Bilingual Aphasia: A Theoretical and Clinical Review · 2017. 10. 4. · variety of acquired cognitive and communicative disorders, including aphasia. For instance, approximately

Bilingual Aphasia: A Theoreticaland Clinical Review

Bonnie LorenzenLaura L. MurrayIndiana University, Bloomington

Purpose: To provide an overview of the potentialbilingual client population in the United States,present current neurolinguistic and psycholinguis-tic views of bilingualism in adults with and withoutaphasia, review related bilingual aphasia recov-ery patterns and the factors that might influencethese recovery patterns, and provide insight intodiagnostic and therapy procedures for addressingthe needs of bilingual clients with aphasia.Method: A review of the literature was conductedto summarize and synthesize previously publishedresearch in the area of bilingual aphasia, high-light unique aspects of aphasia recovery, as-sessment, and treatment, and identify areas inneed of future research.

Conclusions: Despite a growing understandingof bilingualism and the various recovery patternsidentified with bilingual aphasia, there remains adire need for empirically validated managementtechniques, particularly in terms of determiningwhich language to target, identifying which as-pects of various languages are most vulnerable toinsult aswell asmost responsive to treatment, andestablishing how to exploit language similaritiesto maximize treatment efficiency.

Key Words: aphasia, bilingual, recovery,assessment, treatment

In the United States (U.S. Bureau of the Census, 2003),there is a growing prevalence of bilingual speakers, thatis, individuals who use two or more languages in their

everyday activities (Grosjean, 1989). Speech-language pa-thologists (SLPs) can therefore expect referrals for an in-creasing number of bilingual clients who demonstrate avariety of acquired cognitive and communicative disorders,including aphasia. For instance, approximately 45,000 newbilingual aphasia cases are expected per annum in the UnitedStates (Paradis, 2001). With this inevitable increase in ourbilingual caseloads comes the need to determine effectiveand efficient assessment and treatment protocols that take intoconsideration the unique needs and skills of bilingual ver-sus monolingual clients. Accordingly, to increase awarenessand understanding of the theoretical and applied issues sur-rounding service provision to bilingual clients, this articlereviews the existing research by discussing (a) the potentialbilingual client population in the United States, (b) defi-nitions of bilingualism, (c) neurolinguistic and psycholin-guistic views of bilingualism in adults with and withoutaphasia, (d) bilingual aphasia recovery patterns and thefactors that might influence these recovery patterns, and(e) diagnostic and therapy procedures for addressing thecognitive and communicative needs of bilingual clients withaphasia.

The Bilingual Client PopulationDemographics

Census data indicate that individuals who speak more thanone language represent one of the fastest growing segments ofthe U.S. population. For example, on the 2000 U.S. census,47 million individuals 5 years of age and older spoke a lan-guage other than English at home (most frequently Spanishfollowed by Chinese and French), representing a 14% in-crease since 1990. Of the 28 million who speak Spanish astheir primary language, roughly 50% and 90% reportedspeaking English “very well” or with no difficulty, respec-tively, making the majority of this population bilingual. Alongwith this growth, there are increasing numbers of elderlyindividuals. For example, the elderly Hispanic population isthe fastest growing subgroup in the United States (Ameri-can Speech-Language-Hearing Association [ASHA], 1991).Rising numbers of elderly individuals are important becauseof the increased risks of acquiring cognitive-communicativedisorders, including aphasia, associated with aging.

Whereas to many SLPs it may seem remote to have bi-lingual clients on their caseload, Laganaro and Overton Venet(2001) pointed out that bilingual speakers are already com-mon in large urban outpatient settings, and all U.S. regionshave experienced dramatic increases in the population who

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speak a language other than English, with the Midwest onlyslightly behind the South and West in change. Furthermore,these individuals reside in not just large urban areas but alsoless densely populated regions. For instance, Indiana, be-tween the 1990 and 2000 censuses, experienced a 47% changein “Spoke a language other than English at home,” rising from245,826 to 362,082 individuals, with the most significantincreases in rural rather than urban areas (Indiana Commis-sion on Hispanic/Latino Affairs, 2005).

Health FactorsSLPs working with the aphasia population need to be

aware of the risk factors for conditions that cause aphasianot only to provide appropriate client and family counselingand education but also, ideally, to educate the general publicand facilitate prevention of aphasia and other neurogeniccommunication disorders. As Latinos are currently the largestminority in the United States (American Heart Association[AHA], 2005), health concerns particular to this communitywill be reviewed to exemplify the pressing need for estab-lishing efficacious aphasia assessment and treatment proto-cols for bilingual clientele.

Risk factors for stroke, the primary cause of aphasia, in-clude diabetes, smoking, obesity, high cholesterol, and sed-entary lifestyle (AHA, 2005). Whereas current statisticsindicate that Latino individuals age 18 years and older haveslightly lower rates of heart disease, hypertension, and historyof stroke compared with their non-Latino White peers, theyare twice as likely to develop an ischemic stroke due to in-activity, obesity, and diabetes. Likewise, among MexicanAmericans, the fastest growing Latino group in the UnitedStates, stroke incidence is slightly higher at 1.63% comparedto 1.36% for their non-LatinoWhite peers (Morgenstern et al.,2004); transient ischemic attacks at younger ages also are morefrequent in this group of Latino individuals. Compoundingthis increased stroke risk in Latino adults is reduced accessto appropriate health care services. In a study controlling forage, gender, income, education, insurance, and residencelocation, Latino individuals were 33% less likely to receive allnecessary health care services compared with non-HispanicWhite individuals (U.S. Department of Health and HumanServices, 2004). Several factors may contribute to poor healthcare access, including a lack of health insurance, interpreters,and translators (Indiana Commission on Hispanic/LatinoAffairs, 2005).

The implications for SLPs working with this populationare many. They need to be prepared for clients who may nothave received expected levels of care acutely or postacutely,or who may not have access to the full range of typical strokecare services. Significantly, SLPs may find themselves need-ing to advocate for client care, placing more effort into edu-cation, and taking on a larger than usual case managementrole. In summary, the above statistics highlight the rapidlygrowing bilingual population in the United States and furtherunderscore that many of these individuals are at risk fordeveloping medical conditions that can produce aphasia orother cognitive-communication disorders. Consequently,there is a growing need to ensure that SLPs are adequatelyprepared to serve the bilingual population. This includes

understanding the nature of bilingualism and the theoreticalmodels forwarded to explain bilingualism.

Defining BilingualismDebate persists on how best to quantify and qualify, and

thus define, bilingualism (Baker, 1993; Grosjean, 1989;Mcnamara, 1969; Paradis & Libben, 1987). Of the variousdefinitions, Grosjean (1989) characterized bilingual speakersin perhaps the most realistic terms as those who speak two ormore languages in daily life. Perfect knowledge of bothlanguages is not required; instead, people use different lan-guages for different purposes or life domains and conse-quently have different levels of proficiency within theirlanguages across those domains. For example, in the UnitedStates, many immigrants are communicatively competentin their second language (L2), English, for work purposes,but may have quite limited English proficiency in other lifedomains (e.g., church, home).

The terms early and late are often used to describe bilin-gual speakers’ language competency, with early bilingualspeakers (i.e., those who acquire their languages prior to ado-lescence) being assumed to have greater proficiency in L2than late bilingual speakers (i.e., those who acquire L2 afteradolescence; Ardila, 1998). Whereas age, sequence, andmethod of acquisition offer some suggestion of proficiency,there remains great variation, even among speakers withsimilar acquisition histories. Other factors such as the lan-guage used in the school system, personal and social attitudes(e.g., cultural identification and “loyalty”), and family canaffect use and maintenance of both the earlier language (L1)and the later learned L2, even if L1 is used at home (Ardila,1998; Muñoz & Marquardt, 2003). Furthermore, culturalidentity can vary geographically and across generations andsocioeconomic levels, adding to variability.

In addition to varying uses of their respective languages,bilingual speakers may engage in a behavior known as codeswitching: alternating uses of one’s languages to add com-municative intent, emphasis, or emotional value (Muñoz,Marquardt, & Copeland, 1999). Appropriate code switchingrequires linguistic competence in identifying and using lan-guages appropriate to communicative interactions. Code-switching constraints include environmental, social, andpersonal factors, grammatical principles, and level of educa-tion. The acceptability of code switching also varies acrosscommunities: Frequent code switching is considered appro-priate in some communities but uncommon and less acceptedin others. For example, Fabbro (2001a) observed nominalcode switching in Italian-Fruilian speakers. Additionally,Muñoz et al. (1999) identified and described a number ofswitching patterns and found that both speakers with andwithout aphasia exhibited patterns of code switching typifiedas disordered; these data suggest substantial variability inwhat is “normal” across local speech communities. Accord-ingly, for various reasons, bilingual speakers can differ greatlyin their respective uses of and proficiency in their languages.To understand further bilingualism, models used to explainthe neurological, linguistic, and cognitive underpinnings ofbilingualism are next reviewed.

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Models of BilingualismNeurolinguistic Aspects of Bilingualism

Within the field of neurolinguistics, language is viewed asamodular construct in which each linguistic function dependson the involvement of several subcomponents (e.g., spokenoutput involves concept retrieval, lexical selection, syntac-tic organization, and oral-motor programming), and each ofthese subcomponents can be localized in different parts of thebrain (see Fabbro, 1995, for a comprehensive review). Withrespect to bilingualism, neurolinguistic research has focusedon determining where different languages are localized andwhether all of a speaker’s languages are localized in similar ordistinct areas of the brain.

