Multilingual Considerations for Aphasia

Bilingual Aphasia

This page is a resource for practicing clinicians interested in background information, assessment, and intervention with bilingual and multilingual persons with aphasia. The following topics are discussed:

•   Incidence, Prevalence, & Risk Factors

•   Characteristics of Bilingual Aphasia

•   Recovery

•   Assessment

•   Intervention

•   Implications for Rehabilitation

•   Resources

•   References & Readings

Incidence, Prevalence, & Risk Factors

The number of bilingual individuals in the United States (US) population has increased in recent years. An estimated 47 million persons 5 years of age and older speak a language other than English at home. The rise in the number of bilingual persons in the US results in increasing numbers of bilinguals in the aging population—a population at increased risk for developing cognitive-communication disorders such as aphasia. 

In the US, Latinos are the largest minority group, and aging Latinos are the fastest-growing subgroup. Risk factors such as inactivity, obesity, and diabetes put Latinos at twice the risk of ischemic stroke as non-Latinos. Amongst Mexican Americans, the incidence of stroke is 1.63%, compared to 1.36% for non-Latinos, and the frequency of transient ischemic attacks is higher in younger Mexican Americans than in other populations.

It is estimated that 45,000 new cases of bilingual aphasia will occur every year in the US. 

Characteristics of Bilingual Aphasia

As with monolingual aphasia, bilingual aphasia is caused by damage to the language-dominant hemisphere. Because functions for all languages are housed in the same hemisphere with at least partial overlap in neural localization, all languages will be affected in the majority of bilingual persons. However, some lesions in bilingual aphasia can result in differential recovery of languages. 

General Characteristics of Bilingual Aphasia

• Bilingual persons with aphasia will experience the same type of aphasia (e.g., expressive, receptive, or mixed) for all languages they use.

• Aphasia characteristics for each language are similar to those in monolingual persons with aphasia who have similar language proficiency before onset.

• The most salient characteristics of aphasia will differ depending on the languages involved; this occurs because languages may rely more or less on verb morphology, grammatical markers, or other characteristics for meaning.

For example, “In English, the individual may omit verb endings indicating tense, such as –s or –ed. However, in highly inflected languages, such as Spanish or Italian, where verb conjugations are more frequent and carry greater semantic importance, verb tense omissions may not be apparent, despite the reduced overall efficiency in language expression”.

Code-Switching

Both language mixing and language switching are common in typical bilingual individuals:

• Language mixing (LM) is the use of phonemes, morphemes, words, and clauses from one language in a sentence of another language. 

• Language switching (LS) occurs when a person alternates between more than one language. 

LM and LS utilize cognitive abilities of attention and executive control. Impairments in cognitive control may lead to an inability to suppress a language not currently used, resulting in unintentional code-switching in bilingual persons with aphasia. Uncontrollable and pathological LM and LS can reduce communication effectiveness, especially with monolingual partners, and may create further frustration in persons with aphasia.

Recovery

The languages in bilingual persons with aphasia may be affected differentially. One language may be more preserved than another, both languages may be impacted to a similar degree, or there may be fluctuations in the recovery of each language. Language domains and modalities may also be differentially affected in each language.

Language abilities in bilingual individuals and recovery of language functions are influenced by factors such as:

• Age and method of acquisition

• Proficiency in each language

• Use of and exposure to each language

• Motivation

• Social prestige of the languages

Recovery Types

Two general patterns of recovery for bilingual persons with aphasia are discussed in the literature:

• Parallel recovery: the abilities in L1 (first acquired language) and L2 (second acquired language) recover in proportion to premorbid abilities in each language; this is the most common type of recovery.

• Nonparallel recovery: the abilities in L1 and L2 differ from the premorbid proportions of proficiency in each language.

Lorenzen and Murray present an extensive list of additional, nonparallel expressive recovery patterns seen in bilingual persons with aphasia:

•  Differential recovery: one language experiences better recovery than the other.

