidence from a population study. Journal of Child Psychology and Psychiatry, 57(11), 1247-1257. https://doi.org/10.1111/jcpp.12573
Paradis, J., Schneider, P., Duncan, T. S., Oetting, J., & Bedore, L. (2013). Discriminating Children With Language Impairment Among English-Language Learners From Diverse First-Language Backgrounds [Article]. Journal of Speech, Language & Hearing Research, 56(3), 971-981. https://doi.org/10.1044/1092-4388(2012/12-0050)
Parveen, S., & Santhanam, S. P. (2021). Speech-language pathologists' perceived competence in working with culturally and linguistically diverse clients in the United States. Communication Disorders Quarterly, 42(3), 166-176. https://doi.org/https://doi.org/10.1177/1525740120915205
Royal College of Speech Language Therapists Specific Interest Group in Bilingualism. (2007). Good practice for speech and language therapists working with clients from linguistic minority communities. https://www.rcslt.org/members/publications/publications2/slt_assessment_and_intervention_main
Scharff Rethfeldt, W. (2013). Kindliche Mehrsprachigkeit (N. Lauer & J. Leinweber, Eds. 2 ed.). Thieme.
United Nations Department of Economic and Social Affairs Population Division. (2021). International Migration 2020 Highlights.
Wu, S., Zhao, J., de Villiers, J., Liu, X. L., Rolfhus, E., Sun, X., Li, X., Pan, H., Wang, H., Zhu, Q., Dong, Y., Zhang, Y., & Jiang, F. (2023). Prevalence, co-occurring difficulties, and risk factors of developmental language disorder: first evidence for Mandarin-speaking children in a population-based study. The Lancet Regional Health - Western Pacific, 34, 100713. https://doi.org/https://doi.org/10.1016/j.lanwpc.2023.100713