FAQs from the Multilingual Affairs Committee | IALP : International Association of Logopedics and Phoniatrics FAQs from the Multilingual Affairs Committee – IALP : International Association of Logopedics and Phoniatrics

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FAQs from the Multilingual Affairs Committee

FAQs for Parents

We are raising our child bilingually at home, but we are worried that it may cause a delay in language development. We would like to know if a bilingual child is necessarily going to be delayed. In other words, is delay normal in bilinguals?

 Bilingual children’s language development is similar to the development of children learning a single language (Paradis, 2010). Bilingualism itself does not cause language delay (Lowry, 2018). In infancy, bilingual children are sensitive to differences in languages. This indicates a very early ability for language learning. Bilingual infants begin producing their first syllables and words roughly at the same time as children learning a single language. There is also a similar pattern of learning vocabulary and grammar. However, bilingual development may often look like it is delayed because a child’s total language proficiency is distributed over two languages.

If a child is learning a second language or two languages simultaneously, vocabulary development (learning words) may appear to show a delay. Indeed, when the vocabulary of each language is measured separately, it tends to be smaller than the vocabulary of a monolingual child (Hoff et al., 2012). However, when this child’s vocabulary abilities are assessed in both languages, vocabulary is found to be within the typical range or even larger than that of a monolingual child. Vocabulary development in any language is highly associated with the amount of input the child has received in that language (Elin Thordardottir, 2011; Hoff et al., 2012; Pearson, 2007). Input affects early grammar development in a similar manner (Elin Thordardottir, 2015a). Many times, exposure is uneven, and bilinguals vary from each other in terms of language production, with very uneven proficiency across their two languages (children vary in whether their home language or the community language is stronger, and this can change over time).

Parents raising bilingual children should pay extra attention to give enough support especially for the native or minority language because the child may not receive much input in that language in other settings. In addition, it is important that parents understand that assessment of a child’s vocabulary should ideally assess for the native language and the second language. If a child is assessed only one language, this will not show the  true size of the child’s vocabulary knowledge. (See Conceptual Scoring in the Speech Language FAQ). Nevertheless, assessment procedures have been developed that estimate overall vocabulary from the measurement of one language alone coupled with information on exposure to each language (Elin Thordardottir, 2015b).

Bilingual children might be less accurate than same-age monolinguals on some grammatical aspects as compared to their monolingual peers, such as verb tense (e.g., eat/ate), verbal inflections (e.g., works, worked), plurals (e.g., book/books), or gender (e.g., he/she)(Paradis, 2010). In languages with rich morphology bilingual children might show differences on adjective-noun and determiner-noun agreement (e.g., in Spanish: el conejo), case morphology (e.g., in Russian: slon, slona, slonu; in German: Der Clown, Dem Clown) and aspect morphology (e.g., Russian: pil, vypil) . These divergences from monolinguals have been attributed to cross-linguistic influence, the influence from L1 on L2 and vice versa from L2 on L1 (e.g., Cuza, & Pérez 2015, Scharff Rethfeldt 2011, Meir et al., 2017), or alternatively, simply to slight delays in the grammatical development of each language because of divided exposure (Elin Thordardottir, 2015b).

Code switching occurs when bilingual speakers combine words or phrases from both languages spoken. This is not a sign of a language delay. Instead, this is part of the typical development of bilingual speakers and a natural part of bilingualism for both children and adults (Roseberry- McKibbin, & Brice, 2018). Overall, bilingual preschool children have been found to learn each of their languages in a similar sequence as monolingual speakers of these languages (De Houwer, 2006; Elin Thordardottir, 2015a)

We are bilingual parents, but are considering raising our child monolingually at home, using only the societal language. However, we speak the societal language with a strong accent (having immigrated as adults) and are more proficient in our native language. Is this a good idea?

Children who are exposed to two languages from birth typically become highly proficient in both languages, provided they receive abundant and continuous exposure to both. In addition, children who later learn the societal or majority language at school are likely to learn that language with little difficulty and to succeed in school given a strong base in their first language and adequate support and exposure to the second language.

For bilingual language learners, language development depends on the quality and quantity of social interaction with native speakers of both languages (Hoff & Core, 2013; Elin Thordardottir, 2011, 2015, 2019). Quality means that the language spoken must be spoken with accuracy, ease, and fluency. The quantity factor is provided when the parents provide children with frequent interaction in the language they speak with the child with fluency and ease. Quantity means that language interaction between adults and children must be frequent. Given that bilingual parents have a good command of their native language, they are best able to provide children with these quality factors in that language.

Some bilingual children are exposed to two languages within their home, and some are exposed to one language at home, and the societal language in a daycare or preschool setting. In the preschool years, the amount of exposure to each language has been found to exert a far greater influence on the acquisition of each language than how old the child is when bilingual exposure starts (Elin Thordardottir, 2019; Unsworth, 2016). This gives parents flexibility in terms of when to introduce a second language, such as in a daycare or preschool setting. Parents who talk with children about their past experiences, using their native languages, help their children connect with the parents’ culture. Stories also provide children with understanding narratives (stories), which are an important skill in early academic development.

Retention of the first language (L1) can be challenging without sufficient exposure and shift in language dominance can be rather rapid, even with a native language with high status (Scheidnes & Tuller, 2016). Maintaining the first language is even more challenging in minority language environments, when the language has few speakers and low status in the society. Keeping a minority language in use involves special effort. Sometimes children’s native language may be lost (Polinsky, 2007), a process known as language attrition. This process can occur when children are isolated from or not exposed to their native language. This attrition can also happen to different degrees, depending on the possibilities and motivation to use the language.

Parents speaking other than their native language at home has not been discovered to bring better results in child’s second language learning, but rather it has been shown to affect L1 retention (Place & Hoff, 2011).

When should I seek professional help if my bilingual child does not speak or shows performance which is low for his age when compared to his bilingual peers?

You should seek help as soon as possible if you feel your child is struggling with language compared to what you would have expected or compared to other children developing in a similar language environment.

However, keep in mind that young bilingual children can look delayed because each of their languages represents only part of their language knowledge.

A language disorder must appear in both languages to determine a true disorder. If there are other languages that have been learned, assessment must consider all languages that a child has learned or is in the process of learning. If concerns are present, seek professional help. If difficulties appear only in the second language being learned, this does not indicate a disorder. However, if communicative difficulties in either language persist for a long time, some type of support may be necessary.

My child is three years old and we have been raising him bilingually at home. We try to follow the “one-parent-one-language” (OPOL) rule, but we have noticed that our son mixes the two languages together when he speaks. Is this a sign that he has a language disorder?


Where each parent has a different native language, a one-parent-one language strategy can be a good option to ensure that the child gets the desired amount of exposure to each language.

However, it is not necessary for the child’s language learning that parents separate the two languages.

Raising a child according to the OPOL principle does involve great and often demanding efforts, as societal influences may work against caregivers’ interests and ability to raise children actively bilingual (Hammer et al., 2004). Overall, the OPOL strategy does not guarantee balanced bilingualism (DeHouwer, 2007). There is high variation among families and what factors affect language use by families (Yamamoto, 2001). In some migrant families, maximal engagement with the minority language may be more successful than the OPOL principle (Marinova-Todd, Bradford Marshall, & Snow, 2000).


Code switching may occur for several reasons. First, a word may not be currently accessible or pulled from memory to communicate a thought or idea. Second, children may use code switching to ask an adult for help in finding a correct word to label something or express an idea. Third, code switching or mixing has been found to be used to produce longer and more complex sentences by bilingual speaking children. Fourth, code switching occurs more frequently when a child is telling a story. Code switching has a positive aspect, as it shows that a bilingual child has the ability to use words from both languages being learned.

In summary, code switching is a typical language behavior found in bilingual speakers of any age. Code switching does not indicate linguistic incompetence. Instead, code switching may be seen as a marker of linguistic competence.


We are bilingual parents and mix the two languages (code switch) very often. Is it okay to speak both languages to the child and code switch?


Code switching is a typical pattern for both bilingual children and adults and is not a disorder. In many cases, both parents may be bilingual and may themselves code-switch when talking to each other or to the child. This does not harm the child’s learning.


Codeswitching is not used solely for lexical deficiencies, but for pragmatic, social and cultural reasons. Adults use code switching to enrich conversations and interactions. It is a valuable tool that may allow a bilingual family to make their conversations richer and more understandable. Frequently, children will follow the patterns spoken by adults in their environment.


At what age should we expose our child to a second language? Should we wait until our child gets control of the home language first, or should we start as early as possible?


Evidence shows that young learners may acquire native-like mastery of a second language given continued regular exposure to both languages. By age 4, children become more aware of the language to be used in interaction (Paradis, 2010). A positive aspect of early learning of a second language is that it gives the child a greater amount of time for practice in using the second language. This will likely lead to adult mastery of the language. There is some evidence, that for some language domains, it might be beneficial to start early as possible. On the other hand, some domains might develop faster at an older age, and the introduction of  L2 at a later age might help better retention of L1, depending on the circumstances (Blom & Bosma, 2016). Sensitive periods for learning language domains have been found (Granena & Long, 2012), including phonology (pronunciation of sounds), syntax (sentence structure), semantics (words), and pragmatics (the use of language in interaction). In the educational domain, better learning occurs early for L2 phonology, later for lexis and collocation (the lexicon of a language or vocabulary and the arrangement of grammatical terms in a sentence), and morphosyntax in the mid-teen period of learning.


Within the preschool years, the amount of exposure is far more important than the age of first bilingual exposure (Elin Thordardottir, 2019, Unsworth, 2016). Therefore, parents have considerable flexibility in their choices as to when to start exposing their child to a second language.

Additionally, introducing a second language is often dependent on when it is needed and natural for varying reasons (e.g., movement to another country or entry into school).


Which language should I use with my child if the language spoken in the school is different from the one spoken at home ? Should we drop the home language and use only one language? What would happen if we, the parents, drop the home language, but the grandparents continue to use it with the child?

Maintaining a child’s native language while being educated in the school language is positive for many reasons, the most obvious one is knowledge of more languages and ability to communicate with the native language community. The number of different sources of input by second (L2) speakers has been positively related to vocabulary and grammar development in L2 (Place & Hoff, 2011).


Parents vary in how important it is to them to keep their native language. It is important for parents to understand that continuing to speak that language will not hurt the child’s ability to learn the societal language. It is essential to encourage a family to communicate in their native language or languages to preserve their culture and the child’s bilingual or multilingual skills. This will allow the child to understand and speak the family’s language, along with understanding of and participation in the family’s culture and community. Many times, preserving L1 is also essential to parent-child-dialogue.


There are two suggested approaches for language use for the family. The “One Person-One Language” approach applies to families where each parent speaks a different language. Tis approach consists of each parent consistently speaking their own native language to the child. For example, if one parent’s native language is Italian and the other’s language is French, each parent would use that language exclusively in communication with their child.

The “Minority Language at Home” approach applies to families in where both parents speak the same language. It consists of both parents speaking only their native language in communication with the child. For example, if the parents’ native language is Arabic, this is the language that would be used in communication at home with their child. These two approaches may actually be overlapping, depending on the native languages of the parents and whether one of them is (majority) language of the society. There may also be overlap in cases where only the grandparents continue to speak the native language. With time, many families find that use of the societal language within the home tends to increase as all family members live daily experiences in that language. Even at that point, use of the native language typically continues as well.

Outside experiences are essential, such as the playground and playgroups, so that children gain additional experience with the second language.


Our five-year-old is bilingual and has been diagnosed with a developmental language disorder. We have been advised to speak only one language to him at home — the language of school. This will be difficult, since his older sister and brother speak two languages and we are a bilingual family. Should we follow this advice?


This advice comes from the incorrect belief that learning two languages is beyond the capacity of children with language or learning disorders. Research provides no evidence that children with language disorders cannot become bilingual. Instead, there is evidence that children with Down Syndrome (Kay-Raining Bird et al, 2005), autism spectrum disorders (ASD), dyslexia, and a developmental language disorder (DLD) (Paradis, 2010) have become bilingual speakers and readers. Previous research shows that bilingualism does not impede language development in children with DLD (Gutiérrez-Clellen et al., 2008; Morgan et al., 2013; Paradis et al., 2003, among others); children with ASD (Gonzalez-Barrero & Nadig, 2018; Hambly & Fombonne, 2012; Kay-Raining Bird et al. 2012; Meir & Novogrodsky, 2019), children with Down Syndrome (Bird et al.,2005), children with William Syndrome (Perovic & Lochet, 2015) and

children with Hearing Impairments (Bunta, et al., 2016). However, DLD and bilingualism both may have the effect of slowing down language development. Thus, even though the endpoint (highest level of proficiency attained) may not be affected by bilingualism in children with DLD, bilingual children with DLD may be farther behind monolingual peers in each language than monolingual children with DLD at some points in development (Elin Thordardottir & Brandeker, 2013). Therefore, children with DLD will require adequate support to be successful in a bilingual situation (Paradis et al., 2018).


Rather than discontinuing the home language, which would deprive the child of the ability to develop that language, parents are advised to continue to use their home language with the child, but they would also be well advised to provide abundant experiences in that language such as by interactive reading or other language activities.


We planned for our son to attend an immersion school where he can learn through a second language – different from the language we speak at home – and grow up bilingually. But our son has been diagnosed with a developmental language disorder. Does this mean he is not a good candidate for immersion education?


