Language
Rehabilitation of Aphasic Persons in Multilingual Societies:
Theoretical
Bases, Clinical Procedures, and International Perspectives
José G. Centeno, Ph.D., CCC-SLP
Speech-Language Pathology &
Audiology Program
Department of Speech, Communication
Sciences, & Theatre
Contemporary perspectives describe
aphasia and its treatment as complex processes involving multiple factors
beyond linguistic phenomena, and incorporating
additional operations underlying effective communication (i.e., sociolinguistic,
cognitive, psycholinguistic, and psychoemotional phenomena) (Byng et al, 2003;
Code, 2001). Similarly, in the case of bilingual clients, realistic understanding
of aphasia and its rehabilitation requires broad theoretical bases. Yet,
the analysis of aphasic deficits and their management in bilingual clients impose
challenges, particularly due to the intricacies of bilingualism as a phenomenon
and the limitations in clinically-useful research. Growing evidence, however,
suggests that understanding aphasia in bilinguals and its treatment warrants a broad
multidisciplinary approach, based on
neurolinguistic, sociolinguistic, ethnographic, and psycholinguistic factors (Centeno,
in preparation).
This presentation will discuss a
multidisciplinary framework to enhance theoretical, linguistic, and cultural
validity and, in turn, clinical accuracy in the speech-language therapy (SLT)
procedures employed with aphasic bilinguals. Hispanic Spanish-English
bilinguals in the United States (U.S.) will serve as an illustration. The
Assessment
Principles
Differential
Diagnosis
Differential diagnosis is standard
practice in aphasia services with all clients. Yet, in the case of bilingual
speakers, diagnostic accuracy in the distinction of stroke-related linguistic
impairments from pre-morbid linguistic features is enhanced when both formal
and informal assessment procedures are based on the understanding of three critical
areas: (1) bilingualism factors (i.e., language acquisition history and
expressive routines in bilingual discourse), (2) aphasia in bilingual speakers,
and (3) aphasia in monolingual speakers of the two target languages.
1.
Bilingualism Factors:
Language Acquisition History: Variables
shaping language experiences and linguistic gains in both first (L1) and second
(L2) languages, such as contexts of language use, age of acquisition, acculturation,
and socioeconomic circumstances, must be acknowledged (Ardila et al., 1994;
Centeno, 2005a, b; Centeno & Obler, 2001b; Grosjean, 2004; Ogbu, 2002; Paradis,
1987; 2004; Pavlenko, 1998; Reyes, 1995).
Language Usage Routines: bilingual speakers’
discourse features (e.g., language mixing, cross-language transfer patterns,
and dialectal influences) in unimpaired and impaired contexts also are
important (Centeno, 2005a, b; Muñoz et al., 1999; Obler et al., 1995; Zentella,
1997).
2. Aphasia in Bilingual Speakers: Aphasic symptoms in bilingual
speakers may occur as parallel or non-parallel patterns of language
recovery/deficits (Fabbro, 1999; Obler et al., 1995; Paradis, 1987; 2004;
Roberts, 2001).
3. Aphasia
in Monolingual Speakers of the Two Target Languages: Knowledge of
post-stroke language deficits in monolingual speakers of the two languages
spoken by the bilingual aphasic client allows comparisons of (a) the linguistic
deficits across the two languages (e.g., agrammatic errors in Spanish and in English)
and (b) any aphasic symptoms/strategies in the bilingual client that do not
correspond to those in monolingual speakers (see Ardila, 2001; Centeno &
Obler, 2001a, 2003; Menn et al., 1995; Paradis, 2001).
Assessment
Plan
The following
steps are expected to provide realistic input for differential diagnosis:
1.
Sociolinguistic Interview: Acquisitional and ethnographic factors
2. Formal
Testing: Linguistically and culturally equivalent tasks in each language
● Bilingual Aphasia Test (Paradis,
1987)
- Post-stroke recovery/proficiency in
each language
●
- Aphasia testing
3. Informal
Language Sample
● Discourse and language use in conversation
● Compensatory/self-help strategies
Diagnostic Impressions
● Strengths and weaknesses
in L1 and L2
● Aphasic profile: Broca’s,
Wernicke’s, etc.
Intervention
Principles
Therapy contexts should optimally
enhance bilingual clients’ communication in their individual sociocultural
environments. Principled intervention is expected to be based on a multidisciplinary
theoretical rationale and communication contexts meaningful to the bilingual
patient. Such a principled approach would increase theoretical, linguistic, and
cultural validity in therapy (Centeno, 2005a, b, in preparation; Pontón
& Monguió, 2001; Salas-Provance et
al., 2002) while, simultaneously, stimulating various linguistic and cognitive
resources likely to activate language access/recall and use (see Altarriba,
2003; Centeno, in preparation; Gil & Goral, 2004; Harris, 1997; Kiran &
Edmonds, 2004; Kohnert, 2004, 2005; Paradis, 2004; Pavlenko, 2005).
Linguistic
Considerations
Selection
of target language and modality is based on:
●
Language recovery profile
●
Family’s/client’s wishes
●
Language resources at the clinical facility: Bilingual speech therapist?
Interpreter?
●
Research evidence, despite being preliminary and heterogeneous, may be explored
in
therapy.
For example:
- Gains in treated language are better
than in the non-treated language
- Receptive
modalities improve faster than expressive modalities
- Multimodality treatment may be helpful
- Cross-linguistic similarities
(cognates) may enhance improvement.
(Gil
& Goral, 2004; Holland & Penn, 1995; Kiran & Edmonds, 2004; Kohnert,
2004, 2005;
Roberts, 2001)
Other Considerations
●
Evidence and theoretical accounts from other lines of research may be valuable
to enhance
possible mechanisms of languase recall/access and, in turn, use. For
example:
- Bilinguals encode words in different
emotional contexts (Altarriba, 2003; Pavlenko, 2005)
- Elderly individuals actively respond to
emotionally meaningful topics/contexts involving
past
experiences (autobiographical memory) (Harris, 1997)
- Cognitive and neural components may
interact in language recovery (activation
thresholds) (Paradis, 2004)
Hence,
because understanding aphasia in bilingual persons is complex, accuracy in our
clinical decisions will be enhanced when multidisciplinary principles are used
to develop theoretically, linguistically, and culturally valid clinical
procedures. As research evidence continues to grow, speech-language therapists may
clinically explore the use of available findings to improve diagnostic analysis
and create facilitating therapy contexts with bilingual aphasic clients. It is hoped
that this presentation will contribute to the collaborative communication among
speech-language therapists that serve bilingual aphasic persons in different
countries, and provide useful information that may be adapted to other
bilingual/multilingual aphasic individuals in other linguistically diverse societies.
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