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JCPSLP Volume 17, Number 1 2015 15
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