Multilingual Assessment in Pediatrics

Multilingual Assessment in Pediatrics

Assessing children’s speech and language skills is an integral part of our work as speech-language pathologists. We must do so for children from monolingual and multilingual environments. While there are an estimated 5.1 million bilingual children enrolled in schools in the United States (NCES, 2022), it can be challenging to assess children whose first language is not English given the lack of adequate knowledge of speech and language development of bilingual children living in the United States, the lack of appropriately developed and normed assessment tools and tests, and the lack of personnel who speak the language of the child to be assessed. The purpose of this webpage is to give the speech-language pathologist general principles and information on the steps to follow when performing assessments with children whose language is not English.

Purpose of Assessment

According to Kohnert, Ebert, and Pham (2021), a bilingual assessment (as in any speech-language assessment) is performed to identify potential impairment, describe the individual’s communication system, plan a course of action, predict long-term outcomes of the plan, and evaluate the effects of the implemented plan of action over time. The earlier a child is identified, the earlier effective therapy can be provided, and better outcomes can be achieved. The bilingual child uses two language systems that need to be assessed in order to identify if the child truly has a disorder appropriately or if the language difficulties are due to the normal process of second language learning.

Reasons for Referrals

When the speech pathologist receives a referral to evaluate a bilingual child, the referral reasons usually deal with academics, language comprehension, and language expression. In a study by Kayser (1985), over 70% of referrals of bilingual children by teachers were related to academics and comprehension, and approximately 22% with expressive language. The referrals usually mentioned that the child was “not keeping up with the rest,” “does not follow directions,” “unintelligible,” “has trouble with English,” or “the speech unclear.” In the same study, Kayser (1985) also reported that referrals from kindergarten or first grade usually related to speech, but when they came from second grade or above, the concerns were usually academics or comprehension in the classroom. Also, she found common characteristics among Mexican-American children being referred due to language impairment. Some characteristics were: low socio-economic level, Spanish-speaking parents, poor conversational skills, English-only speaking teachers, and classrooms. The clinician should always keep in mind these characteristics of referrals and seek additional information from teachers, parents, and other professionals involved with the student before proceeding with the assessment (Kayser, 1985). 

Roseberry-McKibbin (2015) suggests that many characteristics that might signal language learning disabilities in students, such as non-verbal aspects of language, can result from cultural differences. Nevertheless, some signs are universal.  These include children failing to express basic needs or rarely initiating verbal interactions with peers. Other signs might be that the student uses gestures when vocalizations are expected, peers who speak the same language(s) have difficulty understanding responses or are confused because the student does not give enough information, or the information provided is disorganized. Follow this link for a complete list of characteristics of students with possible language learning disabilities. 

Bilingual Language Development

The language skills of bilingual children are similar but different from those of monolingual children. These language skills are not equally distributed across both languages. Bilingual children may show specific skills in one language but not in the other. Therefore, a comprehensive assessment of bilingual children has to be performed in both languages. A bilingual child is not two monolinguals in one. The acquisition rate of language milestones is similar to monolingual children, provided that both languages are considered. The rate of acquisition of the L1 and L2 varies among different learners. Some considerations are the length of exposure to each language, time of exposure to L2, reasons for learning the L2, academic experience with L1 and L2, ability to use each language, linguistic structure of the two languages, and individual variation. No two children are equal. Any bilingual child might have a relatively equal facility with both languages or the language skills in one language might be superior to those in the other (Kohnert, et al. 2021).

Is it a Language Difference or a Language Disorder?

This question is at the core of a bilingual assessment. The speech-language pathologist has to determine from the general description of the referral if the child has a language impairment or not. According to Kohnert (2010), the following characteristics should be present in order for a child to be identified as speech- or language-impaired: 

• There should be difficulty in both languages. The language impairment manifests itself in both languages because the difficulty is due to a problem with the processing of language input, which would affect both languages. However, the impairments might look different on the surface because each language has different features, and there are different demands for L1 and L2. For example, the nature and frequency of speech errors may differ according to the different sounds and sound patterns of each language or dialect. 

• Late achievement of milestones. Typically developing bilinguals achieve developmental milestones at approximately the same rate as monolingual peers, but the skills might be distributed across both languages. A comprehensive and detailed case history would enable the clinician to determine how the child’s development has progressed over the years. 

