Customizing Treatment for Bilingual Speakers With Aphasia: Bilingual clients with aphasia need clinicians to incorporate individually tailored bilingualism principles into rehabilitation.

José G. Centeno; Ana I. Ansaldo

doi:10.1044/leader.FTR2.21102016.52

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Features | October 01, 2016

Customizing Treatment for Bilingual Speakers With AphasiaBilingual clients with aphasia need clinicians to incorporate individually tailored bilingualism principles into rehabilitation.

José G. Centeno, PhD, CCC-SLP; Ana I. Ansaldo, PhD

Author Notes

Article Information

The ASHA Leader, October 2016, Vol. 21, 52-56. doi:10.1044/leader.FTR2.21102016.52

Rita, 68, was born in Venezuela and arrived in New York City when she was 32. She worked as a cafeteria manager and lived with her husband and two of her four children. She is bilingual in Spanish and English and experienced a left-sided stroke that resulted in Broca’s aphasia in both languages. She speaks in labored, incomplete utterances and struggles with object-naming in both languages. Although she shows aphasic symptoms in both languages, she relies on Spanish—her dominant language before the stroke—more so than on English. Her auditory comprehension is fairly good in both languages, even at the conversational level.

Clinicians are more likely than ever to encounter clients like Rita, given U.S. demographics. The U.S. Census Bureau projects that ethnic and racial minorities—now estimated at 37 percent of the total population—will make up 57 percent of the population by 2060 (see sources). Hispanics are the largest minority, and slightly more than 20 percent of Americans report speaking a minority language at home.

Meanwhile, the incidence and prevalence of strokes—the country’s third-leading cause of death and its leading cause of long-term disability—are higher among blacks, Hispanics, American Indians and Alaska natives than among whites. Older people in minority communities have more stroke risk factors (such as hypertension, obesity and smoking) and higher stroke mortality than their white counterparts, reports the National Institute of Neurological Disorders and Stroke (see sources).

And, of course, Americans are aging. Almost 15 percent of Americans are 65 and older—a number that will rise to more than a quarter of Americans by 2060.

Now consider this finding from a survey conducted among speech-language pathologists serving bilingual adults: Aphasia is the most challenging neurogenic communication disorder they face. Why? Because no one client has the same profile of first- versus second-language rebound. SLPs working with bilingual or multilingual people with aphasia face unique conceptual and clinical challenges. Each client requires us to incorporate individually tailored bilingual elements into assessment and treatment. And for monolingual clinicians, there’s an additional need to use interpreters to assist with intervention.

Unique profiles

The main conceptual challenge is determining the impact of each person’s individual bilingualism trajectory on the aphasia profile. Age of language acquisition interacts with the extent of language use throughout life. Language mastery in each bilingual person depends on how much the first (L1) and second (L2) languages are used across different communication contexts over time. Such contexts include home, social activities, school and work. It is also important to understand how people use language modalities—auditory comprehension, reading, speaking and writing—in those environments throughout life.

Generally, bilingual speakers have a dominant language that they use more frequently across contexts and modalities. But they also use all types of routine conversational variations: For example, they may mix both languages when talking to speakers of the same two languages. This is called language mixing or code switching, as in “Caminé muy rápido. I’m exhausted./I walked very fast. I’m exhausted.” They may also use L1 word order when speaking in L2—for example, they may make grammatical transfer errors such as “the car blue” instead of “the blue car.”

They also may struggle with some L2 sound patterns, using, for example, “banilla” for vanilla, because the L1 does not have a “v” sound. They also may find it increasingly difficult to speak in their L1 because they’ve been primarily using their L2.

Meanwhile, there is little research on how these varying language backgrounds may influence the aphasia profile and language recovery patterns of bilingual speakers, posing diagnostic and treatment challenges for clinicians. We lack valid clinical tools to personalize assessment and treatment for these clients. We need alternative procedures and strategies, as illustrated next.

Language mastery in each bilingual person depends on how much the first and second languages are used across different communication contexts over time.

Service strategies

Let’s return to Rita’s case and walk through our clinical protocol with this bilingual client. Although we (the authors) are bilingual clinicians, monolingual clinicians may still use the treatment strategies we describe—with the help of an interpreter. ASHA’s Practice Portal offers information and guidelines on the use of interpreters.

We grounded Rita’s treatment plan in bilingualism principles and adapted clinical procedures to her individual background and communication needs. Here’s a closer look at our approach:

Intake. We gathered standard information on educational experiences, social background and the like, but also administered a bilingualism history questionnaire to Rita’s husband and daughter, using intake principles described in the literature (see the SIG 14 Perspectives article “The Relevance of Bilingualism Questionnaires in the Personalized Treatment of Bilinguals With Aphasia”). This questionnaire gave us insight into Rita’s pre-stroke linguistic and communicative experiences in both languages. From this, we could estimate her pre-stroke language mastery across modalities and her pre-stroke bilingual mode of communication, and what that could mean for her post-stroke language abilities. We found that Rita had lived a bilingual life in which Spanish was her dominant language. She primarily used Spanish at home and socially, but she communicated in English at work.