Even children who have speech and language disorders are able to acquire two languages. As stated above, studies have shown that many children with a developmental language disorder also have no greater difficulty learning a second language than they have in learning one, given frequent exposure to this language. Research shows that English-speaking children with language delay in French immersion schools in Canada had similar academic achievements with English-speaking children with delay in English-only schools (Paradis, 2018). These findings show that learning through a second language did not affect children’s academic success. In this case, however, one of the languages of school is also the home language. Findings on academic success are somewhat more mixed in some immigrant environments (Elin Thordardottir, 2017). In any case, it is essential to ensure that the school provides the support necessary for children’s academic progress and success, with more frequent language interaction in the school language and support with learning difficulties.


My daughter is fluent in her home language but finds it difficult to acquire the school language. Could there be a delay (impairment) in the second language only?


The average second-language learner may require two years to acquire. Basic Interpersonal Communication Skills (BICS). This type of learning occurs in interaction conversation in which situations context is provided as well as non-verbal cues to support verbal language (Baker, 2011). Cognitive Academic Language Proficiency (CALP) refers to academic language. It may take children five to seven years or longer to achieve the language consistent with the needs for academic success (Vogl, 2013; Elin Thordardottir, 2017). It is not infrequent for children to have difficulty with CALP, as difficulties may appear in reading, writing, spelling, and other academic areas. Awareness of the normal progress in learning a second language is necessary to determine if there is a true disorder. If CALP skills are taking long to develop, some type of tutoring or special education may be required to ensure that the child benefits from school.



Baker, C. (2011). Foundations of bilingual education and bilingualism. Bristol, UK: Multilingual matters.

Bird, E. K. R., Cleave, P., Trudeau, N., Thordardottir, E., Sutton, A., & Thorpe, A. (2005). The language abilities of bilingual children with Down syndrome. American Journal of Speech- Language Pathology.

Blom, E., & Bosma, E. (2016). The sooner the better? An investigation into the role of age of onset and its relation with transfer and exposure in bilingual Frisian-Dutch children. Journal of Child Language, 43, 581-607.

Bunta, F., Douglas, M., Dickson, H., Cantu, A., Wickesberg, J., & Gifford, R. H. (2016). Dual language versus English‐only support for bilingual children with hearing loss who use cochlear implants and hearing aids. International journal of language & communication disorders, 51(4), 460-472.

De Houwer, A. (2005). Early bilingual acquisition: Focus on morphosyntax and the Separate Development Hypothesis. In J. Kroll & A. de Groot (Eds.), Handbook of bilingualism: Psycholinguistic approaches (pp. 30-48). New York: Oxford University Press.

De Houwer, A. (2007). Parental language input patterns and children’s bilingual use. Applied Psycholinguistics, 28(3), 411-424.

Gonzalez‐Barrero, A. M., & Nadig, A. (2018). Bilingual children with autism spectrum disorders: The impact of amount of language exposure on vocabulary and morphological skills at school age. Autism Research, 11(12), 1667-1678.

Gutiérrez-Clellen, V. F., Simon-Cereijido, G., & Wagner, C. (2008). Bilingual children with language impairment: A comparison with monolinguals and second language learners. Applied psycholinguistics, 29(1), 3-19.

Hambly, C., & Fombonne, E. (2012). The impact of bilingual environments on language development in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(7), 1342-1352.

Hammer, C. S., Miccio, A. W., & Rodriguez, B. L. (2004). Bilingual language acquisition and the child socialization process. In B. A. Goldstein (Ed.), Bilingual language development and disorders in Spanish-English speakers (pp. 21–50). Baltimore, MD: Paul H. Brookes.

Hoff, E., Core, C., Place, S., Rumiche, R., Senor, M., & Parra, M. (2012). Dual language exposure and early bilingual development. Journal of Child Language, 39, 1-27.

Hoff, E. & Core, C. (2013). Input and language development in bilingually developing children.

Seminars in Speech and Language, 34(4), 215-226.

Hoff, E, & Core, C. (2015). What clinicians need to know about bilingual development. Seminar Speech Language, 36 (2), 89-99.

Kay‐Raining Bird, E., Lamond, E., & Holden, J. (2012). Survey of bilingualism in autism spectrum disorders. International Journal of Language & Communication Disorders, 47(1), 52- 64.

Kay-Raining Bird, E., Cleave, P., Trudeau, N., Elin Thordardottir, Sutton, A., & Thorpe, A. (2005). The language abilities of bilingual children with Down Syndrome. American Journal of Speech Language Pathology, 14, 187-199.

Lowry, L. (2018. Bilingualism in young children: separating fact from fiction. Hanen Center. Available at http://www.hanen.org/Helpful-Info/Articles/Bilingualism-in-Young-Children– Separating-Fact-fr.aspx.

Lutz, A. (2004). Dual language proficiency and the educational attainment of Latinos. Migraciones Internacionales, 2 (4), 95-122.

Marinova-Todd, S., Bradford Marshall, D. & Snow, C.E. (2000). Three misconceptions about age and L2 learning. TESOL Quarterly, 34 (1), 9-34.

Meir, N. & Novogrodsky. R. (2019). Syntactic abilities and verbal memory in monolingual and bilingual children with High Functioning Autism (HFA). First Language. Available at https://doi.org/10.1177/0142723719849981

Morgan, G. P., Restrepo, M. A., & Auza, A. (2013). Comparison of Spanish morphology in monolingual and Spanish–English bilingual children with and without language impairment. Bilingualism: Language and Cognition, 16(3), 578-596.

Paradis, J. (2010). COST Action IS00804 on the official COST website. Language impairment in a multilingual society: linguistic patterns and the road to assessment. Available at http://bi- sli.org/index.htm.

Paradis, J., Crago, M., Genesee, F., & Rice, M. (2003). French-English Bilingual Children With SLI. Journal of Speech, Language, and Hearing Research, 46(1), 113-127.

Paradis, J., Govindarajan, K., & Hernandez, K. (2018). Bilingual Development in Children with Autism Spectrum Disorder from Newcomer Families. Available at Available at https://era.library.ualberta.ca/items/d53d7b1b-c4d6-4d2f-a595-3ac2ecd8a52c/view/229ca8a8- b060-473d-89a5-93cfc7b9e652/Bilingual-20ASD_FINAL_SummaryReport_05MAR2018.pdf. Pearson, B. (2007). Social factors in childhood bilingualism in the United States. Applied Psycholinguistics, 28, 399-410.

Perovic, A., & Lochet, S., (2015). Grammatical morphology in bilingual Williams syndrome: A single case study. A poster presented at bi-SLI 2015 conference, François-Rabelais University, Tours: France.

Place, S., & Hoff, E. (2011). Properties of dual language exposure that influence 2-year-olds’ bilingual proficiency. Child Development, 82, 1834-1849.

Roseberry-McKibbin, C., & Brice, A. (2018). Acquiring English as a second language: what’s “normal,” What’s Not. Available at https://www.asha.org/public/speech/development/easl.htm#normal

Scheidnes, M., & Tuller, L. (2016). Assessing successive bilinguals in two languages: A longitudinal look at English-speaking children in France. Journal of Communication Disorders, 64, 45-61.

Elin Thordardottir (2019). Amount trumps timing in bilingual vocabulary acquisition: Effect of input in simultaneous and sequential school-age bilinguals. International Journal of Bilingualism, 23(1), 236-255.

Elin Thordardottir (2015a). The relationship between bilingual exposure and morphosyntactic development. International Journal of Speech Language Pathology, 17 (2), 97-114.

Elin Thordardottir (2015b). Proposed diagnostic procedures and criteria for Cost Action Studies on Bilingual SLI. In Armon-Lotem, S., J. de Jong & N. Meir (Eds.), Methods for assessing multilingual children: Disentangling bilingualism from language impairment. Bristol, UK: Multilingual Matters.

Elin Thordardottir (2011). The relationship between bilingual exposure and vocabulary development. International Journal of Bilingualism, 14 (5), 426-445., DOI: 10.1177/1367006911403202

Elin Thordardottir, & Brandeker, M. (2013). The effect of bilingual exposure versus language impairment on nonword repetition and sentence imitation scores. Journal of Communication

Disorders, 46, 1-16.

Vogl, L. (2013). Tips for assessing bilingual children as a monolingual SLP, ASHA Leader. Available at https://blog.asha.org/2013/11/26/leisha-vogle-assessing-bilingual-children-as-a- monolingual-slp/.

Yamamoto, M. (2001). Language Use in Interlingual Families: A Japanese-English Socio- linguistic Study. Clevedon, UK: Multilingual Matters.

FAQs for Speech-Language Therapists

When can developmental language disorder be determined for bilinguals?


Bilingualism can be defined in many ways. Terminology that has to do with age of onset of languages include concepts of simultaneous and sequential/successive bilingualism (Goldstein, 2019). If language is introduced before age 3, then the child is typically considered a simultaneous bilingual. If the second language has been introduced after age 5 (and often after age 3), then the child is typically considered a sequential bilingual (Paradis, Genesee, & Crago, 2011) or children with early second language acquisition (De Houwer, 2009).

These labels are problematic when attempting to classify a bilingual child’s strengths and weaknesses or language dominance. Although language dominance is most often used to indicate greater skill in one language over the other, bilingualism exists in a continuum, meaning that bilingual children may possess skills that are superior in one language, with other skills superior in another language (Goldstein, 2019; Thordardottir, 2011, 2015, 2019). This is related to the fact that languages develop according to different schedules, and also to the fact that children live different experiences in each of their language environments. The difference between simultaneous and sequential is far from clear, also in terms of developmental features. Age of onset for languages, input, language dominance, distributed language skills and weaknesses and strengths across language domains need to be considered. It also needs to be taken into consideration, that language dominance might change. For example, when a child becomes more proficient in a new language, these skills may exceed those of his or her native/first language.


The most essential consideration is that early identification of a disorder is essential to ensure successful language development and academic progress. First of all, the child’s family should be asked if difficulties have been observed and if this child’s development differs from that of siblings and peers of the same age. It is also important that children’s progress be compared with other bilingual learning children, and not with monolingual learners who have been exposed exclusively to the language in question from birth.


A developmental language disorder (DLD) is ideally diagnosed only when both languages are assessed, given that a DLD will appear in all languages spoken by the child. Obtaining information on the child’s development and abilities in both languages is crucial for an evidence-based diagnosis. However, in reality, a formal assessment of both languages is often not feasible for various reasons and is not undertaken (Thordardottir & Topbas, 2019). Some of the difficulties that have been reported in obtaining a diagnosis of a bilingual child include the following: (a) the scarcity of standardized tests that lack of bilingual norms; (b) the challenge of the number of bilingual clinicians who are able to administer and analyze assessment tools, and

  • the absence of information regarding a child’s exposure to languages in question and exposure effects on test performance. Bilingual assessment, therefore, frequently involves a combination of formal assessment and more informal observations. Procedures have also been proposed that estimate the likelihood that a language impairment exists based on formal measurement of only one language, given that this scenario is common in clinical practice (Thordardottir, 2015b). Collecting a comprehensive case history as much as possible is recommended aside formal and informal

Identification of a communication disorder in a bilingual individual requires careful consideration of numerous factors that influence language. A true communication disorder will be evident in each language used by an individual; however, a skilled clinician will appropriately account for the process of language development, language loss, the impact of language dominance fluctuation, and the influence of dual language acquisition and use when differentiating between a disorder and a difference. Language dominance may fluctuate across an individual’s lifespan based on use, input and language history (Kohnert, 2012).


The Factors that May Play a Role in Learning a New Language and Maintaining the First Language


Because of the movement of families across the globe, children are required to learn a new language when entering the new environment. The age of exposure to a second language environment has been found to be a strong predictor of language proficiency in the new language (Bylund, 2009). However, the quantity and quality of input are considered even more important factors (Thordardottir, 2019; Unsworth, 2016). It is common that children can possess different language abilities in their languages and across language domains (Montrul, 2013). Some children can also be stronger in general in the new language and some children in their first language. This can also change over time.


Retention of L1 can be challenging without sufficient exposure and shift in language dominance can be rapid, even if the native language is one of high status in general (e.g. Scheidnes & Tuller, 2016). Maintaining the language is even more challenging in a minority language environment, when the language has few speakers and low status in the society. Keeping a minority language in use involves special effort. Sometimes children’s native language may be lost (Polinsky, 2007). This process is known as language attrition due to the loss of a native language. This process can occur when children are isolated from or not exposed to their native language. This attrition can also happen in different degrees, depending on the possibilities and motivation to use the language. In many cases, there may not be loss of L1 skills, but slowed continued progress in L1 progress. Bilingual instruction has been shown to protect native language skills and may be important for language maintenance (Castilla-Earls, Francis, Iglesias, & Davidson, 2019). Research also shows that exposure is a valid indicator of dominance of relative proficiency in each language (Köpke & Genevska-Hanke, 2018) and attrition may be only temporary if there is a quick return to more balanced use of the native and new language. It is positive to encourage families to continue to use their native language when communicating with children learning a new language, as there are positive factors in bilingualism.