• Bilingual peers at a different level. During the assessment, the clinician might compare the child to other bilingual peers of the same age or siblings considered typically developing. If there are consistent differences between the performance of same-age-level peers, a disorder might be suspected. 

• Parent report. During the interview with parents, the clinician needs to inquire about parental views on the child’s speech-language deficiency and perceptions about the language difficulties he or she is experiencing. In a study conducted by Restrepo (1998), there was a high correlation between the parents’ reports of language input and performance to testing results done by the researchers. Therefore, the information provided by parents is invaluable in considering the child’s proficiency in their first language and how they view their child’s language. (Kohnert, 2010)

The Assessment

According to Goldstein & Fabiano (2007), a complete and comprehensive assessment of a bilingual child needs to be performed in both languages. The clinician needs to consider sociolinguistic variables when examining the interaction of the child’s skills in both languages. This section aims to give the clinician suggestions of steps to follow and considerations for the assessment. This section is subdivided into considerations before the assessment, assessment steps, assessment tools, and a special section for articulation and phonological assessment of bilingual children.

Guiding Principles for Assessment

According to Kohnert et al. (2021), the clinician who assesses a bilingual child needs to bear in mind that assessing this child is more complex because the clinician is dealing with two languages. Furthermore, the assessment method could affect the results. The lack of adequate testing materials and other resources makes the task more difficult. Therefore, the clinician needs to keep in mind certain principles that will guide him or her in performing a valid assessment with a bilingual child.

Identify and Reduce Sources of Bias

Bias in the assessment will fail to identify a child with a disorder or identify a child with a disorder who is typically developing or developing a flawed plan of action for therapy. The information collected would not reflect a child’s areas of strengths and needs. 

Types of bias: 

• Content bias—-the child’s knowledge is measured with tools and methods unfamiliar to his or her experience. 

• Linguistic bias–the language or dialect used in the assessment is inconsistent with the child’s experience. 

• Data interpretation bias–measurement standards are inconsistent with the child’s experience. 

• Cultural bias–There is an unrecognized mismatch between the child’s culture and his or her family and the assessment team. (Kohnert, et al 2021)

How to prevent bias: 

• Review literature on bilingual speech and language development. 

• Review features of L1 and L2. 

• Take into account the child’s age. 

• Take into account the child’s cultural and language acquisition history. 

• Identify peers with similar experiences (siblings, classmates). 

• Consider the expectations from the child’s family, community, culture, and academic team.

• Compare the child’s language change across time. 

• Observe the child’s needs across a range of settings to assess needs. 

• Understand the cultural context in which the child’s languages develop and the assessment and team members’ cultural context. (Kohnert, et al 2021)

Individualize Assessment Timing

One of the most common mistakes that specialists make regarding bilingual children is setting rigid time standards for the child to reach specific language and developmental milestones. For example, the team might decide to wait until a bilingual child has had two years of experience with English before assessing using the commonly known BICS/CALPS guidelines of second language acquisition. Although these guidelines are helpful in the sense that they emphasize that second language learning is a process that takes time, every child’s experience with language acquisition is different. The child’s rate of L1 and L2 development will be affected by the environment, the uses and demands of each language, sociolinguistic factors, and individual differences. It is, therefore, essential to observe how decisions are made regarding the best timing for an assessment (Kohnert, 2014).

Consider L1 and L2 Abilities and Needs

Bilingual children need both languages to communicate in their different family, social, and academic environments. Their bilingualism is not a choice. The speech-language needs to look at the child’s abilities in both languages and past, present, and future needs. Inventories and questionnaires of language use can be done to evaluate present and future needs. Parents, family members, peers, teachers, and other people who interact with the child would be important sources of information. The goal is to consider the child as a whole. The clinician needs to assess the child’s total communication system (Kohnert, 2014). 

Look Beyond the Obvious

This principle again underscores the importance of considering both languages to assess the abilities and needs of the bilingual child. As mentioned before, a bilingual child’s language abilities are distributed across the two languages. Assessing only one language (usually the majority language) could lead to inappropriate identification or misidentification of disorder (Kohnert, 2014). Also, according to Kayser (1995), clinicians tend to assess in the majority language, assuming that because the child speaks some English, it is appropriate to test in that language, perhaps ignoring that L1 might be the dominant language of the child. 

Gather Data Using Multiple Measures at Different Points in Time

This principle stresses the importance of considering various sources of data to make decisions regarding a bilingual child. The goal is to evaluate the child’s performance at different points in time. These considerations are:

• Reviewing developmental and educational reports.

