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Volume 17, Number 1 2015


bilingual or from a CALD background. Accurate information

about a person’s pre-morbid language ability is essential

for determining whether any language differences are due

to pre-existing issues with proficiency versus the post-

morbid effects of aphasia. There are several published

tools that could be used or adapted as the basis of a

language history questionnaire or interview (Marian,

Blumenfeld, & Kaushanskaya, 2007; Muñoz, Marquardt,

& Copeland, 1999; Paradis, Hummel, & Libben, 1989),

which include information such as language acquisition

history; educational history in each language; language use;

self-rating of proficiency in each language (in both spoken

and written modalities), etc. Information about language

use, both pre- and post-stroke, is especially important

for bilingual speakers, as they may utilise each of their

languages in different sociolinguistic contexts (e.g., home

language vs work language) and for different purposes

(e.g., socialising vs occupational duties) (Centeno, 2005).

These usage patterns may alter following a diagnosis

of aphasia. For example, a bilingual speaker who loses

their ability to communicate in English as a consequence

of aphasia may no longer be able to communicate as

effectively with English-speaking grandchildren and friends.

As well as linguistic background, it is important

to consider the influence of cultural variables on the

management process and the way in which these may

affect speech pathology practice. At the same time,

clinicians need to take care not to culturally stereotype

individuals from a particular background. A balance should

be struck between identifying cultural variables that may

impact upon the management process and determining the

extent to which these variables are actually relevant on a

case-by-case basis. Learning from the person with aphasia

and his/her family about the impact of changed language

on the person’s life and on family relationships is a first and

critical step. This process will involve learning about cultural

responses to illness, the individual’s role in the family,

priorities of the person with aphasia for social participation,

and their sense of self. This “insider perspective” (Brown,

Worrall, Davidson, & Howe, 2010) can be explored as the

therapist builds a relationship with the person from a CALD

background and their family, and demonstrates a genuine

interest in knowing about their patient’s culture, response to

health issues, and experience of having aphasia.

Understanding recovery patterns in bilingual individuals

with aphasia is also pertinent in the rehabilitation of bilingual

aphasia. Previous papers have reported the various types

of language impairment and recovery patterns evidenced

by individuals with bilingual aphasia (see Lorenzen &

Murray, 2008; Roberts, 2008). Language impairment and

recovery can occur in varied and complex patterns across

a speaker’s languages so it is necessary to educate the

client and family regarding the client’s relative strengths and

weaknesses in each language. To accurately describe the

nature of language recovery occurring in a bilingual person

with aphasia, it is essential to take into account pre-morbid

proficiency in each language as distinct from the post-

morbid effects of aphasia.

To provide effective management of aphasia in bilingual

individuals, SLPs need a clear understanding of linguistic

features that may present uniquely in bilingual aphasia

and not monolingual aphasia. One example is code-

switching, which occurs when a bilingual speaker alternates

between their two languages (see Ansaldo, Marcotte,

Scherer, & Raboyeau, 2008; Lorenzen & Murray, 2008). In

neurologically normal bilingual speakers, code-switching

may be used routinely when conversing with other bilingual

speakers; however, following a diagnosis of aphasia this

should aim to address areas of the ICF framework that

extend beyond the impairment level.

Clinical issues and challenges

As well as the broader context and challenges outlined

above, there are several clinical issues that require attention

and consideration for the delivery of effective and client-

centred speech pathology services in an Australian context

to people with aphasia who are bilingual or from a CALD

background. While some aspects of speech pathology

service provision to bilingual/CALD clients overlap with

those of monolingual clients, there are also issues that are

unique to the bilingual/CALD clients. Three main areas that

SLPs may need to consider are: a) developing a better

understanding of aphasia in bilingual/CALD individuals; b)

identifying the most appropriate service delivery options for

this caseload; and c) identifying and developing culturally

and linguistically appropriate resources to enhance delivery

of culturally relevant speech pathology services.

Understanding aphasia in people who are

bilingual or from a CALD background

Currently, a wide range of terminology may be employed to

describe the language ability of individuals who are not

monolingual native English speakers including: bilingual,

CALD, non-English Speaking Background (NESB), English

as a Second Language (ESL), functional English, limited

English proficiency. Although many of these terms may

often be used interchangeably in common parlance, their

meanings do not necessarily overlap. For example, a

person may identify as CALD but not bilingual (e.g.,

Australian-born monolingual English speaker with Spanish

parents) or a person may be bilingual but not CALD (e.g.,

Australian-born native English speaker of Anglo-Saxon origin

who has learnt and is proficient in a second language). One

analysis by the Australian Bureau of Statistics (2009) divides

CALD status into four categories: a) born in Australia,

mainly speaks English at home; b) born in Australia, mainly

speaks a LOTE at home; c) born overseas, mainly speaks

English at home; and d) born overseas, mainly speaks a

LOTE at home. These categories illustrate the diverse range

of individuals who may be classified as CALD. The notion of

who can be termed “bilingual” is also a complex and

multidimensional concept (see Lorenzen & Murray, 2008 for

further discussion), with wide variation in the definition and

measurement of bilingualism used within research studies.

A systematic review of research investigating bilingual

aphasia revealed that only 13 of the 77 studies included in

the review provided a theoretical definition of bilingualism

(Kane, Davidson, & Siyambalapitiya, 2014). The most

commonly cited definition was Grosjean’s (1985; p. 467)

definition of “the use of two or more languages or dialects

in their daily lives”.

Clinically, it is important that SLPs identify clear definitions

of these terms and encourage their correct usage within

the health system to ensure accurate communication about

bilingual/CALD individuals and to avoid potential problems

with their management. For example, a bilingual person

who loses their ability to speak English following a stroke,

and subsequently reverts to their native language, may

be misidentified as a person who never spoke English to

begin with (and possibly not receive the appropriate speech

pathology management).

Obtaining a comprehensive language history and current

language profile, from the client and/or their significant

others, is key first step in the process of describing,

assessing, and diagnosing aphasia in individuals who are