Serving Multilingual Clients With Hearing Loss ...
How
Linguistic Diversity Affects Audiologic Management
by Ishara
Ramkissoon & Farhana Khan
These are exciting times for
audiologists serving clients from a myriad of cultural and linguistic
backgrounds. Linguistic diversity, especially, affects audiologic management.
Services are particularly affected when clients have limited English
proficiency (LEP) because test materials are usually available in English only.
The great majority of audiologists
in the United States—80%—are English speakers. However, the latest Census data
indicate that almost 14% of U.S. residents do not speak English, creating a
challenging clinical environment.
Although little information is
available about the incidence of hearing loss among multilingual clients, a
2002 Gallaudet Research Institute survey reported that 8.9% of children who are
deaf or hard of hearing are from homes where more than one language is spoken
and 10.3% are from monolingual Spanish-speaking homes. Thus, audiologists need
specialized clinical knowledge to provide equitable services for such clients.
The client’s linguistic profile,
such as age, number of languages spoken, acquisition age for each language, and
proficiency in each language, affects audiological management. Linguistic
profiles can be quite variable. For example, a client reporting elective
bilingualism has decided to learn a second language and typically has
proficiency in both languages. Alternatively, a circumstantial bi/multilingual
person has learned several languages because of necessity in the communication
environment, and proficiency in each language may be variable.
Communicating with Multilingual
Clients
Despite the language mismatch
between client and audiologist, appropriate clinical communication is
important. Sometimes, a rudimentary knowledge of the individual’s language is
insufficient to ensure an accurate interaction. Audiologists should have the
ability to adjust management when language barriers exist. For example,
enlisting interpreters or speech-language pathology/audiology (SLP/A)
assistants is often a worthwhile decision.
Interpreters are usually competent
in the client’s language, facilitating information gathering, giving test
instructions, and relaying evaluation feedback. Interpreters often share the
client’s social, cultural, or ethnic background and facilitate trust, comfort,
and acceptability in the clinical interaction. Interpreters or assistants are
particularly helpful during pediatric play audiometry. With training, they can
effectively condition young children to the task at hand, facilitating response
accuracy and improved test reliability. During audiologic rehabilitation
sessions, interpreters usually relay information because of the
clinician-client language barrier. Adequate training of interpreters and SLP/A
assistants is required for successful outcomes. Optimum use of interpreters
occurs in a symbiotic relationship with the audiologist, where appropriate
training is provided, and responsibilities, boundaries, and functional limits
are outlined. Clinical interaction is also enhanced when audiologists
demonstrate a basic understanding of the client’s language.
Speech Audiometry
Speech audiometry is most affected
by multilingualism because tests are language-based. Although English test
materials might not yield ideal outcomes for non-native speakers, they are
still popular because of their availability, longevity, research support, and
compatibility with the language of most audiologists.
In clinical practice with
multilingual clients, we often observed that the measured speech recognition
threshold (SRT) did not match the pure-tone average (PTA), and was seldom
within the 5–6 dB clinical norm. SRT measurement is critical in diagnostic
audiology, providing an overall indication of hearing threshold for speech,
serving as a PTA reliability check, and providing a baseline for suprathreshold
tests. Therefore, audiologists have sought alternatives, such as using a subset
of a popular test or using tests in the client’s first language, when
available.
For LEP clients, audiologists often
modify the SRT test by reducing set size, and selecting only familiar words.
Set-size reduction is popular due to convenience, reduced test time, and because
it eliminates the need for alternate tests. However, research from Punch and
Howard indicated that it reduces measurement accuracy, yielding lower SRT
thresholds, which could lead to erroneous diagnostic conclusions.
Although language-specific tests
have been developed, their validity and perceptual saliency are questionable.
These tests are fairly new to audiology and lack clinical research support. The
primary drawback of all non-English speech tests is limited use and
applicability because audiologists are seldom proficient in the language of the
test. In addition, language-specific tests are useful for only one linguistic
group, and do not meet the needs of a multilingual community. Thus, they do not
solve the immediate problems facing English-speaking audiologists.
Given the limitations of these
modified practices, audiologists need an alternate SRT test with
cross-linguistic appeal to accommodate clients from various linguistic
backgrounds. The digit-SRT test may be an appropriate solution because research
demonstrated its applicability in the United States for LEP, non-native
speakers of English. The digit-SRT test is also being used in South Africa and
its evaluation with other multilingual or non-native English speakers is
encouraged.
Although not well understood,
multilingualism influences suprathreshold speech performance. In our
experience, multilingual clients had disproportionately poor test scores,
conflicting with clinical expectations based on pure-tone tests. Linguistic
background influences test performance in a unique manner; however, an overall
unfamiliarity with test words accounts for some discrepancy.
Suprathreshold speech tests are
often conducted in the presence of background noise to determine communication
handicap and evaluate central auditory processing ability. Hearing loss and
linguistic profile influence performance on these tests. For example, research
reviewed by von Hapsburg and Pena indicated that bilingual individuals have
poorer speech perception in noise compared to their monolingual counterparts,
suggesting that adding a challenging auditory environment to a test of
unfamiliar words negatively affected performance.
Alternate suprathreshold tests were
formally developed in languages such as Spanish, French, and Arabic. However,
these tests have limited practical use because audiologists predominantly speak
English and the tests do not meet the needs of a multilingual clientele. In
addition, von Hapsburg and Pena’s review of Spanish suprathreshold tests
developed for monolingual listeners in the United States indicates that
bilingual participants were used to evaluate these tests, making their validity
questionable.
Choices and Intervention
When hearing loss is severe or
profound, multilingualism becomes an important consideration in language
acquisition. There is very little research on bilingual language acquisition or
the effects of multilingualism on communication in children with hearing loss.
Communication choices for children
with hearing loss typically contrast manual and oral systems, with
multilingualism having variable effects on each. The choice of communication
system might be altered in different ways depending on the philosophy of the
parents, educators, and community. In general, oral schools in the United
States and Canada serving children from bilingual homes emphasize a
transitional approach to language acquisition. Families are encouraged to use
the home language with the child while moving toward proficiency in English.
Some schools begin early intervention in English, starting in parent-infant
programs while mainstream schools encourage home language use and development
until formal teaching begins. The empowerment method encourages parental
involvement and the integration of language and culture in communication
development.
Research by Levi et al. indicates
that functional speech perception skills are not different between oral
multilingual and monolingual children; however, multilingual children in total
communication environments are at greater risk for slower development of speech
perception skills than their monolingual peers. It appears that adding a third
language in a total communication environment negatively influences development
of speech perception. Because this is an important consideration for
multilingual families making communication choices for their child with hearing
loss, audiologists should impart this information during the counseling
process.
In conclusion, increased awareness
of the impact of multilingualism on audiology practice has stimulated research,
but ultimately, the responsibility lies with individual audiologists to provide
equitable and relevant care.
أيمن
محمد عبداللطيف محمد خالد
Aiman Mohamed Abdullatif Mohamed Khaled
اختصاصي
النطق واللغة
Speech and Language
Specialist