• Interviewing the family, child, cultural representatives, classroom, and special education teachers to understand the cultural and educational environments and how language is used in each setting.

• Observing the child at home, in the classroom, in the playground, and in the clinic room will provide information on the communicative functioning of the child.

• Testing to gather data on the child’s receptive and expressive skills using picture identification, following instructions, listening to stories, answering questions, and telling stories. (Kohnert, 2014)

Before the Assessment

Before deciding to conduct an assessment, it is crucial to verify that the child’s referral for speech-language services is appropriate.

Pre-Referral Process

According to Garcia and Ortiz (2006), to reduce inappropriate referrals to special education for minority children, the professional needs to address background characteristics, identify the child’s problem, the source of the problems, and the steps to resolve the difficulties first within the classroom setting. The IRIS Center (2008) describes a pre-referral process based on modifying the curriculum and teaching strategies to help students learn. These steps relate to the characteristics of the curriculum and the child’s cultural experience of accessing it, the efforts made to identify the source of the problems and any alternative solutions that have been tried. Click here for a complete list and explanation of the Prereferral Process. 

Preparing for the Assessment

• Research and learn about the child’s cultural, social, and linguistic community. 

• Research and learn about the child’s language characteristics and dialectal differences. 

• Research and learn about the child’s cultural and social conventions to know appropriate greetings, gestures, and other basic formal conventions. 

• Research and learn about the family’s needs and concerns. 

• Review case history if available. 

• Determine if an interpreter will be needed for the assessment. Get together with the interpreter before the assessment to review the plan. Follow this link for more on working with interpreters.

• Select the appropriate assessment tools that will be used. 

• Make a plan. (McLeod & Verdon, 2017)

The Assessment Process

During the assessment process, the clinician can follow the steps outlined below:

Step 1: Perform a Detailed Case history

This step involves gathering previous medical and educational information and interviewing the parents and other family members, teachers, and other essential persons in the child’s life. This step is critical when assessing a bilingual child because the information gathered during this step will be crucial in deciding if the child has a speech-language disorder or not. Of particular interest to the speech-language pathologist is to ask the parents and family members involved with the child information about: 

• The child’s acquisition of L1 and L2. 

• Language(s) spoken at home. 

• Time and length of exposure to L2. 

• Amount of input and output in both languages. 

• Country of birth (immigrant vs. native). 

• Urban vs. rural background. 

• Generational membership. 

• Length of residence in the United States and degree of acculturation. 

• Family structure and child-rearing practices. 

• Play routines. 

• Sociolinguistic factors such as turn-taking, silence, and style of questioning. (McLeod, S., Verdon, S., 2017) 

Step 2: Perform additional routine assessments

• Oral-peripheral exam. 

• Hearing screening to rule out hearing impairment.

Step 3: Administer assessment tools in both languages 

The clinician has several options. According to Kohnert (2014), in bilingual assessments, the clinician cannot rely only on standardized assessments. The clinician will need to use a wide range of tools to assess the child’s bilingual skills fully. Kohnert (2014) classifies the assessment tools between product measures and process measures. Both types of measures have their purposes and need to be part of a comprehensive bilingual assessment. 

• Product Measures: Measure the performance of the child in a specific language. There are two types of product measures: language samples and standardized tests.

• Process Measures: These tools attempt to reduce biases and limitations typical of product-based measures. Examples of process measures are language learning measures, criterion-based measures, dynamic assessment, and portfolio assessment.

Assessment Tools

Following is a discussion of product and process assessment tools:

Language samples

If collecting language samples, a sample needs to be taken for each language. They can be either spontaneous or elicited. They can be obtained during structured or unstructured interactions with parents, siblings, peers, and teachers. For each sample, one must assess and analyze grammatical complexity, vocabulary, and pragmatics. If one does not speak the L1 of the child, the interpreter or other support person from the child’s community must help in analyzing the sample. Also, analyze if proficiency in the language being used responds to the demands of the communicative situation. Language samples need to be described using measures of morphosyntax complexity, utterance length in words, and a detailed analysis of the quality of the child’s utterances, such as the number and type of grammatical errors. Children might exhibit strengths in certain areas and not in others. The size of the language sample and its complexity will vary according to the situation, the topic, and the familiarity with the interaction partner (see Gutierrez-Clellen et al., 2000). 