Research has shown that bilingual instruction has been shown to protect native language skills and may be important for language maintenance (Castilla-Earls, Francis, Iglesias, & Davidson, 2019). Research also shows that exposure is a valid indicator of dominance of relative proficiency in each language (Köpke & Genevska-Hanke, 2018) and attrition may be only temporary if there is a quick return to more balanced use of the native and new language. It is also positive to encourage families to continue to use their native language when communicating with children learning a new language, as there are positive factors in bilingualism.

Children who are proficient in both their native and second languages have improved educational outcomes in terms of school completion rates, grades, achievement test scores, educational aspiration, and personal adjustment (Bedore, 2010). Additionally, the use of the native language has no negative consequences when learning a new language (Levey, Cheng, & Langdon, 2013). International research has also shown that bilingualism may lead to significant enhancements in certain cognitive abilities when compared with monolingual children (Bialystok 2006; Chin & Wigglesworth, 2007; Kovacs & Mehler, 2009). At the same time, it is important to be aware that not all children placed in bilingual contexts become highly proficient in both languages (Thordardottir, 2017). In summary, it is important to encourage the use of the native language, along with opportunities for using both the native and new language.


Typologies of languages have been shown to affect learning a new language through cross- linguistic influence (Jarvis & Pavlenko, 2008; Fabiano-Smith & Goldstein, 2010). Linguistic typology classifies languages according to their structural and functional features. For example, typological classification is shown in words in English (SVO), Chinese (SVO ), and Japanese (SOV). Second language learners may have difficulty with the acquisition of case marked languages if the first language lacks these functions (Yager et al., 2015). On the other, languages sharing many grammatical or phonological features or for example cognates are easier to learn together.


Languages differ in many different ways, as following in these examples.


Italian Vado al cinema stasera [I] go to the cinema tonight
Spanish Salieron a las ocho [They] left at eight
French Nous sommes partis à huit heures We left at eight o’clock
English I am going to the cinema tonight
Russian Ja idu vecherom v kino I go [in the] evening to [the] cinema.


There are languages that have fixed word orders like English (subject-verb-object (SVO): John likes Mary), and there are languages with free word orders, like Russian. In English, “likes John Mary” (VSO) is ungrammatical, while in Russian all combinations are grammatical (e.g., SVO, OVS, SOV, VSO, VOS, OSV). Languages also differ with respect to the placement of adjectives: before or after the noun (e.g., English: a long pencil / a blue pencil; French: un long crayon ‘a long pencil’, but ‘un crayon bleu’ ‘a pencil blue’).


Practitioners must be aware of morphological and syntactic differences across languages when assessing bilingual or multilingual speakers. One example of these differences is presented below from the West‐African language Gbe, with every word expressed by a single morpheme.


Mí tò kpá dó ná Yetì (jí) We are building a fence for Yeti


The languages Finnish, Turkish, Hungarian, and Bantu have words that consist of multiple morphemes, as shown in the example from Finnish that illustrates the word house.


House       Talo                 My house        Talo/ni            In my house                 Talo/ssa/ni

In Italian and Russian, endings added to verbs change the verb for person, as shown in Italian for the subjects of the verb parlare (to speak).

Parlo, parli, parla                                               I speak, you speak, he/she speaks There are also syntactic differences across languages. For example, some languages drop

pronouns (pro-drop languages) while some do not (non-pro-drop languages). Examples of pro- drop languages (Italian and Spanish) and non-pro-drop languages (French and English) are shown below.

Italian Vado al cinema stasera [I] go to the cinema tonight
Spanish Salieron a las ocho [They] left at eight
French Nous sommes partis à huit heures We left at eight o’clock
English I am going to the cinema tonight



Case involves marking of a noun or noun phrase for its syntactic and/or semantic role in a sentence in the following ways: Nominative case (used for a noun or pronoun when it is the subject of a verb, such as Sharon ate a cookie), dative case (to indicate the indirect object or recipient of an action, such as He gave a biscuit to the dog), and instrumental case (to indicate that a noun is the instrument or means that allows the subject to achieve or accomplish an action, such as Sharon wrote a letter with a pen). English expresses the instrumental function through the use of the words with, by, or then followed by a noun that indicates the instrument (e.g., I wrote the note with a pen).



There are languages in which case is absent, such as Vietnamese and English. In this case, grammatical relations are expressed by word order and/or function words (e.g., prepositions, such as in, on, under, and between) or morphological markers attached to verbs (e.g., walk +ed). In Tamil, eight case markers are found next to postpositions (a word or morpheme placed after the word it governs that assigns case, such as ward in upward). German has a rich morphology that allows for subject-less constructions as well as for passivization of intransitive verbs resulting in subject less sentences (e.g. Hier wird getanzt [Dancing is done here]. Within a sentence, diverse cases may be realized (e.g. subject: Die Frau hat dem Jungen den Ball gegeben [The woman NOM has the boy DAT the ball ACC given].


Many languages mark a category of grammatical gender. German has three genders for nouns, which also involves adjectives and articles (e.g. singular Im Garten steht der schöne Baum. [In the garden stands the beautiful tree] plural Im Garten stehen die schönen Bäume [In the garden stand the beautiful trees]. French and Spanish have two genders (masculine and feminine). The German word for moon is masculine (der mond), while the Spanish word for moon is feminine (la luna). In addition, grammatical gender is not present in some languages.


Because languages differ so much in their structures, it is important to compare the language performance of bilingual children to norms for that language in terms of the sequence of development. Even though bilingual children will not follow monolingual norms in terms of the speed of development, simultaneous bilinguals do follow a language-specific sequence of

development in each language (Thordardottir, 2015a). For this reason, bilingual children should not necessarily be expected to have acquired the same grammatical structures in both languages. Second language learners may use more explicit learning strategies than younger bilinguals, comparing the structures of both languages. Children with language impairment may have difficulty with several aspects of the new language for vocabulary, syntactic structure, and morphology (Boerma, Wijnen, Leseman, & Blom, 2017; Blom et al., 2013).Consequently, comparison and careful consideration are needed when interpreting assessment results from bilingual speakers, with factors in both assessment and intervention.


Difficulties might be attested not only in the acquisition of the second language in bilingual children, the above-mentioned factors might also affect the acquisition and maintenance of the first language (e.g., Anderson, 2012; Cuza & Pérez-Tattam, 2015; Montrul & Sánchez-Walker, 2013). Under the influence (direct or indirect) of the second language, children might have some problems with morphology in the first language.


Bilingual children might go through attrition in their first language (loss of some grammatical properties) or incomplete acquisition of certain grammatical properties. For example, bilingual children might have difficulties with gender marking in L1 (e.g., Anderson, 2012; Rodina & Westergaard, 2017). Bilingual children who acquire L1 with rich morphology in tandem with L2 which has sparse case morphology might be less accurate in producing the correct cases in their L1 (e.g., Janssen & Meir, 2018). The first language (the minority language) seems to be more vulnerable to reduced input and bilinguals show smaller vocabularies in their first language as compared to monolinguals in the country of origin (e.g., Mieszkowska et al., 2017).


What are guidelines for the assessment of bilingual-speaking children?


Assessment must determine areas of strength and weakness in both languages and across language domains: syntax, semantics, morphology, pragmatics, and phonology. Shift in skills over time should also be observed; it should also be kept in mind, that balanced bilinguals with equally strong competence in their two languages are rare (Baker, 2011).


Goldstein (2019) has provided guidance for the assessment of bilingual speaking children. The following history areas must be considered for evidence-based assessment.


  • Understand the culture of the family and the community
  • Determine the age of acquisition: is the child a simultaneous or sequential bilingual? (see however the discussion of this factor above).
  • Determine how often and with whom each language is used and how well each language is used


The case history provides an opportunity to learn about the child’s exposure to languages and environments in which each language is used. Information regarding who speaks which language, the frequency in which language is spoken, and the environments in which the languages are spoken are important. In addition, knowledge of a child’s language development in the native language (or other languages learned or spoken) is important. An interview of family members is an important component of the assessment process. Once a child’s history is

completed, assessment can begin. The difficulty in utilizing standardized tests with bilingual children is that normative references are largely available for only monolingual children (Rimikis, Smiljanic, & Calandruccio, 2013. Because bilingual children are a tremendously heterogeneous population, the development of a “bilingual norm” may not be possible (Thordardottir, 2015).


Once a child’s history is completed, assessment can begin. The difficulty in utilizing standardized tests with bilingual children is that normative references are largely available for monolingual children.


It is important for speech-language pathologists (SLPs) to acquire the knowledge, skills, and attitudes required to competently evaluate and address the language needs of bilingual children. As an SLP establishes a rapport with a child, seeking opportunities to communicate with the primary caregiver, case managers, and cultural brokers in the community is valuable. Clinical strategies include successful work with interpreters, selection of appropriate tests and assessment tools, and accessing resources about the language proficiency of primary languages spoken at home are essential (McNeilly, 2019).


Because there are so few standardized tests available to use with bilingual children, informal assessment is often the only approach that is available. However, the direct application of monolingual norms with bilingual children leads to over-diagnosis of bilingual children (Bedore & Peña, 2008), although it can be appropriate in some cases, notably for children with a strong dominance in one language (Thordardottir, 2011). Procedures have been proposed that use different cut-off criteria for bilingual children, prorating the cut-off values based on the child’s particular exposure history (Thordardottir, 2015b). Comparison of each language with monolingual norms will also provide an idea of dominance and of functioning in a monolingual environment (Thordardottir, 2017). One approach is to use standardized tests in an informal way. In this approach, the examiner administers the stimulus items from a test without using the scores required to determine an overall score that is required by the test. When this mode of testing is used, it is important to employ item analysis to determine which items on the test present difficulty.


It is important to acknowledge cultural differences in test taking skills. Not all children will have experience taking tests; when testing these children, more explanations may need to be provided, practice items and stimuli may need to be repeated and reword test items reworded. It may also be necessary to test beyond the test’s ceiling (i.e., above the point where administration of the test would stop if it were being scored according to the instructions in the test manual). The examiner may also ask children to explain their answers in order to determine if they have understood the question. It is necessary to keep in mind that modifications of this kind invalidate any norms that come with the test, as children in the norming sample were administered the test following a strict protocol (Thordardottir, 2015). Other methods of informal assessment are the use of parent questionnaires, comparing data from the child being evaluated with published data on similar children, and the analysis of narratives/conversational samples. One possibility to consider is also using more criterion referenced approaches (Baker, 2011), where the child is profiled on specific language skills and her/his development are assessed comparing her/him to her/himself. It is important to keep in mind that formal tests were not designed to be used as

informal measures, and that some normative reference bases are required to interpret informal data. While these informal approaches are often the only methods available, it must be emphasized that they represent approximations that are subject to a larger error margin than are carefully designed tests that are appropriate for the population being tested.


The narrative approach to assessment is a useful and positive approach for language assessment. Narratives can provide information about a child’s knowledge of vocabulary, grammatical structures, and story structure (Squires et al., 2014). However, it is essential to consider the cultural differences in the style and structure of narratives when assessing children from different language backgrounds (Bliss & McCabe, 2011). Narratives can be described in terms of the structure of the entire story (macrostructure) and the specific types of words and sentences that make up the story (microstructure). School-age children typically create stories that include macrostructure elements (characters, setting, an initiating event, plans developed in response to the initiating event, actions to carry out the plans, a consequence, and internal responses felt by the characters in response to the initiating event or consequence (Stein, 1988). Children with typical language development are more successful in narrative production than children with a developmental language disorder (DLD). Findings also showed that the presence of macrostructure scores in a child’s native language in kindergarten act to predict macrostructure scores in L2 in the first grade. In fact, a number of recent studies have found the macrostructure of narratives to be fairly unaffected by bilingualism (e.g. see Gagarina et al, 2016: the Special Issue “Narrative Abilities of Bilingual Children” in Applied Psycholinguistics) – therefore, pronounced difficulty in telling a story is a sign of language difficulty or impairment, depending on its severity.


Dynamic Assessment is another alternative assessment method (Gillam, Pena, Bedore, Bohman, & Mendez-Perez, 2014; Gutiérrez-Clellen & Peña, 2001). The goals of dynamic assessment are to profile learners’ abilities; to observe learners’ modifiability; to induce active, self-regulated learning; and to inform intervention. What dynamic assessment allows the assessor to tap future skills or the child’s modifiability (i.e., change through mediation). Modifiability involves three factors: child responsiveness (how the child responds to and uses new information); examiner effort (quantity and quality of effort needed to make a change); and transfer (generalization of new skills). All three factors are critical in determining if a child fails on a task because of experience or ability. The format for dynamic assessment is test-teach-retest. In the test phase, the examiner determines the child’s areas of weakness and the base level of functioning, without any aid or assistance. In the teach phase, the assessor models the target behaviors and strategies in meaningful contexts, makes the child aware of how the strategies are to be applied, allows the child to lead some of the time, and increases demands as the skills are mastered. In order to determine how the child has progressed after the ‘teach’ phase, s/he is retested, measuring examiner effort (i.e., how much aid is needed by individuals to maximize their performance), child responsiveness (i.e., how rapidly the child changes in response to teaching), and transfer (i.e., the generalization of the task to other tasks and other domains). Dynamic assessment has been used successfully to differentiate children’s lack of experience from their lack of ability.

Thus, it is a positive approach for assessment of bilingual speaking children.