Assessment. As part of our formal evaluation, we administered an aphasia test in English and its adapted version in Spanish. We modified the Argentinean version of the test into Rita’s Venezuelan Spanish. We reported the results in percentages because norms of the test (developed in Argentina) were not available for Venezuelan Spanish-speakers. For both languages, results showed a similar pattern of Broca’s aphasia, including naming deficits and agrammatic utterances: “Gente … big big … kisen kitchen… food … day and night … trabajando … papel/people … big big … kisen kitchen … food … day and night … working … paper.” Rita performed better in Spanish than in English. In informal conversation with other bilingual speakers, she mixed L1 and L2, a typical feature of bilingual discourse.

Intervention. We designed a treatment plan to facilitate naming and utterance construction. We based this plan on Rita’s sociocultural background and language use routines, such as family celebrations, church activities and work tasks—information we’d collected from the intake procedures and the bilingualism questionnaire. We conducted treatment sessions bilingually, using translation and language-switching to maintain Rita’s pre-stroke bilingual mode of communication. We also sought to give her an evidence-based self-help strategy that would allow her to switch languages when experiencing expressive difficulties in either language.

Research conducted in 2009 (see sources) indicates that a voluntary language-switching strategy—which involves translating from the nontarget language into the target one—may be an efficient way to facilitate language recovery in bilingual speakers with aphasia. Thus, if the word or expression is not available in the target language, the person is encouraged to translate it from the nontarget language.

Also, our incorporation of home, family and work contexts into treatment jibes with research on emotional-cognitive relationships in each language (see sources). And, as it turned out, Rita showed improvement in both languages, more easily naming items and producing short phrases, during her three-month intervention program—after which she moved elsewhere. She used Spanish more frequently than English, consistent with her pre-stroke language dominance pattern.

A voluntary language-switching strategy—which involves translating from the non-target language into the target one—may be an efficient way to facilitate language recovery in bilingual speakers with aphasia.

Addressing the gaps

Rita’s case illustrates how aphasia management may be individualized to each bilingual client for efficient intervention. Yet we need more research to determine suitable evaluation and intervention for the steadily growing numbers of multilingual adults with aphasia in neurorehabilitation programs.

We need more investigators to focus on neurogenic communication disorders in minority adults, conducting research to address service needs among the high numbers of bilingual speakers in this population. And we especially need studies of valid assessment instruments, use of interpreter-assisted clinical services, the role of sociocultural attitudes toward disability, and the implementation of neuroscientifically based intervention.

Sources

Ansaldo, A. I., & Ghazi-Saidi, L. (2014) Aphasia therapy in the age of globalization: Cross-linguistic therapy effects in bilingual aphasia. Behavioural Neurology, 2014. doi: 10.1155/2014/603085.

Ansaldo, A. I., Ghazi-Saidi, L., & Ruiz, A. (2009) Model-driven intervention in bilingual aphasia: Evidence from a case of pathological language mixing. Aphasiology, 24(2), 309–324.

Centeno, J. G. (2010). The relevance of bilingualism questionnaires in the personalized treatment of bilinguals with aphasia. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 17, 65–73. [Article]

Centeno, J. G. (2015). Assessing services with communicatively-impaired bilingual adults in culturally and linguistically diverse neurorehabilitation programs. Journal of Communication Disorders, 58, 58–73. [Article] [PubMed]

Centeno, J. G., Ghazi-Saidi, L., & Ansaldo, A. I. (2017). Aphasia in multilingual populations. In Papathanasiou, I. & Coppens, P. (Eds.), Aphasia and related neurogenic communication disorders (2nd ed.), 331–350. Boston: Jones and Bartlett.

Cruz-Flores, S., Rabinstein, A., Biller, J., Elkind, M. S. V., Griffith, P., Gorelick, P. B., … Valderrama, A. L. (2011). Racial-ethnic disparities in stroke care: The American experience. Stroke, 42, 2091–2116. [Article] [PubMed]

Faroqi-Shah, Y., Frymark, T., Mullen, R., & Wang, B. (2010). Effect of treatment for bilingual individuals with aphasia: A systematic review of the evidence. Journal of Neurolinguistics, 23, 319–341. [Article]

Kiran, S., & Roberts, P. (2012). What do we know about assessing language impairment in bilingual aphasia? In Gitterman, M., Goral, M., & Obler, L. K. (Eds.), Aspects of multilingual aphasia, 35–50). Clevedon, UK: Multilingual Matters.

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National Institute of Neurological Disorders and Stroke. (2016). Health disparities research in neurological disorders. Retrieved from www.ninds.nih.gov/research/health_disparities.

Olivares, I., & Altarriba, J. (2009). Mental health considerations for speech-language services with bilingual Spanish-English speakers. Seminars in Speech and Language, 30, 153–161. [Article] [PubMed]

Ryan, C. (2013). Language use in the United States: 2011. U.S. American Community Survey Reports, ACS-22. Washington, DC: U.S. Census Bureau.

U.S. Census Bureau. (2012). U.S census projections show a slower growing, older, more diverse nation a half century from now. U.S. Census Bureau News, Report CB12-243. Washington, DC: Author.

U.S. Census Bureau. (2014). Annual estimates of the resident population by sex, race, and Hispanic origins for the United States, states, and counties: April 1, 2010, to July 1, 2013. Washington, DC: Author.

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