Thus far, separate, shared, and amalgamated representa-tion theories have been put forth to explain the neural organi-zation of bilingual speakers’ languages. Whereas initiallyresearchers hypothesized that languages resided separately inthe brain, this view was replaced with one in which languagesshared representation (Fabbro, 2001b). In the early, sharedrepresentation approach, all languages were hypothesizedto rely upon the same cerebral areas (Fabbro, 1995); if this wasthe case, however, all languages should be equally damagedfollowing an insult. Because a substantial empirical litera-ture contradicts this predicted outcome and highlights hete-rogeneity in the recovery patterns of bilingual individualswith aphasia (e.g., Fabbro& Paradis, 1995; Paradis, Goldblum,& Abidi, 1982), researchers have proposed additional factors(e.g., quantity of input from the respective languages fol-lowing injury, emotional experiences in the languages, lan-guage use after injury) that might contribute to differentialL1/L2 recovery (Aglioti, Beltramello, Girardi, & Fabbro,1996; Goral, Levy, Obler, & Cohen, 2006; Green, 2005;Minkowski, 1927/1983). Combining shared and separaterepresentation views, the amalgamated hypothesis assertsthat languages share some areas of the brain but also retainsome separate neural areas. Although there are mixed find-ings in terms of both the cerebral (i.e., which hemispheresupports the language or languages) and intrahemisphericneural representations of language in bilingual speakers (i.e.,which structures within a given hemisphere support the lan-guage or languages; Paradis, 2004), most research supportsthe amalgamated view. To illustrate, in most neuroimaginginvestigations, no laterality differences have been foundbetween monolingual speakers and bilingual speakers(Hernandez, Dapretto, Mazziotta, & Bookheimer, 2001;Hernandez, Martinez, & Kohnert, 2000; Kim, Relkin, Lee,& Hirsch, 1997). Right hemisphere damage in bilingualspeakers, consequently, will result in the same patterns ofcognitive-communication deficits that monolingual speakersexperience, and bilingual speakers who suffer left hemispheredamage are at risk for aphasia onset (Paradis, 2004).

Shared lateralization, however, does not imply an absoluteoverlap of languages or sharing of the exact same neuronalcircuits. Whereas research suggests overlap of L1 and L2(Hernandez et al., 2000, 2001; Kim et al., 1997; Perani et al.,1998), investigators continue to explore factors that influencethe extent of this overlap. Age of language acquisition is oneproposed factor. For example, functional magnetic resonance

imaging ( fMRI) studies of early Spanish-English bilingualspeakers completing naming tasks found no activation differ-ences between L1 and L2, indicating significant neural over-lap (Hernandez et al., 2000, 2001). In contrast, Kim et al.(1997) found similar L1-L2 activation in some areas but dif-ferent activation levels in others for late L2 learners engagedin silent sentence generation tasks, suggesting that age ofacquisition plays a role in the pattern of intrahemispheric ce-rebral activation. Proficiency level, however, may have inter-acted with age of acquisition in the Kim et al. (1997) studyand, in fact, is another proposed factor. For example, usinglistening comprehension tasks, Perani et al. (1998) found nodifferences in the activation patterns of early and late bilin-gual speakers when both groups demonstrated high profi-ciency in both languages. De Bleser et al. (2003) used positronemission tomography (PET) to examine activation patternsduring a picture-naming task. The participants were nativeFlemish/Dutch speakers who had good proficiency in theirL2, French. Although De Bleser et al. found minimal activa-tion differences among naming of cognates in L2, cognatesin L1, or L1 noncognates, they did observe a different activa-tion pattern (i.e., left inferior frontal and temporo-parietalareas) when participants named L2 noncognates. They con-cluded that recruitment of additional neural areas was neces-sary when producing words in the less proficient language.Accordingly, one theory of second language acquisition, theconvergence hypothesis, states that regardless of age of ac-quisition, as proficiency increases, so too will the level ofneuroanatomical convergence (Green, 2005).

Language learning modality may also influence the neuralmapping of bilingual speakers’ languages by evoking par-ticipation of different memory stores (Paradis, 2004; Ullman,2001). Implicit memory, more commonly referred to as pro-cedural memory, relates to automatic processes completedwithin nominal awareness, whereas explicit memory, alsoknown as declarative memory, involves controlled processescarried out at the conscious level (Ullman, 2001). These twomemory systems employ distinct cerebral regions: Procedu-ral memory is primarily associated with left frontal and basalganglia structures, whereas declarative memory is primarilyassociated with bilateral temporal lobes structures. Both typesof memory have been implicated in language learning anduse. Implicit memory appears key to L1 development, whichoccurs during childhood; explicit memory has been impli-cated in factual learning and the formal language learningthat typically occurs during L2 acquisition. Automatic pro-cessing, however, is not limited to L1 or languages acquiredduring childhood. That is, with extensive L2 practice, speak-ers may develop implicit competence in which L2 can exploitprocedural memory and speakers can use the L2 automati-cally, without explicitly recalling the rules that support accu-rate comprehension or production (Segalowitz, Segalowitz,&Wood, 1998). Nevertheless, languages learned through for-mal study (typically L2) may have wider cerebral representa-tion and utilize declarative memory more than L1; in contrast,learning and using L1 more often exploits procedural mem-ory and thus may have a more focal subcortical representation.

As these two memory systems employ different cerebralpathways, one or the other may be selectively affected by

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pathology. With respect to aphasia recovery, if metalinguisticknowledge is available but implicit linguistic competence hasbeen compromised, as in the case of subcortical damage, aparadoxical recovery pattern may occur: better recovery of aweaker L2 due to compensatory reliance on more extensive,explicit knowledge of the L2 (Paradis, 2004). Indeed, Agliotiet al. (1996) described a bilingual client who subsequent toa subcortical stroke demonstrated severe L1 (i.e., Venetian)production deficits despite good L2 (i.e., Italian) productionskills and similar degrees of L1 and L2 comprehension in-volvement. One explanation of this recovery pattern is thatthe subcortical lesion location caused greater damage to theL1, leaving the explicit memory systemmore intact and avail-able for L2 processing.

It should be noted that this is only one possible explana-tion, as Green (2005) suggested that the basal ganglia’s role incontrolling competition and pathological switching (vs. im-plicit memory) could also produce this recovery pattern. Thatis, Green proposed that inhibitory processes, similar to thoseused during other inhibition tasks, are involved in success-ful language use by bilingual individuals. This inhibition ofschema within the nonselected language should require exec-utive input via the frontal and subcortical control circuitry.Indeed some f MRI and PET studies have implicated theseneural regions during L2 naming and switching tasks. Forexample, Hernandez et al. (2000, 2001) found increased dor-solateral prefrontal cortex activation during language switch-ing (e.g., naming an object in English or Spanish dependingon a cue) but not nonswitching tasks (e.g., naming objects injust English or just Spanish). Interestingly, a similar pattern ofcompetition mediation has been found for translation (e.g.,Price, Green, & von Studnitz, 1999).

In summary, bilingual speakers appear to have languagelateralized within the left or dominant hemisphere, with mini-mal differences in L1 and L2 localization, particularly formore proficient or early L2 learners. The unique neural cir-cuitry of bilingual speakers as well as the possible involve-ment of cognitive functions in mediating acquisition and useof two languages suggest that following an insult to the lefthemisphere, some distinctive language signs and recoveryprofiles may be observed in bilingual versus monolingualaphasia cases. Whereas neurolinguistic studies to date haveinformed our understanding of language representation in thebilingual brain, they have not yet elucidated how the lan-guages or their subcomponents interact. Research in the fieldof psycholinguistics, however, has offered some explanationsof these interactions.

Psycholinguistic Views of BilingualismPsycholinguistic models of language processing attempt

to explain steps or stages that contribute to language compre-hension and production. For both monolingual and multilin-gual speakers, at least two levels of language representationhave been forwarded: lexical and conceptual (Kroll& deGroot,1997; Levelt, 1999). The lexical level includes informationabout word form and correct syntactic use, whereas the con-ceptual level includes information about word’s meaning ina real-world context. Various models have been proposed

to account for how this system works within the frameworkof a bilingual language system.

One such model, as forwarded by Kirsner, Lalor, and Hird(1993), involves a single system in which all words relatedin form and meaning from both languages are stored together.In this view, the bilingual lexical system is organized simi-lar to that of a monolingual system: Words in a bilingualspeaker’s lexicon are organized according tomorphology, notaccording to language. Therefore, for English-Italian speak-ers, words such as motivation and its Italian equivalentmotivazione would be stored together, whereas words thatshare meaning but not morphology, such as cat and gatto,would be stored separately. Similarly, according to the Bi-lingual Interactive Activation model, words are intercon-nected, and lexical access is not language selective, as thelexicon haswords fromboth languages (Dijkstra&vanHeuven,1998).

In contrast, several hierarchical models have been pro-posed that specify separate lexicons with a shared conceptstore (e.g., Kroll & Stewart, 1990, 1994; Potter, So, VonEckardt, & Feldman, 1984). These models differ in terms ofconnections between lexical stores, conceptual links, or both.For example, within the Word Association Model, L2 wordsare accessed through L1 (Potter et al., 1984); thus, the L2 andL1 lexicons are linked, but only the L1 lexicon has directaccess to concepts via a conceptual link. Conversely, theConcept Mediation Model allows each lexicon, L1 and L2,direct access to the conceptual store (i.e., two separate con-ceptual links) rather than a connection between the twolexicons. Both models have received empirical support, sug-gesting that under different lexical retrieval circumstances,a different model may apply. To illustrate, whereas data frompicture naming (Caramazza &Brones, 1980; Dufour &Kroll,1995; Potter et al., 1984) and priming tasks (Chen & Ng,1989; de Groot & Nas, 1991) support the Concept MediationModel for at least bilingual speakers who are proficient inboth L1 and L2, translation task data suggest that the WordAssociation Model better accounts for the performance ofbilingual speakers who are less proficient in L2 (Chen &Leung, 1989; Kroll & Curley, 1988). Specifically, less profi-cient bilingual speakers more quickly translate words thanname pictures in their L2, suggesting mediation through L1for picture naming rather than a direct L2-conceptual link.Proficient bilingual speakers, however, perform picture nam-ing and translation tasks at roughly similar speeds, supportingaccess to a direct L2-conceptual link.