A young bilingual child’s vocabulary can be assessed by using total vocabulary and conceptual scoring (Gross, Buac, & Kaushanskaya, 2014; Pearson, Fernandez, Levedag & Oller, 1997). An

example of total vocabulary scoring follows when a Spanish/English-speaking child’s vocabulary skills are assessed for describing a picture of a ball through the use of code mixing to convey meaning (striped, round, big, red): “Striped” . . . “round” . . . “grande” . . .“rossa.” If this child were scored for only English, the score would be “2.” If credited for the child’s native language (Spanish) and second language (English), the score would be “4.” If only one language is considered, the child’s true vocabulary knowledge would not be considered.


Conceptual vocabulary scoring is frequently undertaken using the Mac-Arthur-Bates parent report checklist that refers to the number of concepts the child has produced a word for, regardless of language. Thus, if the child has said pajama in French and also in English, that word counts only once towards the conceptual vocabulary score. Studies, across several languages, have indicated that conceptual vocabulary should be roughly comparable to monolingual vocabulary norms (Pearson et al., 1993), with variation expected across particular languages and a child’s knowledge in languages (Thordardottir, Rotherberg, Rivard, & Naves, 2006).


Tests that target language processing rather than language knowledge (vocabulary size or syntactic structures) have been shown to accurately distinguish children with and without DLD, for both bilingual and monolingual speakers (Armon-Lotem & Meir, 2016; Thordardottir & Brandeker, 2013Fleckstein et al., 2018; Hamann & Abed Ibrahim, 2017; Chiat & Polišenská, 2016; Summers, Peña, Bedore, Gillam, & Bohman, 2010). These tests include nonword repetition and sentence imitation. Nonword repetition involves the ability to perceive, store, recall and reproduce phonological sequences. Children with DLD are much more greatly affected by word-length than are TD children, and in this respect, DLD children clearly differ from both monolingual and bilingual children with TD (Thordardottir & Brandeker, 2013)


Given that formal assessment in two languages is often beyond the means of practicing clinicians working with diverse multilingual populations, Thordardottir (2015b) proposed a scoring method in which formal test results are interpreted using different criteria depending on the child’s amount of previous exposure to the language being assessed. For this purpose, history information is used to determine whether the language being assessed is the child’s stronger language, one of about equally strong languages or the child’s weaker language. The cut-off score used for determining a likely presence of language impairment (compared to the monolingual norms of the test) is then adjusted in a different way depending on this classification. This method is based on the strong relationship that has been demonstrated between amount of language exposure and language proficiency.


A number of assessment measures have been developed expressly for bilingual assessment, and continued work is underway to provide data on such tasks across many languages. COST Action IS1804 produced perhaps the most ambitious attempts to date at developing equivalent measures across a large number of languages. These measures, referred to as LITMUS tasks (Language Impairment Testing in Multilingual Settings, Armon-Lotem, de Jong & Meir, 2015), including tests of sentence imitation, nonword repetition, narration, and more, and also a bilingual version of a parent questionnaire that can be used to estimate the likelihood of a language impairment based on various factors.


What are the best approaches to intervention for bilingual children?


For bilingual children, the purpose of intervention is to systematically improve their communication skills in both languages through intervention carried out by a culturally and linguistically competent professional. To do so, a six-step process for intervention is proposed that is highly recommended for bilingual children: choose goals, choose targets, choose the goal attack strategy, choose the intervention approach, choose the language of intervention, and monitor progress.


There is a fairly small, but growing research base on the efficacy of treatment and assessment for bilingual children. Taken together, available studies indicate that targeting both languages in some way is beneficial in that it supports both languages and does not slow down overall learning. No studies to date have indicated that a monolingual treatment is superior (Thordardottir, 2010, 2017). Current studies have also indicated that, in order to advance both languages, both must be directly targeted. For particular language structures, such as vocabulary items or syntactic structures, the evidence is clear that teaching targets in one language does not give rise to these same targets in the other language (Thordardottir et al., 2015: Restrepo et al.

2013). However, carry-over to the other language has been shown for more abstract skills that draw on a common underlying metalinguistic awareness, such as incorporating more complex sentences (that have already been acquired) into narratives (Peterson et al., 2006; Thordardottir, 2017). In actual clinical practice, a direct focus on both languages may not be feasible due to lack of personnel. Bilingual treatment has been created through a collaboration with parents, with mixed results (Tsybina & Erics-Brophy, 2010; Thordardottir et al., 2015). An important consideration in this respect appears to be the necessity to ensure that a strong focus is included on both languages.


For children who speak a first and a second language (thus with fairly late introduction of the second language), main approaches have been described: a Bilingual Approach (with skills common to both languages receiving attention) or a Cross-linguistic Approach (with attention directed at specific linguistic features or social uses of each language separately) (Kohnert, 2010). Within both of these approaches, it is essential to maintain a child’s first language to allow children to communicate and learn from family and friends and to maintain their native culture, values, and beliefs.


Bilingual approach: The approach supports goals that address areas common to both languages, along with errors found with equal frequency in both languages. Two bilingual approaches have been described (Gutierrez-Clellen, 1999). The first consists of the native language being maintained and strengthened in the child’s home while the therapist works with the academic second language. The second consists of the concurrent translation of sentences in one language that are repeated in the other language. In one program, children were provided with lessons in bilingual books that introduced narrative and new vocabulary items in their native language. The following day, the same material was presented in the school language. Some SLTs have used the two language in one session. Others have used both languages in different sessions. It is important to assess learning to determine the best approach.

Cross-linguistic approach: This approach focuses on the linguistic skills unique to each language, with targets on errors noted in a specific language. Support for this approach comes from studies that have shown that in order to advance basic skills in a particular language, that language needs to be directly targeted (Thordardottir et al., 2015; Restrepo et al., 2013). Indeed, basic skills such as vocabulary items and syntactic structures do not transfer directly from one language to the other. Also, because each language of a young bilingual child is acquired according to the specific schedule of that language (Thordardottir, 2015b), the items that need to be worked on may differ markedly between the two languages. Intervention focusing on a particular language has been done in different ways, for example by targeting the two languages in different sessions (Thordardottir, Ellis Weismer & Smith, 1997; Restrepo et al, 2013) or in different settings by the SLP and the parent (Tsybina & Eriks-Brophy, 2010).


Carryover and generalization are important factors in learning. To assure carryover or generalization of intervention goals, the SLT may also provide children with support for repeating what was learned during the session. SLTs can also ask family members to repeat in their own language what was learned in L2 in the therapy session to promote the use of both languages. Another approach is to ask a child to teach the SLT one word from L1 in each session. This acts to contribute to a sense of acceptance.


It may also be important to request an interpreter if the SLT requires this support. Collaboration with interpreter requires that the SLT remain responsible for planning the session, selecting culturally relevant materials, and appropriately administering assessment and treatment (ASHA, 2018). The skills necessary for an interpreter is proficiency in the child’s language, familiarity and a positive attitude the child’s culture, and understanding the importance of following the guidance of the SLT (ASHA, 2004). However, it is important to note that research is lacking on the efficacy of the use of interpreters or on the specific roles that they should assume in therapy. Assessment Tests


There are also some published assessment tools for bilinguals. There are tests and word lists developed to assess children’s articulation and phonology in a variety of other languages.


  • The Bilingual-English-Spanish-Assessment test (BESA) was developed for Spanish- speaking children’s assessment (Peña, Gutiérrez-Clellen, Iglesias, Goldstein, & Bedore, 2018).
  • Pearson Publications (2018) has also offered a site with a wide range of assessment devices.
  • Sources for assessment are presented by McLeod, Verdon, and Bowen (2013) and McLeod & Verdon (2017).
  • Charles Sturt University (2019) presents over 200 studies that address cross-linguistic speech
  • McLeod (2019) offers a compilation of data on typical speech development for English speaking children, designed to be used by speech-language
  • McLeod (2013) also offers information on speech sound acquisition in a book chapter that provides developmental information, in addition to an international guide to speech acquisition (McLeod, 2007).
  • McLeod and Verdon (2014) also offer a review of 30 speech assessments in 19 languages and Grech and McLeod (2012) offer information on multilingual speech and language development and
  • McLeod, Harrison, and McCormack (2012) present information on children’s intelligibility, with a description of a measure of children’s functional
  • Hua and Dodd (2006) offer information on phonological development and disorders in children, based on a multilingual perspective.
  • Hambly, Wren, McLeod, & Roulstone (2013) offer information on the influence of bilingualism on speech production. Guidelines for school-based assessment are offered by Caesar & Kohler (2007).
  • Information on approaches to teaching within bilingual and multilingual classrooms are offered by Levey and Polirstok (2011).
  • A multilingual device, termed Speakaboo (2019) for phonological assessment across several languages has been developed for practitioners who do speak the child’s native language.


The following information on bilingualism is also available on the following websites for the public.



American Speech-Language-Hearing Association (ASHA, 2004). Collaborating with Interpreters and Translators. Available at http://www.asha.org/practice/multicultural/InterpreterTranslator/ American Speech-Language-Hearing Association (ASHA, 2018). Available at https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935334&section=Key_Issues Anderson, R. (2012). First Language Loss in Spanish-Speaking Children. Patterns of Loss and implications for clinical purposes. In B. A. Goldstein (Ed.), Bilingual language development and disorders in Spanish-English speakers (2nd ed., pp. 193-213). Baltimore: Paul H. Brookes Publishing Co.

Armon-Lotem, S., de Jong, J., & Meir, N.(Eds) (2015). Assessing multilingual children: Disentangling bilingualism from language impairment. Bristol. UK: Multilingual Matters. Armon‐Lotem, S., & Meir, N. (2016). Diagnostic accuracy of repetition tasks for the identification of specific language impairment (SLI) in bilingual children: evidence from Russian and Hebrew. International journal of language & communication disorders, 51(6), 715-731.

Bedore, L. M. (2010). Choosing the language of intervention for Spanish- English bilingual preschoolers with language impairment. Evidence-based Practice Briefs, 5 (1), 1-13.

Bedore, L. M., & Pena, E. D. (2008). Assessment of bilingual children for identification of language impairment: Current findings and implications for practice. International Journal of Bilingual Education and Bilingualism, 11(1), 1-29.

Bialystok, E. (2006). The impact of bilingualism on language and literacy development. In Bhatia, T.K., & W.E. Ritchie (Eds.) The handbook of bilingualism (pp. 577-601). Malden, MA: Blackwell Publishing.

Bliss, L. S., & McCabe, A. (2011). Educational implications of narrative discourse. In S. Levey & S. Polirstok (Eds.), Language development: understanding language diversity in the classroom (pp. 209–226). Los Angeles, CA: Sage.

Blom, E., de Jong, J., Orgassa, A., Baker, A., and Weerman, F. (2013). Verb inflection in monolingual Dutch and sequential bilingual Turkish-Dutch children with and without SLI. International Journal of Language and Communication Disorders. 48, 382–393. doi: 10.1111/1460-6984.12013

Boerma, T., Wijnen, F., Leseman, P., and Blom, E. (2017). Grammatical morphology in monolingual and bilingual children with and without language impairment: the case of Dutch plurals and past participles. Journal of Speech, Language, and Hearing Research, 60, 2064– 2080. doi: 10.1044/2017_jslhr-l-16-0351

Bylund, E. (2009). Effects of age of L2 acquisition on L1 event conceptualization patterns. Bilingualism: Language and Cognition, 12(3), 305-322.

Castilla-Earls, A, Francis, D., Iglesias, A., & Davidson, K. (2019). The impact of the Spanish- to-English proficiency shift on the grammaticality of English learners. Journal of Speech, Language, and Hearing Research, 62, 1–16.

Caesar, L. G., & Kohler, P. D. (2007). The state of school-based bilingual assessment: Actual practice versus recommended guidelines. Language, Speech, and Hearing Services in Schools, 38(3), 190-200.

Charles Sturt University (2019). Multilingual Children’s Speech. Available at http://www.csu.edu.au/research/multilingual-speech/speech-acquisition.

Chiat, S., and Polišenská, K. (2016). A framework for crosslinguistic nonword repetition tests: effects of bilingualism and socioeconomic status on children’s performance. Journal of Speech, Language, Hearing Research, 59, 1179-1189.

Chin, N.B., & Wigglesworth, G. (2007). Bilingualism: An advanced resource book. London: Routledge.

Cuza, A., & Pérez-Tattam, R. (2016). Grammatical gender selection and phrasal word order in child heritage Spanish: A feature re-assembly approach. Bilingualism: Language and Cognition, 19(1), 50-68.

De Houwer, A. (2009). Bilingual first language acquisition. Multilingual Matters. Bristol, UK. Elin Thordardottir (2017). Implementing Evidence Based Practice with limited evidence: The case of language intervention with Bilingual children. Revista de Logopedía, Foniatría y Audiología, 34 (4), 164-171.

Fabiano-Smith, L. & Goldstein, B. (2010). Phonological acquisition in bilingual Spanish-English speaking children. Journal of Speech, Language, and Hearing Research, 53, 160–178.

Fleckstein, A., Prévost, P., Tuller, L., Sizaret, E., & Zebib, R. (2018). How to identify SLI in bilingual children: a study on sentence repetition in French. Language Acquisition, 25(1), 85- 101.

Gagarina, N., Klop, D., Tsimpli, I. M., & Walters, J. (2016). Narrative abilities in bilingual children. Applied Psycholinguistics, 37(1), 11-17.

