Attention SLPs: Assessment Considerations in Bilingual Aphasics

When assessing a bilingual aphasic, it is important to consider language assessment in both languages. Bilinguals with aphasia do not always have the same degree of severity in both languages. While abilities can be impaired in a similar way (parallel aphasia), it is also possible for abilities to be impaired to a different extent for each language (dissociated aphasia). Therefore, assessment in both languages is critical for determining the client’s strengths and weaknesses in both languages in order to get a clear picture of the client’s individual presentation of aphasia (Ardila, Aphasia Handbook, 157).

In addition, a monolingual aphasic’s prognosis for recovery is dependent upon aphasia type, aphasia severity, site of lesion, and size of lesion. On top of these factors, there are also many more factors that contribute to a bilingual aphasic’s prognosis of recovery: “pre-stroke language proficiency, balance of proficiency across languages, age of acquisition of each language, patterns of language use pre-stroke, phonological structure of each language”, etc (Kiran and Roberts, 37). Assessing clinicians have to perform an in-depth case history with any influential family members that are available, in order to determine the true severity of the client’s aphasia type. Comparison of pre-functioning and post-functioning language abilities in each language is crucial, otherwise erroneous assumptions and unrealistic goals can ensue. It would be inappropriate for the clinician to work as a language teacher by targeting skills that were not present pre-morbidly (Kiran and Roberts, 39). A clinician can attempt to determine the client’s levels of functioning prior to their stroke via self rating scales (if the client is capable of utilizing a number scale to indicate certain skills), family ratings, as well as determining language acquisition history and patterns of language use for each language (Kiran and Roberts, 40-41).

Kiran and Roberts propose two methods of determining the client’s post-morbid speech and language abilities: verbal fluency and narrative output. Verbal fluency allows a clinician to determine the client’s lexical production based on category or letter (i.e. name all the animals you can in one minute, dígame todas las palabras que empiezan con la letra “b” que sabe Ud.). It also serves as a basis for baseline data, as the clinician can compare the initial assessment performance with future performance on similar tasks. Narrative output is a good way to ascertain the client’s post-morbid language abilities in each language by utilizing a series of pictures to elicit a narrative. This can provide the clinician with a good picture of the client’s current skills regarding syntax, lexicon, morphology and discourse in each language. Again, these tasks can be used for measuring change over time (Kiran and Roberts, 46).

It is crucial that the clinician investigate the client’s morphological skills in each language, as bilingual aphasics, more so that monolingual aphasics, are susceptible to “compound processing impairment”, which means that they are likely to make errors of morphology for compound words – either through omissions or substitutions of morphological units in compound words (Libben, Aspects of Bilingual Aphasia, 54).

Written by: Taylor Viggers, MS, CF-SLP


Kiran, Swathi and Roberts, Patricia M.(2009) ‘Semantic feature analysis treatment in Spanish-English and French-English bilingual aphasia’, Aphasiology,, First published on: 31 August 2009 (iFirst)


Kiran S, Grasemann U, Sandberg C, Miikkulainen R. A Computational Account of Bilingual Aphasia Rehabilitation. Bilingualism (Cambridge, England). 2013;16(2):325-342. doi:10.1017/S1366728912000533.

Paradis, M., Libben, G., & Hummel, K. (1987)  The Bilingual Aphasia Test.  Hillsdale, NJ.: Lawrence Erlbaum.  32 + 127pp.


How does a speaker of another language learn English?

According to Smyk et al (2013), there are five distinct stages of second language acquisition. The first stage is called the “silent/observer” stage, the second is “a few words or formulaic phrases” (sometimes known as telegraphic/formulaic use of language), the third is when language enters a more productive use, with “short sentences and phrases with multiple errors”, followed by the forth stage of “full sentences with a few grammatical errors”, and then finally “native-like production”.

At the first stage, when children are “silent/observing”, the child may appear to be nonverbal or in a sometimes called “silent period”. This is a critical period in which the child is learning the new elements of a language and focusing solely on receptive comprehension of the language. Their knowledge of the language is too minimal for them to produce very much of the language, except for maybe a few words or jargon. It is not uncommon for the child to play with sounds of the new language, as this is a means of exploration of their new language exposure. At this stage, because the child is so reliant on learning through observing the new environment to understand the new language, routines can be very beneficial for accommodating the child. For example, establishing continual use of familiar picture cards, gestures, and phrases that the child can anticipate will give the child a sense of consistency and stability. Pairing the child with slightly advanced speakers to demonstrate good peer models of the language, while also placing an emphasis on social interactions, will also benefit the child’s learning of the language during this period.