The Revised Hierarchical Model (Kroll & Stewart, 1994)addresses this lack of parsimony, allowing each language di-rect access to the concepts store, as well as a direct connec-tion between the two lexical stores. Initially, L2 learnerswould access L2 word meanings through L1 via the connec-tion between the L1 and L2 lexicons. With increased fluency,however, speakers are able to conceptually mediate L2 di-rectly as a link between the concepts store and the L2 lexicondevelops; importantly, the lexical link between L2 and L1does not disappear with the formation of this new conceptuallink. This model also allows asymmetry in the strength oflexical-to-conceptual connections. For example, initial de-pendence on L1 for L2 will result in a stronger lexical link


along the L2 to L1 path, and because L1 initially holds priv-ileged access to meaning, a stronger link between L1 andthe concepts store compared to the link between L2 and theconcepts store. Indeed, this configuration has received sup-port from investigation of the bilingual lexical semanticsystem via neuroimaging (Hernandez et al., 2001), picture-word interference (Hermans, Bongaerts, de Bot, & Schreuder,1998), and semantic comparison protocols (Dufour & Kroll,1995; Edmonds & Kiran, 2004).

Influential Linguistic VariablesIn addition to language fluency as described above, a num-

ber of linguistic variablesmay influence language organizationand abilities in bilingual individuals. For example, using amodel similar to the Revised Hierarchical Model, Paivio,Clark, and Lambert (1988) found that concreteness affectslexical retrieval in bilingual individuals. According to thedual coding theory (Paivio & Desrochers, 1980), separate butconnected verbal representations exist for each language,and these are connected to a shared imagery system. Follow-ing this theory, concrete words could be stored and accessedthrough a combination of verbal and image associations,whereas abstract concepts could be accessed solely throughverbal coding. Therefore, in bilingual speakers, concretewords could be translated directly between the two verbalsystems or indirectly through the imagery system. Indeed,Paivio et al. (1988) found that bilingual individuals demon-strated better recall of concrete versus abstract words. Sim-ilarly, Kiran and Tuchtenhagen (2005) examined the effectof imageability on the naming and semantic judgment abili-ties of 16 Spanish-English participants, one of whom hadaphasia, and found that regardless of the presence of aphasia,task performances were better when concrete stimuli wereused.

Cognate status also appears influential. Generally, cog-nates are words that share meaning and form across languages(e.g., lamp in English and lampara in Spanish; Goral et al.,2006; Kroll & DeGroot, 1997). Across studies, however, re-searchers have applied different definitions and theories ofcognates. For instance, for a pair of words to be consideredcognates, Roberts and Deslauriers (1999) used the combi-nation of a subjective judgment across three authors and ananalysis of features and phonemic similarity with a minimumfeature overlap of 70%; Lalor and Kirsner (2001), on theother hand, defined cognates as morphologically relatedwords. These varying definitions reflect, at least in part, twocompeting explanations of cognates: phonological versusmorphological models.

According to phonological models, cognates share aphonological-sublexical base so that during language pro-duction, there is phonological activation of not only the targetword but also the translated form, strengthening both forms(Costa, Santesteban, & Caño, 2005). Given this phonologi-cal overlap, cognate effects might be viewed as products ofneighborhood density (i.e., the number of phonologicallysimilar words that can be formed by changing one sound inthe target word). Compared to words with few neighbors,words with dense neighborhoods, which would include theircognates, can reach higher activation levels because, as pho-nological segments of words are activated, they feed acti-vation back to the target lexical node so that all words in the

neighborhood are activated. According to morphologicalcognate models, bilingual and monolingual systems worksimilarly (Kirsner et al., 1993; Lalor & Kirsner, 2001): Wordsare clustered together according to shared morphology, re-gardless of whether they belong to the same or a differentlanguage. Consistent with this view, cognates show a long-term repetition priming effect (i.e., improved accuracy inword production after recent exposure to the word) in bi-lingual speakers (Cristoffanini, Kirsner, & Milech, 1986). Inother words, cognates produce a priming effect similar to thatfound with morphologically related words in monolingualspeakers (Napps & Fowler, 1987). Fortunately, studies havethus far shown a positive relationship across the various defi-nitions of cognates. For example, several investigators havefound that in bilingual speakers, including those with aphasia,cognate status positively affects word retrieval and transla-tion accuracy and speed (Goral et al., 2006; Kohnert, 2004;Lalor & Kirsner, 2001). Variation in how the term cognate isdefined may result in conflicting research outcomes in thefuture, however.

Influential Cognitive VariablesAs previously discussed with respect to neurolinguistic

models, the languages of bilingual individuals share a more orless common neuronal system. Additionally, according topsycholinguistic perspectives, these languages have separatebut connected lexicons, with a shared concept store. If there issuch neural overlap, yet possibly different language stores,how are the languages kept separate, and relatedly, how is thecorrect language retrieved? To answer these questions, seve-ral researchers have begun to explore the role of cognitiveprocesses.

Some theorists have proposed that successful language usein bilingual individuals may be achieved through a combi-nation of activation and inhibition. According to Paradis’s(2004) Activation Threshold Hypothesis, activation of anylinguistic property (e.g., word, syntactic construction, phono-tactic schema) within one language causes automatic inhi-bition of the other. This inhibition is not language-specific.Instead the targeted item must receive more activation thancompeting forms, including alternate language possibilities.To inhibit these competing forms, their activation thresholdsare raised. The more often a form is activated, the lower itsthreshold becomes, resulting in easier activation over time.Decreased use of other forms increases their activation thresh-olds, making them more difficult to access over time. Alter-nately, in a somewhat modified version of Paradis’s model,Costa and Santesteban (2004) proposed that with increasingproficiency, bilingual speakers move away from inhibitorycontrol to language-specific selection. Highly proficient bi-lingual speakers retrieve target words via a language-specificlexical selection mechanism rather than through inhibitorycontrol because words from the non-target language do notcompete for lexical selection and therefore do not require sup-pression. Importantly, both theories rely on inhibitory forcesto some degree for correct lexical retrieval. Whether theseinhibitory processes overlap with those used during other,nonlinguistic inhibition tasks, as suggested by Green (2005),has yet to be determined.

To review, psycholinguistic research suggests that bilin-gual speakers have a shared, common conceptual store for


their languages and identifies several variables that can in-fluence lexical retrieval accuracy and speed. Although furtherresearch is needed to resolve issues such as the nature andrelationships of the lexical stores and the mechanisms un-derlying cognate effects on lexical retrieval, data accrued thusfar through the development of both psycholinguistic andneurolinguistic models collectively support that compared tomonolingual speakers, bilingual speakers develop and uti-lize some unique language mechanisms. Indeed, the follow-ing section reviews how bilingual clients with aphasia canexperience language recovery differently than monolingualspeakers.

Bilingualism and AphasiaBilingual clients with aphasia demonstrate a variety of re-

covery patterns in terms of the relative impairments of theirtwo languages (Paradis, 1977). These patterns can be quitedistinct from those of monolingual speakers and in the re-search literature have been described or explained in terms ofoutput abilities, translation abilities, and cognitive factors.Because most bilingual aphasia research has focused on ex-pressive output rather than comprehension, the primary focusof this section is recovery of expressive abilities.

Recovery Patterns: Output AbilitiesDuring the acute recovery phase (i.e., up to approximately

4 weeks after aphasia onset), a client may experience sub-stantial change across either or both languages, dramatic dif-ferences between the languages, or both, resulting in a varietyof dynamic, bilingual aphasia recovery patterns (see Table 1;Fabbro, 2001a; Green, 2005; Paradis, 1977). For instance,Fabbro (2001a) examined 20 right-handed, bilingual Italian-Friulian speakers using the Bilingual Aphasia Test (BAT;Paradis & Libben, 1987) and found that approximately 65%of these clients exhibited parallel recovery, 20% had greaterimpairment of L2, and 15% had greater impairment of L1.Similarly, in a review of 132 cases, Paradis (2001) found thatapproximately 61% exhibited parallel recovery, 18% differ-ential recovery, 7% blended, and 5% selective.

Despite agreement that diverse recovery patterns may oc-cur, exactly what contributes to a given client’s recovery pat-tern is still debated. Over the course of several years, Fabbro

(2001a) assessed and compared the recovery profiles of20 right-handed, bilingual clients with aphasia, all of whomhad learned their L2 between 5 and 7 years of age. He foundthat none of the following variables could reliably predictrecovery patterns: (a) language status (i.e., native languageor currently most used language), (b) lesion type or site,(c) environments in which the languages were used, (d) apha-sia type, or (e) manner in which the languages were learned.After an extensive review of patients and their various re-covery patterns, Paradis (1977) concluded that whereas manyfactors have been proposed to influence recovery pattern,such as age, proficiency, context of acquisition, and type ofbilingualism, recovery patterns most likely result from acombination of these factors.

Recovery Patterns: Translation SkillsBilingual clients with aphasia can demonstrate different

impairment and recovery of translation abilities. Table 2shows the four primary types of translation deficits that havecurrently been identified—inability to translate, spontaneoustranslation, translation without comprehension, and para-doxical translation—and their characteristics (Fabbro &Paradis, 1995; Paradis et al., 1982). A translation disordermay affect either language compromising translation from L1to L2 or from L2 to L1. To account for the variety of trans-lation disorders, Paradis (1984) suggested that translationmay consist of two components, one that allows translationfrom language A to language B, and another component fortranslation from language B to language A. Following this,when a translation disorder occurs, it may be due to (a) one ofthe components being negatively affected, with the other partintact, (b) both components negatively affected to similardegrees, or (c) both components negatively affected but todifferent degrees.