Gillam, R. B., Pena, E. D.., Bedore, L. M., Bohman, T. M., & Mendez-Perez, A. (2014). Identification of Specific Language Impairment in Bilingual Children: Assessment in English. Journal of Speech, Language, and Hearing Research, 57, 2208-2220.

Goldstein, B. Charles Sturt University (2018). Speech assessments. Available at http://www.csu.edu.au/research/multilingual-speech/speech-assessments A. (2019). Bilingual children’s language development: assessment and intervention (pp. 207-226). In S. Levey (Ed.). Introduction to language development. San Diego, CA: Plural Publishing.

Grech, H. & McLeod, S. (2012). Multilingual speech and language development and disorders. In D. Battle (Ed.). Communication disorders in multicultural and international populations (4th ed.) (pp. 120-147). St Louis, MI: Elsevier.

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, 23, 574–586.

Gutierrez-Clellen, V. F. (1999). Language Choice in intervention with bilingual children.

American Journal of Speech-Language Pathology, 8, 291–302.

Gutiérrez-Clellen. F., & Peña, E. (2001). Dynamic assessment of diverse children: a tutorial.

Language, Speech, and Hearing Services in Schools, 32, 212–224.

Hambly, H., Wren, Y., McLeod, S., & Roulstone, S. (2013). The influence of bilingualism on speech production: A systematic review. International Journal of Language and Communication Disorders, 48(1), 1-24.

Hamann, C., & Abed Ibrahim, L. (2017). Methods for identifying specific language impairment in bilingual populations in Germany. Frontiers in Communication, 2, 16.

Hua, Z., & Dodd, B. (2006). Phonological development and disorders in children: A multilingual perspective. Cleavdon, UK: Multilingual Matters.

Iluz-Cohen, P. & Walters, J. (2012). Tenning stories in two languages: Narratives of bilingual preschool children with typical and impaired language. Bilingualism, Language and Cognition, 15, 58-74.

Janssen, B., & Meir, N. (2018). Production, comprehension and repetition of accusative case by monolingual Russian and bilingual Russian-Dutch and Russian-Hebrew-speaking

children. Linguistic Approaches to Bilingualism.

Jarvis, S. & Pavlenko, A. (2008). Crosslinguistic influence in language and cognition. London/New York: Routledge

Kohnert, K. (2010). Bilingual children with primary language impairment: issues, evidence and implications for clinical actions. Journal of Communicative Disorders, 43(6), 456–473.

Kohnert, K. (2012). Processing skills in early sequential bilinguals. In B. Goldstein (Ed.), Bilingual language development & disorders in Spanish-English speakers. Baltimore, MD: Brookes.

Köpke, B., & Genevska-Hanke, D. (2018). First Language Attrition and Dominance: Same or Different? Frontiers in Psychology, 06. Available at https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01963/full

Kovacs, A.M., & J. Mehler, J. (2009). Cognitive gains in 7-month-old infants. Proceedings of the National Academy of Sciences, 106(16), 6556-6550.

Levey, S., & Polirstok, S. (Eds.). (2011). Language Development: Understanding Language Diversity in the Classroom. Los Angeles, CA: SAGE Publications,

Levey, S., Cheng, L-R L, & Langdon, H. W. (2013). The relationship between ethical principles and clinical practice in working with culturally and linguistically diverse (CLD) populations: A tutorial. Speech and hearing Review, 11, Taiwan, CN.

McLeod (2007). The international guide to speech acquisition. Clifton Park, NY: Thomson Delmar Learning.

McLeod, S. (2013). Speech sound acquisition. In J. E. Bernthal, N. W. Bankson & P. Flipsen Jnr (Eds.), Articulation and phonological disorders: Speech sound disorders in children (7th ed., pp. 58-113). Boston, MA: Pearson.

McLeod (2019). Children’s speech acquisition. Available at

http://www.csu.edu.au/ data/assets/pdf_file/0006/227652/Speech-acquisition-summary.pdf McLeod, S., Harrison, L. J. & McCormack, J. (2012). Intelligibility in Context Scale: Validity and reliability of a subjective rating measure. Journal of Speech, Language, and Hearing Research, 55, 648-656.

McLeod and Verdon (2014). A review of 30 speech assessments in 19 languages other than English. American Journal of Speech-Language Pathology, 23, 708-723

McLeod, S., & Verdon, S. (2017). Tutorial: Speech assessment for multilingual children who do not speak the same language(s) as the speech-language pathologist. The International Expert

Panel on Multilingual Children’s Speech. American Journal of Speech-Language Pathology, 26,


McLeod, S., Verdon, & Bowen, C. (2013). International aspirations for speech-language pathologists’ practice with multilingual children with speech sound disorders: Development of a position paper. Journal of Communication Disorders, 46(4), 375-387.

McNeilly, L.G. (2019). Strategies Utilized by Speech-Language Pathologists to Effectively Address the Communication Needs of Migrant School-Age Children, Folia Phoniatrica et Logopaedica 71,127-134.

Meir, N., Walters, J. & Armon-Lotem, S. (2017). Bi-directional cross-linguistic influence in bilingual Russian-Hebrew speaking children. Linguistic Approaches to Bilingualism, 7(5), pp. 514–553. doi:10.1075/lab.15007mei

Mieszkowska, K., Łuniewska, M., Kołak, J., Kacprzak, A., Wodniecka, Z., & Haman, E. (2017). Home language will not take care of itself: vocabulary knowledge in trilingual children in the United Kingdom. Frontiers in psychology, 8, 1358.

Montrul, S. (2013). Bilingualism and the heritage language speaker. In T. K. Bhatia & W. C. Ritchie (Eds.), The handbook of bilingualism and multilingualism (pp. 168-189). Blackwell Publishing Ltd.

Montrul, S., & Sánchez-Walker, N. (2013). Differential object marking in child and adult Spanish heritage speakers. Language Acquisition, 20, 109-132.

Paradis, J., Genesee, F., & Crago, M. (2011). Dual language development and disorders: s handbook on bilingualism and second language acquisition (2nd ed.). Baltimore, MD: Brookes. Pearson Publications. Available at http://images.pearsonclinical.com/images/8380A- 2013Spanish_Buyers_Guide_DM_HQ_HL.pdf.

Pearson, B., Fernández, S., Lewedeg, V., & Oller, K. (1997). The relation of input factors to lexical learning by bilingual infants. Applied Psycholinguistics, 18, 41-58.

Petersen, D., Thompsen, B., Guiberson, M. & Spencer, T. (2006). Cross-linguistics interactions from second language to first language as the result of individualized narrative language intervention with children with and without language impairment. Applied Psycholinguistics, 37, 703-724.

Peña, Gutiérrez-Clellen, Iglesias, Goldstein, & Bedore (2018). Bilingual-English-Spanish- Assessment (BESA). Brooks Publishing, Baltimore, MD. Available at https://products.brookespublishing.com/Bilingual-English-Spanish-Assessment-BESA- P1044.aspx.

Polinsky, M. (2007). Reaching the end point and stopping midway: different scenarios in the acquisition of Russian. Russian Linguistics, 31(2), 157-199.

Restrepo, M. A., Morgan, G.P. & Thompson, M. S. (2013). The efficacy of a vocabulary intervention for dual-language learners with language impairment. Journal of Speech, Language and Hearing Research, 56, 248-265.

Rimikis, S., Smiljanic, R., & Calandruccio, L. (2013). Nonnative English speaker performance on the basic English lexicon (BEL) sentences. Journal of Speech, Language, and Hearing Research, 56, 792–804.

Rodina, Y., & Westergaard, M. (2017). Grammatical gender in bilingual Norwegian–Russian acquisition: The role of input and transparency. Bilingualism: Language and cognition, 20(1), 197-214.

Speakaboo (2019). Available at https://www.kentalis.nl/zoeken?query=speak+a+boo.

Squires, K. E., Lugo-Neris, M. J., Peña, E. D., Bedore, L. M., Bohman, T. M., & Gillam, R. B. (2014). Story retelling by bilingual children with language impairments and typically developing controls. International Journal of Language & Communication Disorders, 49(1):

Stein N. L. (1988). The development of children’s storytelling skill. In: Franklin M. B., Barten S. S., editors. Child language: A reader. New York, NY: Oxford University Press; 1988. pp. 282– 297.

Summers, C., Bohman, T. M., Gillam, R. B., Peña, E. D., & Bedore, L. M. (2010). Bilingual performance on nonword repetition in Spanish and English (2010). International Journal of Language and Communication Disorders, 45(4),480-93.

Elin Thordardottir (2010). Towards evidence-based practice in language intervention for bilingual children. Journal of Communication Disorders, 43, 523-537.

Elin Thordardottir, & Brandeker, M. (2013). The effect of bilingual exposure versus language impairment on nonword repetition and sentence imitation scores. Journal of Communication Disorders, 46, 1-16.

Elin Thordardottir (2015). Proposed diagnostic procedures and criteria for Cost Action Studies on Bilingual SLI. In Armon-Lotem, S., J. de Jong & N. Meir (Eds.), Methods for assessing multilingual children: Disentangling bilingualism from language impairment. Bristol, UK: Multilingual Matters.

Elin Thordardottir, Ménard, S., Cloutier, G., Pelland-Blais, E., & Rvachew, S. (2015). Effectiveness of monolingual L2 and bilingual language intervention for children from minority language groups: A randomized control trial. Journal of Speech, Language and Hearing Research, 58 (2), 287-300.

Elin Thordardottir, Rothenberg, A., Rivard, M.-E., & Naves. R. (2006). Bilingual assessment: Can overall proficiency be estimated from separate measurement of two languages? Journal of Multilingual Communication Disorders, 4 (1), 1-21.

Elin Thordardottir, & Topbas, K. (2019). The social and cultural context of intervention for children with Developmental Language Disorder (Chapter 5). In J. Law, C. McKean, C.-A. Murphy and E. Thordardottir (Eds.). Managing children with language impairment: Theory and

practice across Europe and beyond. Oxon, UK: Routledge.

Tsybina, I. and A. Eriks-Brophy, Bilingual dialogic book-reading intervention for preschoolers with slow expressive vocabulary development. Journal of Communication Disorders, 43(6), 538- 556.

Yager, L., Hellmold, N., Hyoun-A Joo, Putnam, M. T., Rossi, E., Stafford, C., & Salmons, J. (2016). New Structural Patterns in Moribund Grammar: Case Marking in Heritage German. Frontiers in Psychology, 6, 1-10. Available at https://doi.org/10.3389/fpsyg.2015.01716.


FAQs for Teaching in a Diverse Classroom

Group learning


Groups that consist of students who speak the language of learning and teaching (LoLT) within the classroom and second language (L2) learners allow students to gain experience in communicating in the second language. These groups can be organized with structured tasks (e.g., a project) or unstructured tasks (e.g., interviews among students that target favorite activities or other informal topics).


The group context allows L2 learners to interact with first (L1) or majority language speakers. In this way, language exposure occurs within a task, along with allowing informal interaction among students. Given that L2 learners’ social language skills are acquired earlier than academic language skills, group interaction provides a positive context for social interaction. This interaction among students link to Vygotsky’s sociocultural theory that knowledge is constructed in interactions (Green, 2014).


Group learning increases exposure to different thinking strategies. Moreover, different perspectives are shared, which enhances world views. In so doing, learners develop respect for other learners’ perspectives and realize that their world views are valued too. The teacher scaffolds the discussion so that the L2 learner is able to contribute to the task at hand. The L1 learners are able to model language structures in context, during a task/activity.


Content-based Instruction and language instruction approach


Content based instruction (CBI) is a teaching approach that focuses on learning language through learning about information on a particular classroom topic (Cenoz, 2015; Stroller, 2008).

Learning language occurs through group interaction and discussion, rather than teacher instruction or lecture. In this approach, steps consist of choosing a subject of interest, finding sites with information on this subject (e.g., websites, books, videos, or images), and forming small groups to focus on the subject. Within groups, students will be encouraged to discuss information. The final goal is for the group to create a report or presentation. In this approach, students are able to produce the language associated with the task while addressing a language objective in the class. As education reflects the sociopolitical situation, it should not be taken for granted that all students speak the same L1 or share the same culture and this must be considered when implementing CBI (Cenoz, 2015).


In lower grades, a content-based approach can consist of students creating a graphic presentation (e.g., pictures or images) of the lifecycles of butterflies. The corresponding language approach consists of verbal explanations and labels. Later, students can be asked to verbally explain the graphic representation and guided in using connective terms to develop narrative skills (e.g., first, next, then).


In higher grades, topics can address science or math problems. In one high school classroom, instruction integrated math with a functional task. The small group task required students to calculate clothing costs given a percentage of discount. This strategy demonstrates the integration of content and language, Genesee and Lindholm-Leary (2013) state that CBI allows for language to be learned within meaningful contexts.


Pre-teaching of concepts is essential. The teacher can pre-teach the vocabulary or concepts so that a foundation is created before the content-based instruction follows (Wium, 2015). This provides all learners with an understanding, upon which new concepts can be built. Pre-teaching is useful strategy, as diverse learners may present with different levels of competence in the language of learning and teaching [LoLT]. Pre-teaching of vocabulary concepts benefits both oral discussion and literacy lessons (Wium, 2015).