•  Antagonistic recovery: one language is available initially after aphasia onset; however, the language that was available initially disappears or regresses as the other language recovers.

•  Alternating antagonism: antagonistic recovery occurs with alternating availability of each language; cycles of availability may range in length from 24 hours to several months.

•   Blending recovery: even when attempting to speak in only one language, the person with aphasia experiences uncontrolled mixing of grammatical characteristics or words from both (or all) languages.

•   Selective aphasia: impairment is seen in the abilities of one language with no measurable impairment in the other language(s).

•   Successive recovery: one language recovers before the other language(s).

In addition to recovery of expressive output, Lorenzen and Murray also describe four specific types of translation deficits that can occur in persons with bilingual aphasia. Translation deficits are the result of cognitive impairments that impact a person’s ability to translate from L1 to L2, from L2 to L1, or both. Translation deficits include:

•  Inability to translate: the person with aphasia cannot translate from either language to the other.

•  Paradoxical translation: the person with aphasia can translate only in one language.

•  Translation without comprehension: the person with aphasia is able to translate but does not comprehend the meaning.

•  Spontaneous translation: the person with aphasia involuntarily translates utterances that have been produced by themselves or others; they are unable to inhibit translating.

Recovery in Specific Domains & Modalities

Lorenzen & Murray describe recovery within the domains of morphosyntax and semantics, and in the modalities of reading and writing. Little research has been completed on other language domains and modalities.

Morphosyntax

• For bilingual individuals with aphasia who exhibit agrammatism, recovery of morphology and syntax will be highly variable because of different use and importance of grammatical structures across different languages.

• Morphological omissions may be more noticeable in languages that are highly inflected (e.g., Spanish).

• Some grammatical structures that are important for sentence comprehension may be preserved (e.g., studies have shown that retention of morphology is important for sentence comprehension in persons with aphasia who speak German and Italian).

• Variable syntactic recovery may also be the result of central or peripheral deficits. 

• A central deficit affects a person’s language competence and would impact all modalities across all languages in an individual.

• A peripheral deficit affects a person’s language performance and could impact only specific modalities or languages. Languages that use more of a specific linguistic property would be more affected (e.g., if the client has a syntactic impairment, the language(s) that rely more on word order would display more deficits).

• Overall, differences in morphosyntactic characteristics of each language may lead to patterns of deficits that differ from known descriptions of specific aphasia types (e.g., Broca’s aphasia) in English-speaking persons with aphasia.

Semantics

• The types and frequencies of paraphasias across languages may vary.

• Semantic paraphasias in bilingual persons with aphasia may also include retrieving the correct word in the language they did not intend to use.

Reading

• Different strategies may be used for reading in different languages (e.g., phonological or whole-word reading) depending on the orthographic transparency of the written languages. Therefore, if one reading route is impaired, a bilingual person with aphasia may demonstrate more pronounced reading deficits in one language than the other(s).

• Error types may also differ depending on the language(s) impaired. For example, English (an alphabetic language) may be more prone to visually-based errors such as heat for heart, whereas Chinese (a character-based language) may have more semantic errors).

Writing

The transparency of orthography in the languages used by the person with aphasia may also impact writing. Some languages use a phonological route primarily, whereas others use a lexical-semantic route primarily; therefore, if the languages differ in transparency and one route is more impacted than another, the person with aphasia may exhibit differential deficits between languages.

Assessment

The following are assessment considerations adapted from Kohnert.  Many of these suggestions are similar to the ones that clinicians may be familiar with when assessing monolingual clients. However, there are several differences:

• The primary difference is the importance of considering the client’s needs in all the languages they speak. This information can be gathered in various ways, including checklists, questionnaires, or interviewing the client and his or her family.

• Another area of difference is the inclusion of tasks that evaluate the use of multiple languages (e.g., code-switching and translation tasks). These tasks help provide data regarding the client’s ability to shift from language to language and to use skills preserved in one language for productions in another language.