The ability to translate is a cognitive task that goes beyondbeing able to speak and understand two languages (Paradiset al., 1982). The skill of translating involves switching lan-guages and is normally under voluntary control; when thereis a translation disorder, however, the translation may beautomatic, such as in the case of spontaneous translation(Perecman, 1984). Perecman differentiated spontaneoustranslation from language mixing in terms of their differ-ent levels of cognitive processing: She proposed that a

TABLE 1. Recovery patterns found in bilingual aphasia.

Recovery pattern Language characteristics

Parallel recovery Recovery of languages parallels the premorbid relative abilities. If one language were stronger premorbidly,it would return to being stronger.

Differential recovery One language is recovered much better than the other compared to premorbid abilities.Antagonistic recovery One language is initially available, and as the other language recovers, the initially available language disappears.Alternating antagonism Repetition of the above pattern with languages alternating in availability. This may occur within

cycles ranging from 24 hr to several months.Blending recovery Uncontrollable mixing of words and grammatical constructions of two or more languages even when attempting to

speak in only one language. This should not be confused with the common bilingual practice of code switching.Selective aphasia Language loss only in one language with no measurable deficit in the other.Successive recovery The recovery of one language before the other(s).

Note. Adapted from Paradis (2004) and Fabbro (2001a).


spontaneous translation deficit may result from a prelinguis-tic processing disorder, whereas language mixing is a lin-guistic level disorder. Accordingly, a translation disordermay be part of a larger conceptual disorder that affects otherbehaviors in addition to language. It cannot be assumed,however, that the presence of spontaneous translation in thespeech of a person with aphasia indicates a deficit. Grosjean(1985) proposed that some of what appears as involuntarytranslation may in fact be a deliberate communicative strat-egy used to increase communication effectiveness.

Recovery Patterns: Impact of ConcomitantCognitive Deficits

Given that cognitive abilities have been implicated in thedevelopment and use of more than one language (e.g., Green,2005), it is possible that cognitive deficits could contributeto at least some bilingual recovery patterns. For example,impaired cognitive control could lead to differing degrees oftoo much or too little inhibition, and consequently, impairedability to maintain a given language and various recoverypatterns: permanent inhibition (i.e., selective recovery), tem-porary inhibition (i.e., sequential recovery), alternating in-hibition (i.e., antagonistic recovery), greater inhibition in onelanguage (i.e., differential recovery), and loss of inhibition(i.e., blending; Green, 1986).

A possible result of impaired top-down control is patho-logical code switching, a pragmatic disorder in which in-dividuals are unable to control language switching andconsequently code switch in unacceptable circumstancesleading to communication breakdowns (Fabbro, Skrap, &Aglioti, 2000). That is, due to impaired top-down attentionalcontrol, access to the appropriate set of lexical conceptswithin the target language may be compromised by com-petition from the other language. For example, Fabbro et al.reported on a client who exhibited pathological switchingeven when the interlocutor did not understand the alternatelanguage. In addition to the pathological switching, the clientexhibited behavioral and verbal disinhibition. Muñoz andcolleagues (1999) also observed that only participants withaphasia demonstrated higher frequencies of certain switchingpatterns, communication difficulties due to code switchingwhen the social or pragmatic expectation was continued useof one language, frustration with an inability to use the ap-propriate language, or an inability to stop pathological codeswitching. Similarly, Mariën, Abutalebi, Engelborghs, andDe Deyn (2005) reported on uncontrollable language mix-ing following deep left frontal lobe lesions, suggesting the

involvement of a control mechanism. In a study involving atrilingual speaker of English, French, and Hebrew, Goral et al.(2006) found that involuntary switching (referred to as “lan-guage interference”) occurred mainly in French, the leastrecovered language, and that the interference occurred be-tween the languages that shared the most vocabulary. For ex-ample, target English words were more frequently substitutedwith French rather than Hebrew words, despite the client’sstronger Hebrew.

As discussed with spontaneous translation, the presenceof code switching does not only imply an inability to controllanguage output: Whereas increased mixing may at times beatypical according to normal standards, for clients with apha-sia it could be a conscious or unconscious self-cuing strategyto access the correct word in either language or to enhancecommunication in general (Grosjean, 1989). In this case, thelanguage switch or mix could function as a paraphasia thatonly interferes with communication if the interlocutor doesnot speak the language.

Recovery Patterns: Learning FactorsLearning mechanisms such as Hebbian learning may also

contribute to variation in bilingual aphasia recovery (Green,2005). Hebbian learning, a primary means of function res-titution, involves increased synaptic efficacy through neuro-nal reconnection, resulting in increasingly strong connectionsover time (Hebb, 1949). Stronger undamaged neuronal cir-cuits compete to control output, suppressing not only circuitstemporarily malfunctioning due to diaschisis but also therepair and resurgence of damaged circuits. Selective, antag-onistic, and differential recovery may therefore reflect res-titution via Hebbian learning in which only one pathway wasstrengthened (Green, 2005): (a) selective recovery may bedue to progressive use of one language, which consolidatesand isolates its network from the other; (b) continued growthin dominance of one language could eventually completelyinhibit use of the other language, resulting in an antagonisticrecovery; and (c) if the lexical semantic system of one lan-guage is impaired marginally more than that of the other, thatweaker language may not benefit from Hebbian learning,resulting in differential recovery of the already strongerlanguage.

Recovery Across Language Processes and ModalitiesAs with monolingual aphasia, recovery varies significantly

across language processes andmodalitieswith bilingual aphasia.

TABLE 2. Translation deficits found in bilingual aphasia.

Translation deficits Language characteristics

Inability to translate Inability to translate from either language to either languageParadoxical translation Ability to translate in one language but not the otherTranslation without comprehension Ability to translate language promptly but lack the ability to understand its meaningSpontaneous translation Inability to inhibit translating, producing involuntary translations of utterances that they or others have said

Note. Adapted from Fabbro (2001b).


This section examines pertinent research regarding re-covery of syntax, semantics, reading, and writing. Otherlanguage processes (e.g., phonology, pragmatics) and mo-dalities (i.e., gesture) have received less empirical attention,and thus further research is needed to determine whetherbilingual clients with aphasia demonstrate unique recoverypatterns in these aspects of communication.

Morphosyntax. Patterns of grammatical recovery can behighly variable in bilingual speakers due to core linguisticdifferences in their languages, such as the relative importanceof specific linguistic properties, for example, morphologicalmarkers, word order, and prosody (Green, 2005). As ex-plained by Paradis (1988), language impairments dependon how the system can break down, which is determined bythe structure of the language system. For example, syntacticdisorders apparent at the surface of a speaker’s grammarare dependent on the language’s structure; accordingly, mor-phological breakdown may be more noticeable in a highlyinflected (e.g., Spanish) versus minimally inflected language(e.g., English). Indeed, when evaluating agrammatic Italian-Friulian speakers who were exhibiting parallel recovery,Fabbro (2001a) observed different levels of pronoun omis-sion in Italian versus Friulian. Italian is a partial pro-droplanguage, meaning it allows speakers to “drop” the subjectpronoun if the subject can be inferred from the context—forexample, if an Italian speaker stated, “Mio padre è avvocato”(“My father is a lawyer”), his or her next sentence couldbe “Lavora in centro” (“Works downtown”) in which thepronoun “he” can be excluded; conversely, Friulian, likeEnglish, is a non-pro-drop language, meaning speakers mustuse the subject pronoun regardless of the referent’s trans-parency. The bilingual speakerswith agrammatism in Fabbro’sstudy made more frequent pronoun deletion errors in Friulianthan in Italian, suggesting that this error pattern was mostlikely a consequence of required pronoun use in Friulian.Relatedly, because Italian allows pronoun dropping, pro-noun omission errors were nominal: The speakers withaphasia appeared to make fewer errors, simply because theywere able to avoid this syntactic mistake. Another examplepertains to case- and gender-marking deficits, which varysubsequent to aphasia onset depending on the individual’slanguages (Menn, O’Connor, Obler, &Holland, 1995). Speak-ers with aphasia who use languages with case marking (e.g.,German, most Slavic languages) often demonstrate substitu-tion errors in case marking (e.g., use an incorrect morphemeto indicate nominative/subjective case). As case marking islimited to the possessive “s” in English, case errors are in-frequent in English speakers with aphasia. Similarly, gender-marking errors will be common if speakers with aphasia uselanguages that have gendered nouns (e.g., for the Englishnoun phrase “a /the house,” Spanish requires the use of agender-specific determiner una/la and the feminine wordending a).

Variable syntax profiles among bilingual speakers withaphasia may also result from differences in the nature of theirsyntactic impairment. There are two general views to accountfor syntactic problems in aphasia: a central deficit disorder,in which syntax competence or knowledge is impaired, and aperipheral deficit disorder, in which syntax performance isimpaired (Grodzinsky, 2000; Paradis, 1988). Impaired syntax

competence assumes that all grammatical knowledge is cen-trally represented, and thus, an impairment would affect alllanguage modalities. Conversely, a peripheral deficit is de-fined as a modality-specific deficit and is considered a per-formance deficit. A peripheral deficit could, then, produce a“double dissociation” wherein an individual with aphasiamay, for example, demonstrate syntactic breakdowns in writ-ing but not speech or reading (Bub & Kertesz, 1982; Paradis,1988). With respect to bilingual speakers with aphasia, sim-ilar deficits across languages would suggest a central deficit(Paradis, 1988). If the deficit is peripheral, there may be adissociation between languages, depending on what syntacticoperation has been affected, resulting in differential languageoutcomes such as: (a) if there is a structure dependent defi-cit (e.g., difficulties with tense or case marking), the languagewith the more extensive morphological system will be moreimpaired; (b) if lexical access is impaired, the languagewith greater use of free or bound grammatical morphemeswill be more impaired; and (c) if a syntactic level deficitoccurs, the language that relies more heavily on word orderwould be more impaired.