Create a positive learning environment


Create a positive view of diversity and differences. Tell students “good try” if errors occur, rather than focus on errors. This will aid the students’ learning as a positive environment is essential to eliminate anxiety and negative feelings.


Teachers should display sensitivity to diverse learners’ contributions, with barriers to learning are avoided. The teacher can use language elicitation strategies of expansion to model language structures. Forced alternatives also give L2 learners the choice of the target word, providing them with the feeling of owning their response. The quality of the teacher’s feedback to a learner’s response is important (Pascoe, Harty & le Roux, 2015) and will encourage the learner to develop confidence her/his replies.


Classroom goals and lessons


Posting information on topics, goals, and lessons on walls, with labels presented in native languages spoken in the classroom will enhance learning. This approach will value all languages, making all children feel welcome and proud of their native languages, while embracing the LoLT. It also allows the learners to hear the phonology of the different languages.


Depending on the grade of the learner, phrases in the LoLT that are on the walls will provide support for the L2 learner when writing in the school language. Learners can also be encouraged to have their personal word dictionaries that they make up according to the activity they are engaged in. This will help them to be independent when these words are needed for written activities in subsequent lessons (Moonsamy & Durbach, 2016). Provide bilingual tools in the classroom, such as dictionaries. Picture dictionaries are available for younger aged classrooms in a number of different languages (e.g., Spanish, Korean, Vietnamese, and a number of other languages).


Within the classroom, sessions devoted to the school language allow greater exposure and experience with the second language to second language learners. During these sessions, spoken language can be accompanied by visual supports to aid comprehension. Other sessions can be devoted to bilingual lesson learning. Allowing students to express ideas and lesson content in the language they chose to use. Such exchanges will support the learner in their transition into the LoLT. This will also act to create a positive learning environment.

Code switching


Within the classroom, treat code switching as a positive way for students to communicate. This is a device used to request help in finding a target word in a second language or a means for creating a longer and complex sentence. “Code switching follows the ‘agreed upon’ community rules. It occurs to enhances meaning, emphasize a shift in topic, conveys humor, ethnic solidarity and attitude towards the listener (Owens, 2014, p.178). When assessing, note code switching and the context (audience), as you would with non-linguistic cues. Code switching will depend on the individual’s mastery of the two languages.


Background knowledge


It is important to not assume background knowledge. Within the diverse classroom, students have different experiences, culture, language, and knowledge. These are factors that play an important role in learning. Each learner brings their world view to their learning and this experience bridges new learning with prior knowledge (Moonsamy & Durbach, 2016). Learners who have not had a particular experience should be allowed to develop the experience, through video clips, film and pictures.


Informal assessment of learning skills


Informal and ongoing assessment (formative assessment) allows monitoring of students’ learning This can take place through some of the strategies described earlier: informal quizzes, or submission of best and least learned information or material at the end of a class. Younger students can be given a list of learning goals or topics and asked to put a plus or minus sign next to those best or least learned. In higher grades and college classrooms, students can be provided with sample questions for exams and quizzes to provide monitoring and ongoing assessment of successful learning.



Universal Design for Learning (UDL)


Universal Design for Learning (UDL) addresses the variability associated with students’ learning and the diversity found across the world’s classrooms (CAST, 2011; CAST, 2018a, 2018b, 2018c; Ralabate, 2011: Ralabate et al., 2012). UDL provides ways to remove barriers to students’ learning for those with/without disabilities from primary school through college. UDL also uses a formative approach to learning, based on continued assessment of students’ learning.


In contrast, traditional approaches to learning utilize summative assessment (e.g., quizzes, exams, and a final exam) that assesses learning at discrete points. However, a final exam is offered too late in the academic year of a course to offer support for learners’ difficulties. UDL guidelines provide ways for Multiple Means of Representation (multiple ways that information can be presented), Multiple Means of Action and Expression (multiple ways that students can act and express learning), and Multiple Means of engagement (multiple ways that students can be engaged within a classroom) (CAST, 2011).



Multiple Means of Representation: Information can be presented in videos with text and sound, vocabulary items and main ideas can be highlighted, verbal directions can be presented with images and text for children who learn better through visual, auditory, or tactile means.


Multiple Means of Action and Expression: Students are given the opportunity to share what they have learned, to ask questions and tell stories or draw pictures about their personal experiences, or to retell a story from a book that was read to them. They are given ways to express their learning through the means that are available to them through verbal or other means.


Multiple Means of Engagement: Children have different interests, cultural and language backgrounds, and experiences. Some are shy. Awareness of these differences allows a teacher to consider ways to engage children’s participation within the classroom. Thus, children can be engaged through the opportunity to present through drawing, recording, or through verbal means of engagement.



I read to the children in my classroom. Can the Universal Design for Learning help me read successfully so that children are engaged and learn?


The following model was used in a preschool class that followed UDL guidelines. The teacher read a book about a child who comes to school without food in his lunchbox and other children each share a piece of food from their own lunchboxes. Before reading the story, students were introduced to the vocabulary words used in the book (Multiple Means for Representation).

During this task, students were asked questions by use of the vocabulary words in the story: have you have ever been surprised, shared, or forgotten something (Multiple Means for Action and Expression and Multiple Means for Engagement). Vocabulary words were also accompanied by pictures to demonstrate the meaning of words. In summary, vocabulary words are presented before reading a story, children are engaged by asking questions regarding the vocabulary words (e.g., forgotten – have you ever forgotten anything? Lost – have you ever lost anything). The goal is to engage children to support their interest.


I teach in a high school class. How can I use the Universal Design for Learning (UDL) in my classroom?


The following UDL guidelines can be used in high school and college classrooms to ensure that barriers are removed for variable and diverse learning skills.


Multiple Means of Representation: PowerPoint presentations, videos, handouts, and posts in the classroom or on a webpage can be used to address visual and auditory learning. Posts and discussion about goals for specific lessons in the classroom can be used, along with consistent and frequent feedback to students on their learning skills.


Multiple Means of Action and Expression: Encourage the formation of small groups to discuss material related to the lectures, as recommended earlier in this section. Each group can appoint a speaker to express questions, conclusions, or issues that emerge during discussion. Students can be asked to anonymously turn in questions at the end of a class. This is a formative assessment approach that allows identification of students’ strengths and weaknesses in learning and removes the anxiety associated with speaking in a classroom (Multiple Means of Engagement).


Multiple Means for Engagement: Students can be provided with sample questions for exams and quizzes to prepare them for the material to be studied and learned. Sample questions from a final exam allow students to understand the scope of the classroom learning goals. Practice quizzes can be used with questions that are similar to those in the actual quiz to prepare students for later learning goals. The opportunity to retake a quiz can be offered if learning requires further study, based on findings that students are able to achieve higher scores on retakes through awareness of what they did not understand or learn.


Are there any technological apps or devices that are available for the classroom? Some of my students have visual problems, some have difficulty with memory, and others have problems expressing themselves.


UDL emphasizes the need for accessible information for students with disabilities (large print, technical devices and apps, and interpreters), and multiple formats (computers or software, graphic organizers, manipulatives, and PowerPoint). High-tech (e.g., computers, iPads, videos) or low-tech (e.g., picture cards or alphabet boards) approaches can used within the classroom. Computers allow enlarged text for students with visual difficulties. Students with reading disorders can be offered text-to-speech software. Assistive features can be built into an iPad for students who require support for visual, hearing, motor, or literacy needs. The following are some of the technological supports that allow teachers to remove barriers for children’s learning.


Dyslexia Toolbox (www.readingrockets.org/literacyapps/dyslexia-toolbox) allows students with dyslexia a variety of assistive technology features.

Kidspiration (www.inspiration.com/Kidspiration) is software for early grade learners that uses pictures, text, numbers, and spoken words for vocabulary, word recognition, reading comprehension, writing, and critical thinking skills. This software can be downloaded and used for all areas of study.

Scene and Heard (www.therapy-box.co.uk/scene-and-heard ) is an app that can be used for storytelling and images for those who require larger context. The app provides a

communication book, color coded visual timetable, and options for adding audio and video to a program or task. This app can be downloaded to an iPad.

Smart Notebook (https://education.smarttech.com/products/notebook) allows an instructor to create learning activities though animation. Students can use desktop computers, tablets, laptops, or any other device to engage in and complete the activities created the instructor. With the use of this program, classroom tasks can address a variety of topics (e.g., match, science, shapes, language tasks, and any task chosen by the instructor).

SmartPen. (http://livescribe.com/en-us). This pen captures the audio and ties it to written notes on special paper. The recording can then be played back with a simple touch of the pen on the paper

ModMath (www.modmath.com ) is a free iPad app that provides students with dyslexia and dysgraphia to solve math problems without use of a pencil.

MyTalkTools (https://mytalktools.com/dnn/) is an app for students with communication difficulties. This app allows students to communicate by the creation of words, sounds, and pictures.

Stop, Breathe & Think (https://app.stopbreathethink.org ) is an app that addresses the users’ feelings and moods.

Voice Dream Reader (http://voicedream.com) is an app that benefits students with reading disabilities and an attention-deficit/hyperactivity disorder (ADHD) is This app allows students to highlight text which can then be read to them.


For students with an autism spectrum disorder (ASD), there a number of apps for children with the diagnosis of autism spectrum disorder (https://educationalappstore.com/best-apps/5-best- autism-apps-for-iphone-and-ipad).




Autism Spectrum Disorder sites. https://www.educationalappstore.com/best-apps/5-best-autism- apps-for-iphone-and-ipad

American Speech-Language-Hearing Association. (2001). Guidelines for developing formative assessment plans for implementation of new standards for the certificate of clinical competence. Cenoz, J. (2015). Content-based instruction, and content and language integrated learning: the same or different? Language, Culture and Curriculum. 28:1, 8-24, DOI: 10.1080/07908318.2014.1000922. http://doi.org/10.1080/07908318.2014.1000922

Council of Academic Accreditation in Auditory and Speech-Language Pathology and Council for Clinical Certification. Available at https://caa.asha.org/resources/formative-assessment-plans. CAST (2018a). UDL and the learning brain. Wakefield, MA: Author. Retrieved from http://www.cast.org/our-work/publications/2018/udl-learning-brain-neuroscience.html

CAST (2018b). Understood: making an online parents’ resource about learning and attention issues. Available at http://www.cast.org/our-work/capacity-building/case-stories/understood- making-online-parents-resource-learning-attention-issues.html# .WzOWvtVKiUk

CAST (2018c). Available at http://www.cast.org/about#.WykfLFVKiUk

CAST (2011). Universal Design for Learning Guidelines. Wakefield, MA: Author. Retrieved from http://udlguidelines.cast.org

Dalton, E. M., Mckenzie, J. A., Kahonde, C., 2012, ‘The implementation of inclusive education

in South Africa: Reflections arising from a workshop for teachers and therapists to introduce Universal Design for Learning’, African Journal of Disability 1(1), Art. #13, 7 pages. http://dx.doi. org/10.4102/ajod.v1i1.13.

Dyslexia Toolbox. http://www.readingrockets.org/literacyapps/dyslexia-toolbox Genesee, F. & Lindholm-Leary, K. (2013). Two case studies of content-based language education. Journal of Immersion and Content-based Language Education, 1, 3-33. http://doi:10.1075/jicb.1.1.02gen

Green, L. (2014). Thinking students: how children and adolescents develop as thinkers. In L. Green’s (Ed.) Schools as Thinking Communities. Pretoria: Van Schaik Publishers.

Greenberg, K. (2005). Cognitive Enrichment Advantage: teacher handbook. KCD Harris and Associated Press.

Hartmann, E. (2015). Universal design for learning (UDL) and learners with severe support needs. International Journal of Whole Schooling, 11(1). 54-67.

Kidspiration. http://www.inspiration.com/Kidspiration

Levey, S. (2008). Evidence-based analysis of formative assessment. Perspectives on Issues in Higher Education, 11(1), 29-35

Levey, S., & Sola, J. (2013). Speech-language pathology students’ awareness of

differences versus disorders. Contemporary Issues in Communication Sciences and Disorders, 40, I8-14

Lynch, M. (2017). 7 must have app and tools for students with learning disabilities. Available at: https://www.thetechedvocate.org/7-must-app-andtools-students-learning-disabilities

Madrazo, G. M., Jr., & Motz, L. L. (2005). Brain research: implications to diverse learners. Science Educator, 56-60.

Meyer A., Rose, D. H., & Gordon, D. (2014). Universal Design for Learning: Theory & Practice. Wakefield, MA: CAST.

ModMath. http://www.modmath.com

Moonsamy, S., & Kathard, H. (2015). Speech-language Therapy in the School Context (Eds.). Pretoria: Van Schaik Publishers.

Moonsamy, S. & Durbach, F. (2016). Language & Literacy Assessment & Support. In M. Nel,

  1. Nel & A. Hugo (2nd Ed). Learner Support in a Diverse Classroom. Pretoria: Van Schaik Publishers.

MyTalkTools. https://www.mytalktools.com/dnn

Moran, M. J. (2007). Competence and the development of technical skills. In A. M. Guilford, S.

  1. Graham, & J. Scheuerle (Eds.), The speech-language pathologist: From novice to expert (pp. 77-88). Upper Saddle River, NJ: Pearson.

Owens, R. (2014). Language Disorders: A Functional Approach to Assessment and Intervention, Sixth Edition. Boston, MA: Pearson.