• A final and fundamental consideration for bilinguals that may be overlooked when assessing monolinguals is the overall cognitive abilities of the client. As bilingual research has shown, bilingual competency has cognitive and linguistic basis; it is important to assess a client’s cognitive functioning.

General Considerations   

The client’s proficiency in each language (past and present) and their motivation/need for each language should guide the clinician in deciding which language(s) to assess and ultimately which direction to focus treatment:

• Proficiency in each language

• Age at acquisition of languages

• Language use

• Do they currently use multiple languages? In what contexts?

• What language is spoken in the home environment? Work environment?

• Motivation/need for each language

• Is there a preferred language?

• What language(s) to assess

• Are there language assessments available in the client’s language?

• Using data acquired in previous bullets, make a decision regarding which language(s) to assess, taking into account both the desires of the client, their family, and your clinical judgment.

Gathering and Interpreting Data: Data at the Individual Level 

The following areas related to the individual client should be assessed:

1. Review medical records

2. Medical/social history

3. Relevant health information

4. Client interview: use ethnographic methods; collaborate with an interpreter or bilingual family member/friend

5. Educational/occupational history

6. Social circumstances

7. Preferred activities

8. Computer literacy level

9. Assessment of cognitive processing system

10. Perception of/attention to auditory stimuli

11. Problem-solving (e.g., arithmetic or complex problems)

12. Categorizing, sequencing, or organizing non-linguistic information

13. Emotional status: does the client easily become overwhelmed or frustrated?

14. Patient fatigue: measure this by increasing cognitive demands (e.g., background noise or time pressure)

15. Unintentional language mixing

16. Frequency and conditions

17. Client response

Examples of assessments:

• Computer software programs

• Cognitive-Linguistic Quick Test

• NEUROPSI-Attention and Memory

• Wisconsin Card Sorting Test

• Language and communicative ability: past and present (assess in all of the client’s languages)

• Previous language experience, pattern of use, and report of language proficiency

• Language Experience and Proficiency Questionnaire (LEAP-Q)

• Auditory comprehension

• Language production

• Reading

• Writing

• Confrontation naming

• Automatic speech production tasks

• Word/sentence repetition

• Translation tasks

• Ability to code-switch

Examples of assessments:

• Language Experience and Proficiency Questionnaire (LEAP-Q)

• Bilingual Aphasia Language Summary Form

• Bilingual Aphasia Test (BAT)

• Adapted into many languages including Arabic, Cantonese, Korean, Russian, Spanish, Vietnamese, and Yiddish

• Multilingual Aphasia Examination

• Clinician-developed criterion-referenced tasks

• ASHA Functional Assessment of Communication Skills (FACS)

Data at the Environmental Level

Information should be gathered to identify potential barriers or facilitators to participation. The following should be considered:

• Identify linguistic resources or limitations of the family. 

• Does the client/family participate in a larger community?

• Is there a bilingual family or community member they would like to include in meetings?

• Linguistic isolation (e.g., no one in the home over 14 speaks the majority language proficiently)

• Access to technology (e.g., assistive listening devices, computers, or Internet)

• Are there any other environmental barriers that exist which would prevent the client from receiving optimal care?

Intervention

*Empirical evidence for the treatment of bilingual aphasia is limited; however, several authors have provided general guidelines for treatment based on current evidence.

Which Language or Languages to Treat

• For bilingual persons with aphasia, it is important to treat all languages used prior to the onset of aphasia and which are needed in the client’s environment. Treatment that purposely excludes one language can isolate bilingual clients with aphasia from their social networks.

• Research has demonstrated that treatment in one language results in positive or neutral outcomes for untreated language(s); therefore, if a clinician does not speak all of the client’s languages, they may provide direct treatment in only one language and use indirect methods for treating the other language(s).