As proposed by MacWhinney, Bates, and Kiegl (1984),cue strength may also account for differences in productivesyntactic deficits among speakers’ various languages. Theseresearchers demonstrated that cue strength, the degree towhich a given grammatical aspect can be utilized for sentenceinterpretation, varies across languages: The stronger the rela-tive cue, the more likely the cue will be preserved. To illus-trate, participant-verb-object is the canonical order for bothSpanish and English, but Spanish speakers have more free-dom to vary word order from this canonical order. Therefore,canonical word order has greater cue strength in English,and accordingly, its use often remains preserved followingaphasia onset in English speakers. In languages in which ca-nonical word order has a lower cue strength, such as Spanish,it may be less preserved. Similarly, to compare grammaticalerrors across languages with differing levels of morphologyand word-order freedom, Bates, Friederici, and Wulfeck(1987) examined adults with Broca’s aphasia, Wernicke’saphasia, or no aphasia who spoke English, Italian, or German.All three languages have a canonical, participant-verb-objectorder, but Italian and German also allow quite flexibleword order. To compensate for this flexibility, these twolanguages utilize morphology for sentence interpretation inthat (a) German has a significant and productive case sys-tem attached to articles, and (b) Italian requires reliance onagreement markers. Conversely, English utilizes little mor-phology, necessitating dependence on word order for in-terpretation. These language differences, according to atraditional impairment perspective, could place German andItalian language users at a disadvantage if aphasia impairsmorphology more than other language features (e.g., wordorder). Bates et al. found, however, that both Italian andGerman participants with Broca’s aphasia maintained mor-phology use to a much greater degree than would be ex-pected; in fact, no aphasia type was associated with omissionrates equal to that demonstrated by English speakers withaphasia. Although similar syntactic recovery patterns havebeen observed in other morphologically rich languages suchas Spanish (e.g., Ostrosky-Solis, Marcos-Ortega, Ardila,


Roselli, & Palacios, 1999), additional studies comparing therelative maintenance of morphology across languages wouldbe beneficial, with tighter control for language impairmentand testing tools. Regardless, this line of research indicatesthat reconsidering previous assumptions about morphosyntaxand aphasia is needed, particularly given that these language-specific differences influence the appropriate identificationand selection of morphosyntactic treatment targets.

Another example relates to the proposed dichotomy be-tween agrammatism and paragrammatism. Agrammatismis typically characterized by telegraphic speech, includingomission of grammatical inflection and function words, re-duced phrase length and syntactic complexity, and Broca’sarea lesions (Goodglass, Kaplan, & Barresi, 2001); in con-trast, paragrammatism is typified by empty speech (i.e., wordsor phrases meaningless to the communication situation, in-cluding indefinite terms, neologisms, other paraphasias, andrepetitions), inflection substitution errors, frequent use offunctors, and Wernicke’s area lesions. This dichotomy ofomission versus substitution, however, may be overstated dueto the disproportionate number of aphasia studies done inEnglish, a word-order strict, morpheme-impoverished lan-guage. For example, in a study of agrammatism in two bi-lingual Spanish-Catalan speakers with Broca’s aphasia, theparticipants were observed to make verb errors in both lan-guages that were considered uncharacteristic of traditionaldescriptions of Broca’s aphasia (de Diego Balaguer, Costa,Sebastián-Galles, Juncadella, & Caramazza, 2004). There-fore in bilingual speakers, patterns of grammatical deficits inclients with aphasia can differ from what was previously as-sumed, and whether and how these traditional grammaticalprofiles apply to other languages, particularly within bilin-gual speakers, requires further examination.

A growing literature thus indicates that the linguistic char-acteristics of each language used by bilingual speakers withaphasia must be considered when describing their morpho-syntactic strengths and weaknesses. Failure to consider theseinfluential linguistic factors may result in inaccurate docu-mentation of the presence, severity, and nature of grammat-ical deficits.

Lexical semantics. Specific considerations also apply tothe recovery of lexical semantic abilities in bilingual speakerswith aphasia. Whereas much research has focused on mono-lingual speakers of English, research involving monolingualspeakers who speak a language other than English suggeststhat the types and frequencies of paraphasias vary across lan-guages. Consequently, types and frequencies of paraphasiasmay also vary across a bilingual speaker’s different lan-guages. For example, Ardila (2001) observed that Spanishspeakers produce more phonemic or literal paraphasias in-volving vowels than do speakers of other languages. This ispossibly due to a one-to-one correspondence of vowels andtheir sounds, making vowels in the Spanish language moresalient. Research with bilingual speakers has also highlightedsome unique paraphasia considerations. For instance, seman-tic paraphasias may sometimes result from interlanguageinterference, with the speaker choosing the correct word,but from the wrong language. Goral et al. (2006) reportedon a trilingual speaker whose L1 was Hebrew but who usedEnglish and French more frequently than Hebrew at the time

of his aphasia onset. Levels of interlanguage interferenceerrors varied across his languages, which the authors at-tributed to differing levels of lexical connectedness amonghis languages. That is, when the client was speaking in French,he produced many non-target language words in English,which often were cognates. Conversely, when speakingHebrew, a language less related to either French or English,he produced significantly fewer interference errors. There-fore, interlanguage interference represents a possible sourceof paraphasias not encountered when dealing with aphasia inmonolingual speakers.

Several unique factors may influence lexical access speed,accuracy, and recovery in bilingual speakers with aphasia. Forexample, investigators have begun to explore the effects ofcognate status on naming skills and have found that cognateselicit better pretreatment performance than noncognates inparticipants with aphasia (Kohnert, 2004; Lalor & Kirsner,2001; Roberts & Deslauriers, 1999). This benefit may not,however, apply to both languages, as Roberts and Deslauriers(1999) found that in adults with aphasia, cognate status onlyimproved L2 naming accuracy. Therefore, this line of bi-lingual aphasia research, albeit limited, has consistently re-vealed improved naming accuracy and speed with cognatesversus noncognates, with additional research needed to iden-tify the limits of this generalization.

Reading and writing. Recovery of reading and writingabilities in bilingual individuals with aphasia has receivedsome empirical attention. Some research suggests that theseindividuals may utilize different reading strategies in theirdifferent languages, particularly if their languages divergein terms of orthography transparency. For instance, withEnglish, a language with nontransparent orthography (i.e.,one cannot always “sound out” words), individuals may usea combination of phonological and logographic (i.e., wholeword) reading approaches (Sampson, 1985). Spanish, in con-trast, has transparent orthography, as words are pronouncedas written, and allows accurate reading aloud even whenwords are completely unknown (Ardila, Rosselli, & Pinzon,1989). As a result, individuals may more easily and regularlyemploy a phonological route to read Spanish (Ardila, 1991).Iribarren, Jarema, and Lecours (1999) have pointed out,however, that whereas transparent orthography may favor aphonological reading route, it does not preclude the use oflogographic reading. Indeed, researchers have identified theuse of logographic reading in participants from languagebackgrounds with transparent orthographies (e.g., Basso &Paulin, 2003; Iribarren et al., 1999). Clinicians should beaware of these potential cross-linguistic differences in readingroutes, which may in turn produce different patterns of read-ing deficits subsequent to aphasia onset in bilingual indi-viduals. For example, disturbance of just one reading routecould impair reading one language more than the other or,at the very least, influence what type of stimuli might beappropriate.

Reading disturbances subsequent to aphasia onset mayinclude surface dyslexia, deep dyslexia, or phonological dys-lexia (Dérouesné & Beauvois, 1979; Marshall & Newcombe,1973). Just as the surface manifestations of these dyslexiatypes differ, so may their manifestations across languages,making the identification of such deficit patterns difficult. For


example, surface dyslexia, characterized by a regularizationand thus misunderstanding of irregularly spelled words, maybe uncommon in speakers of orthographically transparentlanguages (Iribarren, 2007). Conversely, compared to clientswho regularly employ both routes to read their language(s),clients using languages that primarily rely upon a phono-logical reading route may be at greater risk for severe forms ofphonological dyslexia, a reading disorder distinguished byimpaired use of the phonological reading route.

As with reading, orthography transparency may influencethe types of writing profiles observed in bilingual clients withaphasia. For example, Spanish, Italian, and Russian have aphonological writing system in that words are spelled as theysound (Ardila, Rosselli, & Ostrosky-Solis, 1996); that is, theletters are pronounced the same way, regardless of the wordin which they are found. English and French, conversely, arenot purely phonological, as evidenced by the fact that a writ-ten word in either of these languages may be quite differentfrom its phonographic form; as a result, writing in these lan-guages is achieved through a combination of grapheme/phoneme correspondence (i.e., a phonological route) andvisual gestalt, or whole-word recognition (i.e., lexical se-mantic route). Therefore, use of either a phonological and/ora lexical semantic system for writing will depend, at leastin part, on the particular linguistic characteristics of thelanguage.

Ardila et al. (1996) argued that in languages such as Span-ish, two different types of writing errors can be found: homo-phone or orthographic errors and nonhomophone errors.Homophone errors are phonologically correct and occurwhen two letters have the same phonological quality, couldbe interchanged, and thus still produce a word that soundscorrect, despite being misspelled. For example, in Spanish,letters g and j both are associated with the /x/ sound, somujer(woman) could be spelled phonetically as either “muger” or“mujer.” These spelling errors exist in healthy populations.Conversely, nonhomophone errors involve some letter ad-ditions, omissions, or substitutions, which change the word’swritten representation (e.g., “muer” for “mujer”). These errorsare only found in brain-damaged individuals. For instance,using a dictation task, Ardila et al. examined the occurrence ofhomophone and nonhomophone errors in the written Span-ish of 92 healthy participants and 14 who had brain damage(i.e., individuals with Broca’s aphasia, Wernicke’s aphasia,or right hemisphere damage). Whereas all groups made ho-mophone errors, the groups with aphasia most frequentlymade nonhomophone errors such as letter substitutions, ad-ditions, and omissions. Additionally participants with Broca’saphasia made semantic paragraphias (e.g., lápiz Y papel,judicialY policia), and participants withWernicke’s aphasiamademoremorpheme substitutions and fewer omissions thanthose with Broca’s aphasia.