Pascoe, M., Harty, M. & Le Roux, J., 2015, ‘Language, literacy and learning in the classroom’, in S. Moonsamy & H. Kathard (Eds.), Speech-language therapy in a school context: Principles and Practices, pp. 175–195, Van Schaik, Pretoria.

Ralabate, P. K. (2011). Universal design for learning: meeting the needs of all students. The

ASHA Leader, August 2011, 16, 14-17.

Ralabate, P., Hehir, T., Dodd, E., Grindal, T., Vue, G., Eidelman, H., Karger, J., Smith, F., & Carlisle, A. (2012). Universal design for learning: Initiatives on the move: Understanding the impact of the Race to the Top and ARRA funding on the promotion of universal design for learning. Wakefield, MA: National Center on Universal Design for Learning.

Rao, K, & Meo, G. (2016). Using universal design for learning to design standards-based lessons. SAGE Open,6(4), 1-12.

Scene and Heard. https://www.therapy-box.co.uk/scene-and-heard

Scott, S. S., McGuire, J. M., & Foley, T. E. (2010). Universal design for instruction: a framework for anticipating and responding to disability and other diverse learning needs in the college classroom. Equity and Excellence in Education, 40-49.

Smart Notebook. https://education.smarttech.com/products/notebook SmartPen. http://www.livescribe.com/en-us.

Stoller, F.L. (2008). Content-based instruction. In N. Van Deusen-Scholl & Hornberger (Ed). Encyclopedia of language and education, vol. 4: Second and foreign language education (pp59- 70). NY: Springer.

Stop, Breathe & Think. https://app.stopbreathethink.org

Teacherswithapps (2017). Available at https://www.teacherswithapps.com/50-best-ipad-apps- for-reading-disabilities.

United Nations Refugee Agency. Figures at a glance 2017. Retrieved from http://www.unhcr.org/figures-at-a-glance.html Accessed in:24/10/2017 Voice Dream Reader. http://www.voicedream.com

Wium, A. (2015). Supporting teachers in emergent literacy. In S. Moonsamy & H. Kathard (Ed). Speech-language Therapy in a School context: Principles and Practices. Pretoria: Van Schaik Publishers.

FAQs for Aphasia and Alzheimer’s Disease

A woman of 65 age, who was a Moroccan-English-French trilingual speaker, recently had a Progressive Primary Aphasia (PPA). She migrated from Morocco to the USA in her 30s.

Should we look for a bilingual or trilingual speech-language pathologist (SLP) to work with her? She lives in the USA.


If a bilingual or trilingual SLP is not available, it is essential to appoint a translator or an interpreter whose services are professional and reliable. A translator or a family member may be used who is trained to provide appropriate support. Interviews with the family should determine the individual’s experience in each language, such as the age of acquisition and the level of proficiency that has been achieved in each language. This information is essential to establish the individual’s knowledge prior to the neural injury. In this way, it may be possible to determine the preference of the individual being treated.


In the case of an acquired language disorder, an SLP who lacks one or more of the languages spoken by the client, intervention in one of the individual’s languages may generalize to the languages that are not treated (Goral, Levy, & Kastl, 2010; Kiran & Roberts, 2010; Kiran, Sandberg, Gray, Ascenso, & Kester, 2013; Kurland & Falcon, 2011; Miertsch, Meisel, & Isel, 2009). However, the non-treated language may also interfere with the language being used in intervention (Goral, Naghibolhosseini, & Conner, 2013; Keane & Kiran, 2015). This problem may be determined once intervention begins.


Differential recovery may occur for the case of a neurodegenerative disease for an individual who has acquired different languages across her life. In the case of an individual who has acquired a Moroccan Dialect as the first language, Modern Standard Arabic as a second language, French as a third language, and English as a fourth language, therapy in French or English will probably help the recovery of Arabic. In the diglossic situation (when two dialects or languages are used), there is the potential to enable a systematic investigation of recovery patterns in between L1 (Moroccan Dialect) and L2 (Modern Standard Arabic). When languages are close or related, cross-linguistic transfer can occur, as when a speaker applies knowledge from one language to another. In therapy, generalizations from L2 to L3 or L3 to L4 depends on the presence of cognates and non-cognates in the target language. Cognates are words in two languages that share a similar meaning, spelling, and pronunciation. Cognate examples from Spanish and English consist of accident/accidente, cause/causa, and importance/importancia. In therapy, individuals can be made aware of cognates for understanding or learning a second language.


Do multilinguals (speakers of more than two languages) with Progressive Primary or Secondary Aphasia always recover the first language they learned or their most dominant language before the aphasia better than their second or weaker language?


Differential, selective, or successive recoveries would result from problems caused by a focal lesion in the case of progressive primary aphasia (PPA). An example of a diglossic situation can be illustrated by Moroccan Arabic, with various spoken dialects specific to each speech community (low or medium) and modern standard Arabic (MSA) that has formal linguistic

variety (or “high”). Structural characteristics (e.g., syntax and semantics) are primary and allow us to measure the relationship between the two languages spoken by the bilingual/multilingual individual. There are languages that share many structural features, while other languages are more distant from one another. Indeed, when both languages are structurally close, they can rely on the same processing processes (Moroccan Arabic and Classical Arabic). This is not the case for two languages that are more distant from one another in structure, such as English and Arabic (Khamis-Dakwar & Froud, 2012).


Studies on language recovery in vascular and degenerative aphasia give us different conclusions. It’s known that explicit knowledge is affected by pathologies that affect memory processing, such as Alzheimer’s disease. In contrast, a stroke allows knowledge to remain intact.

Multilingualism as a competence that is part of the “cognitive reserve” (the mind’s resistance to damage of the brain). Multilingual and polyglossic aphasia individuals contrast with those with Alzheimer’s disease. The aphasic individuals have greater explicit memory while preserving implicit knowledge, such as the knowledge of L1 (Dakwar, Ahmar, Farah, & Froud, 2018).


Is it important to know the language history of bilingual/multilingual persons before the aphasia to understand their aphasic symptoms?


It has been emphasized many times that it is essential to include all the patient’s languages in the assessment of his or her language skills, provided that the patient consents and collaborates during a very lengthy investigation. In this interview, it is important to ask when the individual acquired the language or languages that are spoken, along with the individual’s speaking proficiency in these language or languages. An assessment in each of the languages, however, requires the availability of appropriate, normed, validated, equivalent, and comparable tests for each language. If the SLP lacks the individual’s languages, an interpreter or family members may be consulted.


What are Bilingual Approaches to Intervention for Aphasia?


Given the growing number of the bilingual population across the globe, clinicians must be aware of the factors involved in cross linguistic therapy (Ansaldo & Saidi, 2014). Centeno (2008) presented tasks for intervention with bilinguals to address recovery that consist of cognitive training, the use of cognates, and multi-modality stimulation through the use of speaking, writing, and reading. Multimodality stimulation facilitates access to preserved cognitive abilities in either language of a bilingual aphasic individual (Gil & Goral, 2004).


Lorenzen & Murray (2008) present additional intervention tasks for bilingual individuals with aphasia: the general stimulation approach (Watamori & Sasnuma, 1976), phonemic cueing (Roberts, de la Riva, & Rhéaume, 1997), cueing hierarchy treatment (Galvez & Hinckley, 2003), reading and naming treatments that focus on shared aspects of languages (Kiran & Edmonds, 2004; Laganaro & Venet, 2001), cognate therapy approach (Kiran & Tuchtenhagan 2005; Kohnert, 2004; Lalor & Kirsner, 2001; Roberts & Deslauriers, 1999), compensatory strategies capitalizing on dual language abilities (Lorenzen & Murray, 2008), and the use of one language to cue another (Goral, Levy, Obler, & Cohen, 2006).

Intervention Approaches and Factors for Bilingual/Multilingual Speakers with Aphasia


Based on research, the following factors have been shown to play a positive role in intervention relative to therapy approaches and factors that contribute to progress. Some intervention approaches have been adapted to a variety of different languages, such as melodic intonation therapy (MIT), while other approaches can be adapted to different language speakers, such as MIT and Promoting Aphasics’ Communication Effectiveness (PACE). In addition, the other approaches are appropriate for all language speakers (e.g., semantic, cognitive, and restorative approaches).


Cognates: The first area to consider in intervention for bilingual clients are cognates (e.g., “tiger” in English and “tigre” in French). Another area of language to consider are clangs, a type of homophone (e.g., “bell” as metal object that rings and “bel” as a word denoting beauty).

Noncognates are words that share meaning but not phonology (e.g., “butterfly” in English and “Mariposa” in Spanish). Evidence is shown for word recognition and translation for cognates, with generalization from the treated first language to the untreated second language only for cognates (Kohnert, 2004). In addition, there is evidence for faster response time for cognates as compared to noncognates in picture naming, word recognition, and word translation.

(Ansaldo & Saidi, 2014)


Cross-Linguistic Transfer: Cross-linguistic transfer of therapy effects (CLTE) are as reported when therapy is provided in the postmorbid stronger language or when proficiency after stroke is equivalent in both languages (Ansaldo & Saidi, 2014). Research has also shown that transfer across languages has been found in Indo-European languages, regardless of the particular language learned (Goral, Levy, & Kastl, 2010; Kiran & Iakupova, 2011; Kohnert, 2004; Miertsch, Meisel, & Isel, 2009).


Semantic Intervention: Evidence shows better CLTE through the use of a semantic approach. Semantic intervention consists of lexical semantic retrieval strategies through word recognition, semantic association, and cueing (Kohnert, 2004). In this program, intervention begins with the use of the client’s native language within two sessions in the first week. The second week follows this pattern through the use of the client’s second language. A one-week interval is scheduled between these sessions. All productions are accepted and encouraged if produced in the first or second language learned. The words used in intervention are incorporated in both written and spoken language. Tasks included the identification of pictures of intervention items, matching written words with pictures, generation of semantic associations to target words (e.g., words with their pictured referent; generating semantic associations (rose, flower, red, smell, garden, water), the completion of cloze tasks  (She sweeps the floor with a                                                                                                                                   ), writing the names of dictated training words; and confrontation naming with varied levels of cues (such as phonological cues and carrier phrases) (Kohnert, 2004, p. 299). The potential for CLTE from the treated to the untreated language depends on the word type, the degree of linguistic overlap between languages, the type of therapy approach, pre- and postmorbid language proficiency, and the status of cognitive abilities (Ansaldo & Saidi, 2014, p. 1).


The Restorative Approach: The objectives of the restorative approach are to restore and improve altered linguistic functions following the stroke. It is a set of strategies for learning, reconstructing

the language of individuals with aphasia implemented on the basis of speech and language assessment, as shown in Schuell’s intensive auditory stimulation approach (Schuell, Jenkins, & Jiminez-Pabon, 1964). In this approach, the auditory modality is the foundation, with task difficulty increased over time. Stimuli and tasks must be repeated to be effective, with adequacy of stimulation determined by the individual’s ability to provide a response. Maximum responses must be elicited. In addition, sessions should begin with familiar and easily accomplished tasks.


Melodic Intonation Therapy (MIT): Melodic Intonation Therapy (MIT) is a rehabilitative procedure with a neurobehavioral rationale (Albert, Sparks, & Helm, 1973; Sparks, Helm, & Albert, 1974; Sparks & Holland, 1976). This approach has been successful in intervention with varied linguistic populations, such as English, Romanian, Persian, and Japanese (Seki and Sugishita, 1983; Popovici and Mihailescu, 1992; Baker, 2000; Bonakdarpour, Eftekharzadeh, & Ashayeri, 2003), and Italian (Cortese, Riganello, Arcuri, Pignataro, & Buglione, 2015). In addition, MIT has been adapted to French (Van Eeckhout & Bhatt, 1984), Arabic (Al-Shdifat, Sarsak, & Ghareeb, 2018), and other languages spoken across the world. This approach has proven to be effective in the application to other languages. This is an essential factor, given the growing number of immigrants and refugees across the globe and the necessity to adapt to the needs of these populations. MIT uses a melodic and rhythmic approach in working with individuals with non-fluent aphasia (Norton, Zipse, Marchina, & Schlaug, 2009). MIT begins with singing 2-3 syllable phrases with progress to longer utterances. Stressed syllables are sung on higher pitches, with unaccented syllables on lower pitches. This approach begins with frequently used words (e.g., water) and social phrases (How are you?). MIT can be applied to various languages spoken by the individual given intervention, taking account of stress patterns that differ across languages.


The Cognitive Approach: It is known that aphasia is frequently accompanied by deficits of attention, short-term memory (STM) and working memory (WM), and that such memory impairments may negatively influence language abilities and treatment outcomes. Consequently, treating STM and WM impairments in PWA should not only remediate these memory impairments but also play a positive role in their response to language therapy programmes (Murray, 2012). To address attention, sessions followed a pattern of traditional language treatment (e.g., treatment tasks progressed from matching letters to picture-word matching to matching colors and shapes and copying and recalling designs (Lincoln & Pickersgill,1984). Findings were improved language and nonverbal reasoning. To address working memory, 17 weeks of sentence repetition was used in intervention (Francis, Clark, & Humphreys,2003). Intervention began with two function words (e.g., go, had) to address auditory memory and semantic recall. The next step consisted of longer utterances that utilized a progression to more complex stimuli.