• For bilinguals speaking two or more languages that have linguistic similarities, the clinician may provide treatment in one language with words that are similar in form and meaning in both languages (i.e., Cognate Therapy).

• Treatment directed toward areas of cognitive-linguistic overlap or treatment focused on strengthening cognitive processes underlying language (e.g., attention, perception, etc.) may assist in improving all language(s) in bilingual persons with aphasia.

Treatment Planning

When determining intervention goals, strategies, and stimuli for a bilingual individual with aphasia, the clinician should consider the following:

• Needs and experiences of all languages

• Proficiency and use of each language before and after the onset of aphasia

• Emotional value that each language has for the client

• Characteristics of all the client’s languages (e.g., syntax)

• Communicative purpose (e.g., expressing wants and needs, social interaction, etc.) and environments of use (e.g., family, health care providers, etc.) for each language

• The clinician may involve other persons in treatment of bilingual adults with aphasia:

  • Family members play an important role in helping to develop intervention materials and implement treatment in language(s) that the clinician does not speak

  • If interpreters or translators are used during treatment, it is important to educate them on aphasia in bilingual individuals, brief them on treatment prior to the session (e.g., review materials, procedures, etc.), and  debrief after the session

Treatment Approaches

• Cognitive-Based Approaches: Intervention focused on strengthening basic cognitive processes may be used to increase the skills of all languages in a bilingual person with aphasia. This approach may also be beneficial when there is a mismatch between clinician and client language and is especially useful for initial treatment with persons with severe nonfluent aphasia.

• Language-Based Approaches: Treatment focused on improving listening, speaking, reading, or writing should be provided in all languages needed by the client. For bilinguals speaking two or more languages with similarities, a clinician may provide cognate treatment for naming: train words in one language that have words with similar form and meaning in the other language (e.g., rose in English and rosa in Spanish). The clinician may also provide direct therapy in one language and indirect therapy in other language(s) with assistance from family members, caregivers, or community members.

•  Communication-Based Approaches: Intervention focused on improving functional communication with bilingual clients with aphasia can assist in increasing the overall effectiveness of communication. One approach is to shape unintentional code-switching into a functional communication strategy.

• Environmentally-Directed Approaches: Treatment focused on reducing barriers and increasing opportunities for bilingual persons with aphasia includes caregiver, family, and staff education and training, as well as group therapy. With the assistance of an interpreter, aphasia groups consisting of monolingual individuals may be effective for bilingual clients with aphasia and their families. The clinician may consider forming bilingual aphasia groups in areas with large populations of bilingual persons. 

Cross-Linguistic Transfer (CLT)

CLT refers to generalization from a treated language to an untreated language. CLT is a way to ensure effective and efficient therapy in bilingual individuals with aphasia. 

In systematic reviews of the literature, Kohnert and Faroqi-Shah, Frymark, Mullen, and Wang explained:

• Research on CLT in treatments with bilingual clients with aphasia is scarce.  

• Results from the studies are mixed. 

• Current evidence should be viewed with caution due to methodological concerns and because many studies were performed on adults in the acute phase of recovery without accounting for spontaneous recovery. 

• Faroqi-Shah, Frymark, Mullen, and Wang found modest evidence that treatment in one language had positive effects and CLT for bilingual individuals with aphasia. Specifically, they noted the following:

  • Treatment in L2 led to positive outcomes in receptive and expressive language in L2, even in those with chronic aphasia.

  • CLT for expressive and receptive language occurred in more than half of the participants in the studies, regardless of whether treatment occurred in L1 or L2; however, the magnitude of change was larger when treatment occurred in L1.

  • Age of acquisition and language typology did not impact treatment outcomes or CLT. However, Kohnert noted that CLT might differ depending on factors such as the similarities between languages, proficiency of each language, premorbid use of each language, and modality.