Due to increased transparency in the orthography of Span-ish and other similar languages (e.g., Italian and Russian), itmay be possible to identify unique writing errors such ashomographic and nonhomographic, with the latter being prev-alent only among the brain injured population. The presence ofthese errors and the subtypes made (e.g., letter additions vs.omissions) can vary across aphasia type. To date, most readingand writing research that extends beyond English, however,

has been done with monolingual participants with aphasia.Accordingly, future studies are needed to examine whether andhow these different surface manifestations identified in mono-lingual individuals might vary when a person reads andwrites in more than one language, particularly if the lan-guages differ in terms of orthography transparency.

In summary, although bilingual aphasia research has re-vealed significant variation in recovery across morphosyntax,lexical semantics, reading, and writing, additional investiga-tions are needed to understand fully the nature of this re-covery process. Regardless, unique recovery patterns dictatethat novel assessment and treatment approaches, some ofwhich are reviewed below, should be considered when pro-viding direct services to patients with bilingual aphasia.

Implications for Assessing and Treating ClientsWith Aphasia

Due to the aforementioned differences between bilingualversus monolingual aphasia, managing bilingual aphasia willnecessarily diverge, at least in part, from monolingual apha-sia diagnostic and treatment practices. That is, traditionalprocedures documented as effective with monolingual speak-ers may require alteration or complete revision to meet theneeds of bilingual speakers. Although nominal empiricalresearch is currently available to guide effective managementof bilingual aphasia, growing anecdotal evidence is emergingfrom clinical practice.

Because bilingualism varies dramatically across individ-uals, it is imperative that clinicians and researchers avoid sev-eral common false assumptions. First, it cannot be assumedthat premorbid abilities in each language were equivalent,or that being bilingual implies a certain level of proficiencyfor all bilingual speakers (Muñoz&Marquardt, 2003). Second,SLPs should not attribute postmorbid differences betweenthe languages to brain damage, as they may already havediffered premorbidly (Kiran & Tuchtenhagen, 2005). Fol-lowing this reasoning, SLPs must consider the various domainsof language use when developing management plans for theirbilingual clients with aphasia.

AssessmentTo obtain an accurate assessment of language proficiency

in bilingual clientele, several measures must be taken, someof which overlap with those used to evaluate monolingualclients and some of which are unique to meet bilingual clients’needs. When dealing with the sudden onset of aphasia, suchas in stroke, there are certain recommendations for approach-ing assessment as recovery unfolds. During the acute recov-ery phase, as is recommended for monolingual speakers (e.g.,Holland & Fridriksson, 2001), assessment should focus onevaluating basic communication needs due to the dynamicnature of acute recovery (Fabbro, 2001a). During morechronic recovery phases when language abilities stabilize,more comprehensive assessment can be completed. Fur-thermore, during and following treatment, periodic re-assessments are required to monitor for changes in recoverypatterns. Throughout this assessment process, SLPsmust also


dedicate time to counseling and educating caregivers andfamily members who may be confused and alarmed by thesudden onset of aphasia, other concomitant signs, or recoverypatterns.

When planning an assessment for a bilingual client, seve-ral important areas should be considered to identify specificlinguistic and possibly cultural aspects that may affect bothevaluation and intervention. An essential first step is collectinga history of language use from the client, family members, orothers who may be familiar with the client’s language use(Muñoz & Marquardt, 2003; Muñoz et al., 1999; Roberts &Deslauriers, 1999). Research indicates that self-reporting, ac-crued through interviewing, self-rating scales, or languageuse questionnaires, is generally consistent with actual lin-guistic ability and thus an efficient and effective approachto obtain language histories (MacIntyre, Noels, & Clement,1997; Ross, 1998). For example, the language use question-naire developed by Muñoz et al. (1999) includes questionsabout language acquisition, educational history, and lan-guage use, and has been used with both clinical and non-clinical populations. More recently, Marian, Blumenfeld, andKaushanskaya (2007) developed the Language Experienceand Proficiency Questionnaire (LEAP-Q), which coversacquisition history and context, language use, languagepreference, and a proficiency rating, and has validity andreliability data available for a nonclinical population. Theauthors, however, emphasized that LEAP-Q is not yet in-tended for a clinical population, even though it may be use-ful in obtaining language histories from these individuals. IfSLPs opt to create their own questionnaires, they shouldinclude questions pertaining to the following: age and man-ner of acquisition (i.e., home vs. formal schooling), currentuse of each language, relative proficiencies, literacy levelsin each language, and modalities in which each language isused (Paradis, 2004). Identifying bilingual clients’ premorbidproficiency levels is germane to establishing the severity ofimpairment within each language and across modalities. Forexample, during informal interaction, a client may demon-strate only slightly stronger language abilities in one languagethan the other, suggesting a parallel deficit. It may be the case,however, that the client was significantly more proficientpremorbidly in one of the languages and thus has sustaineda significant loss in one language and only minimal in theother. Conversely, as not all bilingual speakers are literatein both languages, an apparent reading deficit may actuallyreflect a premorbid state.

When formally assessing the client’s language abilities, itis imperative that each language, whether used regularly oronly for specific purposes, be thoroughly evaluated, usingtests designed for bilingual speakers (Paradis, 2004). Assess-ment of both languages is important for several reasons. First,clients may be unaware of which of their languages is moreimpaired and will make life choices based on their perceiveddeficits. Second, if the SLP only speaks one of the languages,he or she may wrongly perceive or assume that the otherlanguage is less impaired when it is not. A complete assess-ment will ensure an accurate picture of the strengths andweaknesses within each language. It may also reveal lan-guage deficits that are only detectable in one of the lan-guages due to structural differences of the languages. The

goal is to understand relative deficits across languages andmodalities so as to determine which languages to include intherapy or, alternately, to identify specific goals for eachlanguage.

If the SLP does not speak the client’s language, interpreterassistance may be needed (see ASHA, 1989, for guidelineson proficiency requirements). Due to difficulties associatedwith using interpreters (e.g., training, reliability), interpretersshould only be employed when no SLP is available whocan speak the client’s language (ASHA, 1989). Importantly,family members should only be used as a last resort, be-cause it may be difficult for them to participate objectivelyin assessment without providing personal input into theprocess. Whereas one might assume that an SLP who isproficient in each of the client’s languages would be bestqualified to administer these tests, this is not always thecase. For example, if a client is suspected of pathologicalswitching, it is important that the SLPs doing each lan-guage assessment speak only that language (Grosjean, 1998).For instance, when assessing a client’s Spanish skills, itwould be ideal to have a tester who only spoke Spanish sothat any English utterances could not be assumed to beintentional.

With respect to formal test selection, Paradis (2004) warnedagainst the folly of using tests that are simply translations ofEnglish tests; such tests are constructed with little or no con-sideration of linguistic and possible cultural differences. In-stead, SLPs must identify linguistically equivalent tests thatevaluate similar types and levels of abilities in each of theirclients’ languages. Linguistic equivalence implies that allareas of linguistic comparison (e.g., vocabulary, syntax struc-tures) are of equal difficulty in the respective languages. Forexample, across tests, grammatical constructions must havethe same level of difficulty or complexity; simply translat-ing a particular grammar tense or construction does not guaran-tee that the construction is equally difficult in the otherlanguage. Minimal pairs or rhyming words that are used forphonological tasks will obviously differ if simply translatedand thus no longer meet the phonological task’s require-ments. Likewise, whereas vocabulary on aphasia batteries istypically controlled for frequency of use, translation equiva-lents in another language may have different frequencies,making them more or less common or difficult. Finally,because languages differ structurally (e.g., word order, in-flectional morphology, complexity of construction such aspassive voice), the structural complexity and relevance ofa structure may also vary across languages. To be equiva-lent, a structure of similar complexity rather than similar useneeds to be chosen. These are only a few ways in whichstructures may differ, exemplifying why an assessmentbattery needs to be completely rewritten prior to using itcross-linguistically. As a result, it may be most wise to usea testing tool that has been specifically designed for multiplelanguages.

Perhaps the most frequently used bilingual aphasia test, atleast in the research literature, is the BAT (Paradis & Libben,1987). The BAT does not classify aphasia type but rathermeasures bilingual clients’ ability to use each of their lan-guages in unilingual settings. That is, it identifies whichlanguage skills and linguistic structures have been affected


for each language. The BAT includes a detailed language usehistory questionnaire and sections to assess deficits in lan-guage use and translation, as well as language interferenceissues. A computer program is available to evaluate responsesin more than 100 different languages and make comparisonsacross languages. Importantly, the BAT is not simply a trans-lation of an English aphasia test; rather, tests in each languagewere developed with linguistically and culturally appropri-ate words and syntactic structures (Fabbro, 2001a). A fewother aphasia batteries are available for bilingual clientele andcan be used for classification of aphasia. These include theMultilingualAphasia Examination—SpanishVersion (Benton&Hamsher, 1994; Rey, Sivan, & Benton, 1991) that has beenstandardized and normed on a Latino sample, the WesternAphasia Battery—Spanish Version (Kertesz, Pascual-Leone,& Pascual-Leone, 1990), a Spanish version of the Psycho-linguistic Assessment of Language Processing in Aphasia(Kay, Lesser, & Coltheart, 1992), a Spanish version of theBoston Diagnostic Aphasia Examination (Goodglass &Kaplan, 1986) that has available norms (Rosselli, Ardila,Florez, & Castro, 1990), and the Aachen Aphasia Test (Huber,Poeck, Weniger, & Willmes, 1983), which is available inseveral languages.