Promoting Aphasics’ Communication Effectiveness (PACE): This approach is based on the relationship between the PWA and the clinician. Promoting Aphasics’ Communication Effectiveness (PACE) is a treatment designed to improve conversational skills. The positive aspect of the PACE program is that it can be adapted to any language used in a bilingual therapy approach. Given the positive effect of cognates in bilingual approaches to aphasia, the clinician can use cognates in the use of the PACE approach. In this approach, the PWA and clinician take turns as the message sender or receiver. Picture prompts for conversational messages are hidden from the listener, and the speaker uses his or her choice of modalities for conveying messages (Davis & Wilcox, 1981). The clinician is aware of the pictures used in this task, but the PWA is only aware

of the picture that is revealed to him or her. The client can use spoken language, gesture, pantomime, drawing, or pointing to communicate the topic within the picture. The clinician models the various methods of communication (e.g., gesture, etc.) to provide a guide for the client.


Computer-Based and Augmentative and Alternative Communication (AAC): AAC is an approach that involves supplementing or replacing natural communication modalities with picture communication symbols, line drawings, Blissymbols, and tangible objects and/or manual signs, gestures, and finger spelling. AAC includes speech-generating communication devices (Beukelman & Mirenda, 2005). Computer-based treatment involves the use of computer technology (e.g., touchscreen tablets) and/or software programs to target various language skills and modalities (Kurland,Wilkins, & Stokes, 2014). Simple picture boards can also be used in intervention, with pictures chosen by client and family to enhance communication.


Technological Approaches to Aphasia: There has been an emergence of non-invasive brain stimulation, specifically Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS), as potential treatments for post-stroke aphasia. Much remains unknown about how these techniques cause clinical improvement or about their long-term efficacy, side-effects, and safety (Torres, Drebing, & Hamilton, 2013). Specific treatment protocols will vary, based on each individual’s unique language profile and communication needs with respect of his mono-lingual, bilingual or multi-lingual status. The goal of each treatment should be achievable and functional with an emphasis to maximize quality of life and communication participation and success with the best generalization to daily life activities.


What are the problems with those diagnosed with Alzheimer’s Disease? Are there any solutions to supporting these problems?


Alzheimer’s disease (AD) comprises 60–80% of all dementia cases in the world (Alzheimer’s Association, 2015). Research has been pointing to bilingualism as a viable means for delaying or preventing Alzheimer’s disease. Strong epidemiologic evidence has been shown individuals who maintain an active social, mental, and physical engagement contribute against the onset of dementia (Craik, Bialystok, & Freedman, 2010). Evidence has also shown that lifelong bilingualism is a further factor contributing to cognitive reserve, which acts to compensate other brain pathologies (Craik et al., 2010).


Alzheimer’s dementia presents with decline in various areas of function that include memory/orientation, reasoning, visuospatial ability, word retrieval, and behavior changes. Most types of dementia get worse over time and do not have a cure (Korytkowska & Obler, 2016).

However, those with dementia can be provided with opportunities to engage in activities and social interaction (National Collaborating Centre for Mental Health, 2007). Visual and hearing tests should be provided to assure successful interaction. Finally, augmentative approaches can be used, such as picture boards, to assist communication.


It is important to inform caregivers that communication must be adapted to the difficulties found in this disorder. Given slowed processing of spoken language, communication must consist of slowed speech and simple sentences to aid comprehension (Small, Gutman, Makela, & Hillbouse, 2003). It is also recommended that speakers repeat utterances to aid comprehension.

In addition, yes/no questions are more effective than open-ended questions (e.g., WH questions, such as who, what, where, and why).





Al-Shdifat, K.G., Sarsak, J., & Ghareeb, F. A. (2018). Exploring the efficacy of melodic intonation therapy with Broca’s aphasia in Arabic. South African Journal of Communication Disorders, 65(1). Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018128/pdf/SAJCD-65-567.pdf

Albert, M. L., Sparks, R. W., & Helm, N. A. (1973). Melodic intonation therapy for aphasia.

Archives of. Neurology. 29, 130-131

Alzheimer’s Association. (2015). Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 11(3), 332.

Ansaldo, A. I., & Saidi, L. G. (2014). Aphasia therapy in the age of globalization: cross- linguistic therapy effects in bilingual aphasia. Behavioural Neurology. Available at https://www.researchgate.net/publication/307706935_Aphasia_Therapy_in_the_Age_of_Globali zation_Cross-Linguistic_Therapy_Effects_in_Bilingual_Aphasia

Baker, F. A. (2000). Modifying the melodic intonation therapy program for adults with severe non-fluent aphasia. Music Therapy. Perspectives, 18, 110-114.

Beukelman, D., & Mirenda, P. (2005). Augmentative and alternative communication. Bonakdarpour, B., Eftekharzadeh, A., & Ashayeri, H. (2003). Melodic intonation therapy in Persian aphasic patients. Aphasiology, 17, 75-95.

Centeno, J. G. (2008). Multidisciplinary evidence to treat bilingual individuals with aphasia. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations.66-71.

Cortese, M. D. , Riganello, F., Arcuri, F., Pignataro, L. M., & Buglione, I. (2015). Frontiers in Human Neuroscience. Available at https://www.frontiersin.org/articles/10.3389/fnhum.2015.00520/full.

Craik, F. I. M., Bialystok, E., & Freedman, M. (2010). Delaying the onset of Alzheimer disease: Bilingualism as a form of cognitive reserve. Neurology, 75(19), 1726-1729.

Dakwar, R. K., Ahmar, M., Farah, R., & Froud, K. (2018). Diglossic aphasia and the adaptation of the Bilingual Aphasia Test to Palestinian Arabic and Modern Standard Arabic. Journal of Neurolinguistics, 47, 131-144.

Davis, G. A., & Wilcox, M. J. (1981). Incorporating parameters of natural conversation in aphasia treatment: PACE therapy. In R. Chapey (Ed.), Language intervention strategies in adult aphasia (pp. 169–193). Baltimore, MD: Williams & Wilkins.

Goral, M., Levy, E. S., & Kastl, R. (2010). Cross-language treatment generalisation: A case of trilingual aphasia. Aphasiology, 24(2), 170–187.

Francis, D. R., Clark, N., & Humphreys, G. W. (2003). The treatment of an auditory working memory deficit and the implications for sentence comprehension abilities in mild receptive aphasia. Aphasiology, 17, 723-750.

Galvez, A., & Hinckley, J. (2003). Transfer patterns of naming treatment in a case of bilingual aphasia. Brain and Language, 87(1), 173-174.

Gil, M., & Goral, M. (2004). Nonparallel recovery in bilingual aphasia: Effects of language choice, language proficiency, and

treatment. International Journal of Bilingualism, 8, 191-219.

Goral, M., Levy, E. S., Obler, L. K., & Cohen, E. (2006). Cross-language lexical connections in the mental lexicon: Evidence from a case of trilingual aphasia. Brain and Language, 98, 235-247 Goral, M., Naghibolhosseini, M., & Conner, P. S. (2013). Asymmetric inhibitory treatment effects in multilingual aphasia. Cognitive Neuropsychology, 30(7–8), 564–577.

Katz, R. C., & Wertz, R. T. (1997). The efficacy of computer-provided reading treatment for chronic aphasic adults. Journal of Speech, Language, and Hearing Research, 40(3), 493-507. Keane, C., & Kiran, S. (2015). The nature of facilitation and interference in the multilingual language system: Insights from treatment in a case of trilingual aphasia. Cognitive Neuropsychology, 32(3–4), 169–194.

Khamis-Dakwar, R., & Froud, K. (2012). Aphasia, language, and culture: Arabs in the US.

Aspects of Multilingual Aphasia, 8, 275-288.

Kiran, S., & Iakupova, R, (2011). Understanding the relationship between language proficiency, language impairment and rehabilitation: evidence from a case study. Clinical Linguistics and Phonetics, 25(6-7), 565-583.

Kiran, S., & Edmonds, L. A. (2004). Effect of semantic naming treatment on crosslinguistic generalization in bilingual aphasia. Brain and Language, 91(1), 75-77.

Kiran, S., & Roberts, P. M. (2010). Semantic feature analysis treatment in Spanish-English and French English bilingual aphasia. Aphasiology, 24(2), 231–261.

Kiran, S., Sandberg, C., Gray, T., Ascenso, E., & Kester, E. (2013). Rehabilitation in bilingual aphasia: Evidence for within- and between-language generalization. American Journal of Speech-Language Pathology, 22(2), S298–309.

Kiran, S., & Tuchtenhagen, J. (2005). Imageability effects in normal Spanish–English bilingual adults and in aphasia: Evidence from naming to definition and semantic priming tasks.

Aphasiology, 19(3-5), 315-327.

Korytkowska, M., & Obler, L. K. (2016). Speech-Language Pathologists (SLP) Treatment Methods and Approaches for Alzheimer’s Dementia. Perspectives of the ASHA Special Interest Groups, 1(2). 122-128.

Kohnert, K. (2004). Cognitive and cognate-based treatments for bilingual aphasia: A case study.

Brain and Language, 91, 294-302.

Kohnert, K. (2004). Cognitive and cognate-based treatments for bilingual aphasia: a case study.

Brain and Language, 91(3). 294-302.

Kurland, J., Wilkins, A. R., & Stokes, P. (2014). iPractice: Piloting the effectiveness of a tablet- based home practice program in aphasia treatment. Seminars in Speech and Language, 35(1), 51. NIH Public Access.

Kurland, J., & Falcon, M. (2011). Effects of cognate status and language of therapy during intensive semantic naming treatment in a case of severe nonfluent bilingual aphasia. Clinical Linguistics & Phonetics, 25(6–7), 584–600.

Laganaro, M., & Overton Venet, M. (2001). Acquired alexia in multilingual aphasia and computer-assisted treatment in both languages: Issues of generalization and transfer. Folia Phoniatrica et Logopaedica, 53, 135-144.

Lincoln, N. B., & Pickersgill, M. J. (1984). The effectiveness of programmed instruction with operant training in the language rehabilitation of severely aphasic patients. Behavioral Psychotherapy, 12, 237-248.

Lorenzen, B., & Murray, L. L. (2008). Bilingual aphasia: A theoretical and clinical review.

American Journal of Speech-Language Pathology, 17, 299-317.

Miertsch, B. J. M. Meisel, J. M., & F. Isel, F. (2009). Non-treated languages in aphasia therapy of polyglots benefit from improvement in the treated language. Journal of Neurolinguistics, 22(2),135-150.

Murray, L. L. (2012). Direct and indirect treatment approaches for addressing short-term or working memory deficits in aphasia. Aphasiology, 26(3-4), 317-337.

National Collaborating Centre for Mental Health (2007). Dementia: A NICE-SCIE Guideline on Supporting People with Dementia and Their Careers in Health and Social Care. NICE Clinical Guidelines, 42. Leicester (UK): British Psychological Society.

Andrea Norton, A., Zipse, L., Marchina, S, & Schlaug, G. (2009). Melodic intonation therapy: shared insights on how it is done and why it might help. Annals of the New York Academy of Science, 431–436.

Popovici, M., & Mihailescu, L. (1992). Melodic intonation in the rehabilitation of Romanian aphasics with bucco-lingual apraxia. Romanian Journal of Neurological Psychiatry 30, 99-113. Rau, M. T., & Fox, L. E. (2009). Treatment approaches to aphasia: Contributions of VA clinicians. Aphasiology, 23(9), 1101-1115.

Roberts, P. M., de la Riva, J., & Rhéaume, A. (1997). Effets de l’intervention dans une langue pour l’anomie bilingüe. Presentation at the annual Canadian Association of Speech-Language Pathology and Audiology conference, Toronto, Canada.

Roberts, P. M., & Deslauriers, L. (1999). Picture naming of cognate and non-cognate nouns in bilingual aphasia. Journal of Communication Disorders, 32(1) 1-22. Sparks, R., Helm, N., & Albert, M. (1974). Aphasia rehabilitation resulting

Schuell, H., Jenkins, J. J., & Jiminez-Pabon, E. (1964). Aphasia in adults. New York: Harper & Row.

Seki, K., & Sugishita, M. (1983). Japanese-applied melodic intonation therapy for Broca aphasia.

No to Shinkei 35, 1031-1037.

Small, J. A., Gutman, G., Makela, S., & Hillbouse, B. (2003). Interventions for persons with Alzheimer’s disease: Strategies for maintaining and enhancing communicative success. Journal of Speech, Language, and Hearing Research, 46, 353-367.

Sparks, R., Helm, N., and Albert, M. (1974). Aphasia rehabilitation resulting from melodic intonation therapy. Cortex, 10, 303-316.

Sparks, R. W., & Holland, A. L. (1976). Method: melodic intonation therapy for aphasia.

Journal of Speech and Hearing Disorders, 41, 287-297

Torres, J., Drebing, D., & Hamilton, R. (2013). TMS and tDCS in post-stroke aphasia: Integrating novel treatment approaches with mechanisms of plasticity. Restorative Neurology and Neuroscience, 31(4), 501-515.

Van Eeckhout, P., & Bhatt, P. (1984). Rythme, intonation, accentuation: la rééducation des aphasies non-fluentes sévères. Rééducation Orthophonique, 22, 311-27.

Watamori, T., & Sasnuma, S. (1976). The recovery process of a bilingual speakers with aphasia.

Journal of Communication Disorders, 9, 157-166.