In the telegraphic stage, in which the child is now using some expressive output, sentence construction is rather fragmented and many errors exist. Single words, such as the utilization of only a content word, can comprise a child’s attempt at verbal expression during this stage. Pattern books, small group activities, advanced conversational partners, and routines are all especially beneficial for children during this stage. Educators need to be aware of the need for gestures, visual aids, and repetitions during this time.

During the productive stage, in which short sentences and phrases with multiple errors are produced, the child relies on formulas to build sentences. Sentences often contain errors that are overgeneralizations. They may use nonspecific words and fillers, and dysfluencies are likely to be present. During this stage, the introduction of more complex stories is acceptable. Children will need time to respond, due to the added effort they are making to formulate sentences. Additionally, they will need to have frequent check ins for comprehension, to make sure that they are truly understanding what is asked of them/new lessons. Educators can start to introduce more advanced vocabulary, in terms of tier II level words.

When the child enters the stage of being fluent with errors, the child now understands a lot of what is going on around him with increased ease. In this stage, the child can communicate effectively, though an accent and errors will still exist. It is important for educators to know that a need for supports is necessary, such as emphasizing grammatical markers when mistakes are made or providing models of proper phoneme production. The need for supports will be specifically essential when new context is introduced.

At the final stage, native-like proficiency, the child will make age-appropriate errors in language, though the child communicates in the second language with ease and is an adept communicator. An accent may still be present, and influence from the child’s dialect may be embedded in the child’s language. At the stage, it is likely safe to assume that the child’s comprehension is age-appropriate, but educator’s still need to be aware of the fact that academic struggles may be present. Educators should review key concepts, offer extra help and support whenever necessary, and keep ELLs on their radar in terms of any language struggles that may come up.

It is important to be proactive in finding potential speech and language deficits in order for the child to have the best potential for academic success. Effective practice starts with effective assessment. Rather than “waiting to fail”, educators should avoid this tendency and instead screen children early on. Educators should screen by looking for key skills, with a manner even as simple as a basic checklist. These checklists can include acknowledgment of concepts such as the amount of speaking the child engages in, the amount of opportunities the child has to speak, the relevance of a child’s comments on the established conversational topic, etc. This screening can also serve as a baseline for comparison of later data collection.

Because we know that literacy can be a problem for second language learners, it is essential to bear in mind the need to tie in curriculum and thematic contexts in reading activities. Educators need to acknowledge the fact that text is a rich platform for discussing a unit and therefore literacy can be tied in to every academic discipline. Thematically related literary works within larger units of studies helps to bridge the gap across school subjects, while building literacy skills. Combining larger units of study with books allows for children to grow their experiences within that topic of study to further solidify their understanding.

Written by: Taylor Viggers, MS, CF-SLP

Smyk, E., Restrepo, M. A., Gorin, J. S. & Gray, S. (2013). Development and validation of the Spanish-English language proficiency scale (SELPS). Language, Speech, and Hearing Services in Schools, 44, 252-265.

Why isn’t my child eating?

Are you concerned about the number of foods your child eats? Are mealtimes a struggle? Are you worried that your child is not receiving adequate nutrition? The following information is provided to help you understand more about the difference between picky eating, and disordered eating, sometimes called “feeding refusal”.

First, here are some myths about feeding refusal:

1. Children that have feeding refusal are just difficult children with difficult behaviors. FALSE
Children that refuse to eat often have good reasons: they may have aversions to food or past traumatic experiences associated with eating that makes them afraid to eat. Your goal should be to change your child’s eating experience from scary to enjoyable and pleasurable.

2. Children who have pediatric feeding refusal are just picky eaters. FALSE
Picky eaters will usually eat at least one food from most food categories/textures, and will touch/taste new foods. Your child is likely a picky eater if they have a mostly balanced diet with little nutritional concern.

Feeding refusal is not a feeding disorder caused by pickiness or preference. Children with feeding refusal have trouble gaining weight due to limited food intake. They may display a decreased appetite with accompanying behaviors of head turning, spitting out food, vomiting, and/or forced mouth closure upon the presentation of foods they dislike. Sensory aversions may accompany feeding refusal, which means that touching, smelling, and licking new foods may evoke strong resistive responses.

What can I do to help my child at home?
1) Start by integrating food into play at non-mealtimes, such as encouraging a restaurant-theme for dramatic play.
2) Allow your child to explore foods with their hands through painting with food or water play.
3) Expose your child to different food scents, starting with milder smells, such as bread or pasta, then gradually introducing stronger scents.
4) Finally, slowly transition your child to eating in the following order: Bringing food to the lips>licking>taking a small bite then removing>chewing and spitting out>chewing and swallowing Start with foods that are similar to ones that your child likes, and then you may attempt some non-preferred textures.