In addition to standardized testing, SLPs often obtain andanalyze language samples for quantity and quality of produc-tion. Here again, a cross-linguistically comparable measuremust be used. Because of differing structural characteristicsof languages, measuring language quantity according to pro-cedures developed for English may under- or overestimateproblems in other languages. For example, syntactic com-plexity is often quantified by computing the mean length ofutterance, the number of verbs per utterance, and the numberof subordinate clauses (Paradis, 2004). Because norms forthese measures vary across languages, the client’s perfor-mance in each language needs to be compared against itsrespective language norms, rather than solely compared to theother language. Additionally, Paradis suggested that analy-sis procedures may require modifications. Take for examplethe type–token measure, which typically divides the numberof different words (i.e., types) by the total number of words(i.e., tokens) to measure lexicon diversity. To remediate someproblems associated with lexical structure differences acrosslanguages, Paradis suggested that when doing a type–tokenanalysis, only lexical items (not grammatical words) shouldbe counted. For instance, a language without articles or cop-ulas would have a higher type–token ratio than a languagewith these word types, because it would have fewer redundantwords, appearing artificially more diverse. Similarly, if a lan-guage uses noun phrases as compound words, each constit-uent of the compound should be counted as one word whencomparing to languages in which several separate wordsmean the same thing. Finally, if reading and writing are as-sessed, SLPs must be aware of any visual field cuts or neglectthat could differentially affect two languages if they are readfrom opposite directions (Paradis & Libben, 1987). There-fore, SLPs must be cognizant of these and other possible lan-guage differences so as to make accommodations that willensure that bilingual clients’ abilities are accurately assessed.Failure to do so could result in incorrect assessment of aphasiapresence, severity, or classification.

Due to increasing evidence that possible concomitant,cognitive disorders may influence aphasia signs and recov-ery in monolingual speakers (e.g., Murray, 1999) as well asbilingual speakers (e.g., Green, 2005), cognitive testing maybe indicated. Similar to the limited availability of languagetests, there are few appropriate tools for examining multi-lingual clients’ cognitive abilities, although researchers arebeginning to tackle this issue (Rey et al., 2001). A limited setof translated language and cognitive tests are listed in theAppendix, and a more complete discussion of normative dataavailable for various language and cognitive tests can befound in Roberts (2001).

In summary, clinicians working with the bilingual aphasiapopulation must consider and thus evaluate their clients froma multitude of angles to develop the most effective and ef-ficient treatment (Fabbro, 2001a; Roberts, 1998). For exam-ple, Green (2005) advocated that an essential first step inplanning treatment is to assess and understand the client’s re-covery pattern across and within languages to create practicalgoals that will target specific loci of breakdown in the lan-guage system. Next, clinicians need to understand (a) whatmay be driving particular recovery patterns, (b) whethercognitive deficits are in any way contributing to languagebehaviors, and (c) how these factors interact with their clients’needs and wishes. Additionally, depending on clients’ needsand preferences, clinicians must determine which languageor languages to target and then maximize treatment efficiencyby analyzing those languages for similarities of underlyingstructure to determine how best to exploit these similarities inconcert with natural learning processes. Finally, the client’scommunication community can also influence assessmentand treatment choices and recovery patterns and thus be uti-lized as a valuable resource in all aspects of client manage-ment (Laganaro & Overton Venet, 2001).

TreatmentWhereas researchers often provide suggestions regarding

treatment of bilingual aphasia (e.g., Paradis, 2004; Roberts,2001), sufficient experiential support of these suggestions iscurrently lacking. Additionally, the available empirical liter-ature has so far focused on a limited set of linguistic abili-ties (e.g., word retrieval; Edmonds & Kiran, 2006). Theseinitial investigations, however, can provide both cliniciansand researchers with ideas for developing treatment protocolsfor bilingual clients and highlight the many managementissues unique to the bilingual client population that still needto be resolved in future studies.

For most bilingual clients, the same principles applied todesign effective therapy for monolingual speakers would beused. For example, selected treatment strategies should en-sure client success by choosing accessible language targets(Roberts, 2001). Additionally, some existing traditional treat-ments have been found effective with bilingual clients, in-cluding the general stimulation approach (Watamori &Sasnuma, 1976, 1978)—in which intensive auditory stimu-lation, repetition, naming, reading, and writing tasks arepracticed at varying levels of linguistic complexity—andphonemic cuing (Roberts, de la Riva, & Rhéaume, 1997), inwhich initial phonemes of words are used to facilitate lexical


retrieval. Other treatment protocols (e.g., Melodic IntonationTherapy, which uses music-like intonation and rhythm to aidspoken word and phrase production; Sparks, Helm, & Albert,1974) have been successfully used with monolingual speak-ers of other languages (see Roberts, 2001, for a review), butadditional research is needed to determine not only the effectsof these treatments on bilingual aphasia but also the degree ofcross-linguistic generalization they can achieve. For example,to address word retrieval difficulties, Galvez and Hinckley(2003) provided to a client with transcortical motor aphasia acuing hierarchy treatment in each of his languages. The client,a 71-year-old left-handed man, reported equal proficiencyin Spanish and English prior to his stroke; he reportedly usedboth languages daily, Spanish at home and English at work.Whereas treatment produced within-language improvementsacross language modalities, no cross-linguistic generalizationwas observed, suggesting that this treatment may notgeneralize across languages.

Aphasia treatment must also extend beyond protocolsdeveloped for monolingual English clients. Goals should bebased on pre- and postmorbid language proficiency and usepatterns (Roberts, 2001); for example, reading therapy shouldonly be applied to the languages that the client premorbidlyused for reading. SLPs should also consider specific char-acteristics of each of their clients’ languages, as syntacticimpairments may differ across languages (Ardila, 2001; Bateset al., 1987) and different strategies may be more or less ap-propriate (Cuetos & Mitchell, 1988; Ostrosky-Solis et al.,1999; Roberts, 2001). For instance, bilingual Spanish/ Englishspeakers may use gender as a cuing strategy for word re-trieval in Spanish (Roberts, 2001) but not in English due to thelack of gender marking in English. Accordingly, treatmentsolely based on a monolingual English framework may notexploit the full range of potential strategies available.

With respect to remediating specific language domains,reading and naming treatment studies have demonstratedcross-linguistic generalization when training has focused onshared aspects of clients’ languages (Kiran & Edmonds, 2004;Laganaro & Overton Venet, 2001). Indeed, a cognate therapyapproach is based on the possibility that the two lexiconsof a bilingual speaker may be functionally and neurologi-cally interconnected, which should thus allow across- aswell as within-language gains (Costa et al., 2005; Kiran &Tuchtenhagen, 2005; Lalor & Kirsner, 2001; Roberts &Deslauriers, 1999). For example, Kohnert (2004), adoptinga phonological view of cognates, explored cross-linguisticgeneralization following a therapy to target naming of10 cognates and 10 noncognates. The participant with apha-sia, a proficient Spanish-English speaker whose L1 wasSpanish, first received the cognate-based treatment in Span-ish and then English. Generalization occurred from L2 toL1 for both cognates and noncognates following Englishtreatment, but only for cognates after Spanish treatment.Therefore, a cognate effect was found with generalizationfor cognates in both directions. Relatedly, Laganaro andOverton Venet (2001) reported on a Spanish-English speakerwith aphasia whose L1 was Spanish but who used Englishprofessionally at work. Because reading in both languageswas equally impaired, these researchers concluded impair-ment of similar reading processes in both languages and

further hypothesized that if shared reading processes areimpaired, treatment aimed at improving the shared pro-cesses should result in cross-linguistic generalization.Accordingly, they provided this client two different treat-ments: first, a lexical, letter-by-letter reading inhibition task,and second, a phonological assembly and encoding task,which included phonological blending activities. Indeed,the lexical treatment evoked generalization from the treatedto the nontreated language, supporting the notion thattargeting strategies shared by the languages promotesgeneralization.

Which language is trained may also influence therapy ef-ficiency. Kiran and Edmonds (2004; Edmonds & Kiran, 2006)have shown that lexical semantic treatment of participants’weaker language may produce generalization to their strongerlanguage. In their 2004 study, a lexical semantic treatment wasprovided to two Spanish-English speakers with equivalent,postmorbid, across-language deficits, one of whom was pre-morbidly English dominant, while the other was premorbidlybalanced. They found that premorbid dominance contributedto cross-linguistic patterns of generalization: For the partic-ipant with a balanced Spanish-English profile, within-language and cross-linguistic generalization was found.That is, treatment for this individual was initiated in Spanish,and generalization was found to semantically related Spanishwords (e.g., manzana-naranja), and in English for both thetrained item (e.g., manzana-apple) and semantically relateditems (e.g., manzana-orange). For the participant who wasEnglish dominant, within-language generalization to relatedsemantic items was found only in the dominant language (e.g.,apple-orange) but not in the weaker language (e.g., manzana-naranja). Cross-linguistic generalization was only foundfollowing treatment of the weaker language (Spanish), withgeneralization to words in the dominant language (English)for both the trained item and semantically related items; cross-linguistic generalization to the weaker language (Spanish) didnot occur following treatment of the dominant language(English). In 2006, Edmonds and Kiran again reported cross-linguistic generalization in 2 premorbidly English dominantparticipants only when their weaker language (Spanish) wastreated. A third participant, who was premorbidly equallybilingual, was only trained in Spanish and demonstratedcross-linguistic generalization to English. Whereas addi-tional studies encompassing more participants and directlycomparing treatment protocols are needed, these prelimi-nary findings suggest bilingual aphasia treatment can bedesigned to maximize cross-linguistic generalization and,thus, treatment efficiency, via training targets in only onelanguage.