Standardized formal tests

If there are tests available in the child’s first language, and the clinician decides to use them, several considerations are to be kept in mind when using these tests. It is essential to be careful how the results are used. Following are some precautions:

• Translated tests. Many tests are translations of their English versions. According to Stubbe-Kester and Peña (2002), this invalidates any results from the test because the hierarchy of difficulty of test items or complexity of language forms would be different in English and other languages. Thus, the test would not reflect the developmental order of items of the target language. 

• Test Normative Data. Before using a test, review its normative data and ensure the test was normed with a population with the same linguistic and cultural characteristics as the child. The clinician needs to look in the test manual to see language proficiency in the normative group. There is evidence suggesting that bilinguals score differently from monolinguals in certain cognitive measures (Rosselli, et al., 2010).

• Test Sensitivity and Specificity: According to Plante & Vance (1994), the recommended minimally acceptable criterion is 80% for specificity and sensitivity in a test when evaluated with a specific group of children similar to the child being assessed. 

• Language Learning Measures or Limited Training Tasks: In these measures, the child is given new information (invented words or grammar rules) through modeling and imitation in structured contexts. After a familiarization and practice period, the child is tested to determine how successful they are. The goal is to measure the amount of gain before and after the test (Eisenberg, et al., 2020). 

• Criterion-Based Measures: These are based on school curricula and involve measuring performance in both languages to compare and determine if the deficits are associated with disabilities or if they reflect the process of second-language acquisition. When data are available in both languages, clinicians can distinguish background differences and prevent a biased placement in special education (Ortiz & Yelich, 1991).

• Dynamic Assessment (DA): This type of assessment is based on Vygotsky’s concept of Zone of Proximal Development (ZPD). The child brings to the learning situation his or her interests, motivation, and knowledge. The adult is responsible for maintaining the child’s interest. In assessment, DA helps the clinician determine how a child learns, identify the child’s potential for change when given guided support by the examiner, induce self-regulated learning, and inform intervention. The potential for change is measured by three factors: child responsiveness, examiner’s effort, and transfer (Hasson & Joffe, 2007).

• Portfolio Assessment: A portfolio assessment is a collection of the student’s work samples. These samples more accurately reflect the child’s growth, achievements, and efforts in meaningful tasks relevant to the curriculum and activities in the classroom. It provides an opportunity to see what the child CAN do and the process of learning, instead of what the child cannot do typical of product measures. Teachers observe and record children’s learning behaviors (Yilmaz, et al., 2021). Follow this link for the advantages of portfolio assessment.

Step 4: Additional Measures for Articulatory and Phonological Disorders Assessment: 

• According to Gildersleeve-Neumann & Goldstein (2014), the clinician will need to examine the child’s skills “broadly” (e.g., segmental accuracy, phonological patterns) and “deeply” (consonant and vowel accuracy, sound errors). 

• According to Fabiano & Goldstein (2007), the following are the measures needed when assessing articulation and phonological disorders in bilingual children: 

  1. Assess both languages: single word and connected speech (conversation or narrative) samples should be obtained in both languages. The phonological acquisition is not parallel. Each language has different trajectories.

  2. Perform an independent analysis. Phonetic inventory in both languages using single-word and connected speech samples and organizing the inventory. 

  3. Perform a relational analysis. Overall consonant and vowel accuracy in each language and accuracy of shared elements. There is higher accuracy on shared phonological elements as compared with unshared ones. This aids in goal development. 

  4. Perform an error analysis. Bilingual children sometimes use a language-specific phonological element in the production of the other language. Ex. Using the Spanish trill in English. This should not be counted as an error. 

  5. Perform phonological pattern analysis. Patterns vary across languages. It is important to determine typical and atypical patterns for the language and age of the child. Ex. English allows 3-member onset clusters, and Spanish allows only two. If this error is present in English, it is developmental, but it might be considered delayed if present in Spanish.

  6. Diagnosis. It will be present in both languages if a child has a fundamental language-learning problem, delay, or disorder. If only one language is assessed, it is impossible to differentiate between phonological disorder and low language proficiency. 

Assessment Results

After administering the different assessment tools the results are analyzed. The clinician will determine if the child is typically developing and needs other types of academic support or if the child has a speech or language disorder. Then, the process of planning for intervention begins. The results from the assessment, especially the dynamic assessment results, will help determine goals for intervention and the most appropriate techniques for therapy.

Student Contributor: Alexandra Guerra-Sundberg, Winter 2008.

Updated October 2023