*Reward your children with praise, hugs and kisses when they behave appropriately – such as sitting at the table, tolerating new foods on their plate, or kissing a food they’re not yet ready to put in their mouth. You can also try rewarding your child with a bite of a preferred food after they have tried a new food, or allowing them to play a preferred activity after a successful mealtime. Positive reinforcement for desirable eating behaviors will encourage your child to behave the same way in the future.

More references:

Love Me, Feed Me by Katja Rowell M.D
-Feeding Matters:
Written by: Taylor Viggers, MS, CF-SLP

(Special thanks to Devyn Jones, MS, CF-SLP, an Arizona-based speech-language pathologist for collaboration on this material)
Baird, E., Capeci, W., & Klein, J. (n.d.). A Group Approach to Pediatric Feeding. Lecture presented at ASHA – 2011, San Diego. Retrieved April 12, 2016, from

Weaver, C., CCC-SLP. (2008). Evaluation and Management of Behavioral-Based and Sensory-Based Feeding Problems. Lecture presented at ASHA – 2008, Chicago. Retrieved April 12, 2016, from

Williams, Keith E., Douglas G. Field, and Laura Seiverling. (2009). “Food Refusal in Children: A Review of the Literature.” Research in Developmental Disabilities 31.3 (2010): 625-33. Web. 7 Apr. 2016.

Should I raise my baby bilingual, and if so, why?

Some parents may be apprehensive when deciding what language(s) they should speak in to their infant. Are you concerned that more than one language could overload your baby? Are you worried that if you speak one language and your partner speaks another to your baby that your baby will be confused? The following information is provided to encourage parents/caregivers to speak the languages that they value with their child, as soon as the baby is born!

When a child is exposed to two languages from birth, they have the unique ability to hone in on the important phonemes (sounds) of any language(s) presented to them through statistical learning. In addition, they are capable of tracking the intonational patterns of the languages that they are exposed to in order to further delineate the two (or more) languages. However, this ability to differentiate and adapt to more than one language does not always remain. This critical period is noted, according to researchers, between 6-8 months, and starts to disappear around 10-12 months. But why does it disappear? At 10-12 months, the baby loses this skill so that he/she is better prepared to become a master of the languages that his/her parents and caregivers speak. Therefore, it is easy for a baby to learn more than one language the earlier that it is introduced, and acquiring another language becomes harder as one gets older. (For more information about this critical period, feel free to view the following TedTalk: – link below

However, this ability to delineate languages does not mean to suggest that the two systems of each language function independently. The two languages, when they are provided with equal experiences (equal quantity and quality of language), function harmoniously, in that they positively influence one another. For example, when the child speaks in one language, they have to simultaneously inhibit the other language from infiltrating the first language that they are using. In contrast, the flexibility to switch back and forth between the two languages, known as code-switching, also indicates a superiority of the overall executive functioning of the individual. Efficient code-switching is exemplary of an overall greater ease of switching between many different types of tasks. Having the control to inhibit one language, while also controlling the easy flow from one language to the other, shows efficient language processing skills. Further executive function research indicates that bilinguals may learn novel words faster, due to a need for fewer exposures (Kaushanskaya, Gross, and Buac, 2014). Overall, this superior control ability is directly correlated to length of bilingual experience. Therefore, theoretically, bilinguals from birth would have the strongest control ability.

Differences in vocabulary of bilinguals from monolinguals may erroneously be perceived as a disadvantage of bilingualism. A bilingual from birth probably has a smaller vocabulary in each language than a similar monolingual, but when the entire lexicon is taken in to consideration, the bilingual has an overall larger vocabulary. Similarly, due to the presence of two languages, and the obligation to endlessly inhibit a language while the other is being used, bilinguals may have a slower response time or processing time, but this processing time is practically imperceptible, and is not obvious to the average person. It can therefore be concluded that while a minuscule difference in response time may be present, a bilingual’s overall executive functioning skills are stronger than that of a monolingual’s, as evidenced from better control over inhibition and more precise selective attention, due to the nature of being bilingual.

Written by: Taylor Viggers, MS, CF-SLP

Buac, M., Gross, M., & Kaushanskaya, M. (2014). The role of home language environment in the development of monolingual and bilingual children’s vocabulary skills. Journal of Speech, Language, and Hearing Research, 57, 1804-1816.


Gross, M., Buac, M., & Kaushanskaya, M. (2014). Conceptual scoring of receptive and expressive vocabulary measures in simultaneous and sequential bilingual children. American Journal of Speech-Language Pathology.