  • Both literature reviews found that current evidence demonstrates that treatment in one language, even L2, can lead to improvement of receptive and expressive abilities or have no negative effect on the untreated language. Therefore, clinicians may consider administering direct treatment in L2 for early to late bilinguals with L2 proficiency that is moderate to high. 

  • However, Kohnert cautioned that indirect methods of treatment should still be used with the other language(s). 

Effective Treatments

Lorenzen and Murray noted several treatments that have been shown to be effective with bilingual clients with aphasia or monolingual clients with aphasia in languages other than English. The authors also provided a list of treatments that demonstrated cross-linguistic transfer and suggested several compensatory strategies appropriate for bilingual clients.

Traditional Treatments Effective with Bilingual Clients with Aphasia

•  Stimulation approach: Intensive auditory stimulation, repetition, naming, reading, and writing tasks with varying levels of complexity are used to restimulate underlying language processes in all modalities.

•  Phonemic cueing: Initial phonemes are used to facilitate word retrieval.

Treatments Effective with Monolingual Clients with Aphasia (in languages other than English)

•  Melodic Intonation Therapy: Intonation and rhythm are used to increase verbal language production.

•  Cueing hierarchy treatment: Hierarchies of cues and prompts are used to facilitate word retrieval.

Treatments with Demonstrated Cross-Linguistic Transfer (CLT)

• Reading and naming treatments: CLT has been demonstrated when reading and naming treatments are focused on shared aspects of languages, for example:

• Cognate therapy is effective for CLT of word retrieval gains. Therapy consists of targeting words that have similar form and meaning in both/all languages (e.g., plate in English and plato in Spanish). This treatment is appropriate if a client’s languages share similarities.

• Cognitive treatment: Cognitive intervention may result in CLT in persons with concomitant cognitive impairments. Treatment tasks may include: card sorting, simple math calculations, letter searches, and other cognitive activities.

Compensatory Strategies

In addition to impairment-level treatments listed above, the following compensatory strategies have been suggested to increase functional communication in bilingual individuals with aphasia.

• Use of translation for word retrieval difficulties: The person with aphasia produces a target word in another language in order to cue himself or herself.

• Intentional use of cognates or language mixing to increase functional communication: The person with aphasia intentionally uses words in another language to communicate with other persons; this strategy is especially useful for those living in bilingual communities with persons who understand all languages the client uses.

• Training communication partners to understand cognates in a language they do not speak: The clinician teaches a conversation partner words used by the client in his or her other language(s); then, the person with aphasia can use language mixing with the trained communication partner.

• Training the use of metalinguistic knowledge: The clinician uses a structural approach with grammatical exercises to draw the client’s attention to the surface features of language.

• Visual Action Therapy: This technique utilizes everyday tools (e.g., hammers and screwdrivers) in therapy to improve functional communication.

• Promoting Aphasics’ Communicative Effectiveness: The clinician and client take turns sending and receiving messages in a conversation. The client is encouraged to use any mode of communication (e.g., visual, gestural, graphic, verbal, etc.) to send his or her messages.

• Functional Communication Treatment: This therapy approach focuses on improving functional communication within personally relevant communicative situations and activities by using role-play and everyday materials (e.g., menus).

• Communicative Strategies: The person with aphasia and his or her conversational partner are taught strategies to support functional communication (e.g., requesting clarification, repeating, or using gestures or writing).

Implications for Rehabilitation

Transfer from treated to non-treated language(s)

• At this time, there is no definitive data on CLT. Some researchers suggest the CLT will occur in proportion to the degree of similarity between the various aspects of the treated language and non-treated language.  Other researchers report no transfer to the non-treated language, while still others posit that bilingual treatment should be most effective as it would stimulate several types of language processing.

• It should not be assumed that if treatment in one language is ineffective, treatment in another will also be ineffective.  The clinician should use his/her clinical judgment in deciding which language(s) to treat and be willing to try another if treatment is not effective in the targeted language.]

Student Contributor: Kristina Mustacich, Spring 2012