Our recent review of the literature identified no empiricalstudies of syntax treatment for bilingual aphasia. Based onreports of cross-linguistic generalization in other languagedomains (e.g., Kiran & Edmonds, 2004), however, syntaxtreatment may be most effective for bilingual speakers whenfocused on underlying syntactic processes (e.g., inflectionalphrase structure) shared across languages rather than on sur-face structures of just one language. SLPs also need to re-call that different syntactic outcomes across languages mayreflect the relative importance of corresponding surface struc-tures within each language. For example, as pointed out by


Bates et al. (1987), the maintenance of morphosyntax may beat least partially affected by its relevance.

Cognitive treatments may be appropriate for those bilin-gual clients with concomitant cognitive deficits. For instance,Kohnert (2004) developed a nonlinguistic cognitive treat-ment for a 62-year-old bilingual man with severe nonfluentaphasia. His L1 was Spanish, but he had lived in the UnitedStates for 25 years and used English in work and social set-tings and both languages at home. Kohnert hypothesized thatimproving cognitive processing efficiency to support lan-guage behavior would result in cognitive as well as languageimprovements. Cognitive training was provided across 14 ses-sions, each an hour long, and consisted primarily of atten-tion tasks (e.g., visual scanning, visual number, and lettersearches). As predicted, following treatment, accuracy andspeed on the trained cognitive tasks improved, as did per-formance of untrained language comprehension (e.g., sentencecomprehension) and production (e.g., picture description)tasks. Whether the cognitive training solely contributed tothese language gains, however, cannot be established defin-itively: Whereas the client was most likely beyond sponta-neous recovery (i.e., more than 1 year after aphasia onset),there was ample language stimulation and practice during thecognitive training sessions via natural discourse (e.g., greet-ings, instructions, feedback). Thus, due to the inherent pres-ence of language in most therapy procedures, it is difficult toidentify the degree of improvement, which can be attributedto a cognitive treatment.

There are also special considerations when training bilin-gual clients’ use of compensatory strategies. For example,bilingual speakers with and without aphasia often successfullyuse one language to cue another, and these self-correctionsmost frequently involve producing the target word in thewrong language, intentionally or unintentionally, to cue thecorrect target (Goral et al., 2006; Roberts &Deslauriers, 1999).Given that explicitly teaching self-cuing is a successfulword retrieval strategy among clients with aphasia in gen-eral (e.g., Abel, Schultz, Radermacher, Willmes, & Huber,2005), utilizing these self-corrections, the powerful con-nection of cognates, or both could be effective strategiesfor bilingual speakers with aphasia, especially if they livein a bilingual community. Additionally, when these self-correction attempts are unsuccessful, use of a cognate, albeitin the wrong language, may still be understood, even bysomeone who does not speak the “wrong” language (Roberts& Deslauriers, 1999).

Although unintended code switching can interfere withcommunication intent, its use could be harnessed as a com-pensatory strategy (Muñoz et al., 1999), particularly if theclient with aphasia lives in a bilingual community. In someinstances, it may be most efficient to adapt to the client’sstrengths by training daily communication partners to under-stand cognates in the other language or to accept those cog-nates commonly used as semantic paraphasias by the client.Family members, caregivers, or even coworkers could also betaught vocabulary commonly used within the language withwhich they are unfamiliar but that the client uses. Viewedfrom this perspective, code switching can enhance functionalcommunication. To determine if this is an appropriate option,SLPs need to identify their clients’ communication goals,

communication environment at home, and ability to manipu-late volitionally code switching.

Although augmentative and alternative communicative de-vice use is an option for monolingual individuals with aphasia,a review of the literature indicates nominal exploration ofthis treatment approach for bilingual speakers with aphasia.Spanish versions of one digitized speech device, the Spring-Board Communication Aid by Prentke Romich Company,have recently been developed and used with bilingual clients(Cross, 2005). This system, designed for persons with apraxiaand for children, is available in two Spanish forms, that ofSpain and the U.S. domestic market, with a vocabulary setallowing for spontaneous speech. Additionally, device promptsand support materials are provided in Spanish as well asEnglish, so the system can be switched between the two lan-guages. Despite such device availability, SLPs should beaware of cultural barriers to such technological solutions, asethnic culture and non-English language backgrounds areoften barriers to successful device use (Reed & Newton,2004).

Summary and Future DirectionsBecause individuals who speak more than one language

are one of the fastest growing segments of the U.S. popula-tion and many of these individuals are at risk for developingmedical conditions that can produce aphasia and other com-munication disorders, there is a growing need to ensure thatSLPs are adequately prepared to serve the needs of the bi-lingual population. This review, which focused primarily onresearch pertaining to Spanish-English bilingual aphasia dueto the dramatic increase in Spanish-English speakers in theUnited States and the considerable research available fo-cusing on these languages, indicates a dire need for furtherempirical investigation of many issues pertaining to under-standing and managing bilingual aphasia.

First, debate persists regarding how best to quantify andqualify bilingualism and other linguistic concepts (e.g., cog-nate status) unique to bilingual speakers. It also is not yetclear how certain linguistic considerations (e.g., the natureand relationship of each language’s lexicon) and cognitivefactors (e.g., attention, inhibition) influence language selec-tion and use in healthy bilingual speakers; consequently, howthese factors contribute to the variety of recovery patternsobserved in bilingual aphasia requires further exploration.Second, most bilingual aphasia research has involved rela-tively weak study designs (e.g., case descriptions, smallgroup designs) and often failed to control for confoundingvariables such as differing levels of premorbid language abil-ities (e.g., Bates et al., 1987). Thus, replication and extensionof these studies are needed. Lastly, there has been limiteddevelopment and critical evaluation of assessment and treat-ment protocols designed to meet the unique characteristicsand needs of bilingual clients with aphasia. For example, inresearch and clinical practice, no consistent means have yetbeen established to evaluate the pre- and postmorbid lan-guage abilities of bilingual clients; regular use of specificinterview and/or rating tools and linguistic and cognitive testsmay make comparison across future studies more meaning-ful and evaluation of clients more reliable. Likewise a scant


treatment literature contains mixed findings regarding howto maximize cross-linguistic generalization and has so farfocused almost exclusively on remediation of lexical seman-tic abilities.

In conclusion, demographic data indicate an urgent needfor researchers and clinicians to address the many empiricalquestions and management needs identified in this review.ASHA’s (2003) Code of Ethics requires SLPs to evaluate theeffectiveness of their services and only provide services whenbenefit can reasonably be expected. With nominal researchcurrently available regarding managing bilingual aphasia,SLPs are left to make clinical decisions without the appro-priate support. Additional empirical investigation, therefore,is crucial to ensure ethical provision of services to this rapidlygrowing client population.

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Received March 3, 2007Accepted December 18, 2007DOI: 10.1044/1058-0360(2008/026)

Contact author: Bonnie Lorenzen, Department of Speech andHearing Sciences, 200 South Jordan Avenue, Bloomington,IN 47405-7002. E-mail: [email protected].


Appendix

Examples of Cognitive and Language Tests Available in Other Languages

Test Description, translations, and/or normative data

Aachen Aphasia Test (Huber et al., 1983) Multiple languages

Addenbrooke’s Cognitive Examination (Mathuranath,Nestor, Berrios, Rakowicz, & Hodges, 2000)

Adapted clock drawing tests in Spanish (García-Caballero,García-Lado, et al., 2006), as well as other languages(see García-Caballero, Recimil, et al., 2006)

Behavioral Assessment of the Dysexecutive Syndrome(Wilson, Alderman, Burgess, Emslie, & Evans, 1996)

Chinese version (Chan & Manly, 2002)

Boston Diagnostic Aphasia Exam (Goodglass & Kaplan, 1986) Spanish (García-Albea, & Sanchez-Bernardos, 1986),and other language versions

Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1986) Spanish version with normative data (Kohnert,Hernandez, & Bates, 1998)

Clinical Evaluation of Language Fundamentals (Semel, Wiig,& Secord, 1997)

Spanish version

Cognitive Linguistic Quick Test (Helm-Estabrooks, 2001) Spanish version with normative data

Consortium to Establish a Registry for Alzheimer ’s Disease(Velasquez et al., 2000)

Spanish cognitive test battery

Mini-Mental State Examination (Folstein, Folstein,& McHugh, 1975)

Spanish version with normative data (Reyes de Beamanet al., 2004), and additional language versions

Neuropsychological Screening Battery for Hispanics(Pontón et al., 1996)


Psycholinguistic Assessment of Language Processingin Aphasia (Kay et al., 1992)

Spanish version

Repeatable Battery for the Assessment of NeuropsychologicalStatus (Randolph, 1998)

Spanish version

Rivermead Behavioral Memory Test (Wilson, Cockburn, &Baddeley, 1985)

Chinese version (Wai-kwong Man & Li, 2001)

Severe Impairment Battery (Saxton, McGonigle-Gibson,Swihart, Miller, & Boller, 1990)

Available in several languages such as French, Italian,and Swedish (see Boller, Verny, Hugonot-Diener,& Saxton, 2002)

Test of Everyday Attention (Robertson, Ward, Ridgeway, &Nimmo-Smith, 1994)

Cantonese version (Chan, Hoosain, & Lee, 2002)

Wechsler Adult Intelligence Scale (Wechsler, 1984) Spanish version and other languages

Western Aphasia Battery—Spanish (Kertez et al., 1990). Spanish version

Woodcock-Muñoz: Pruebas de aprovechamiento—Revisada(Woodcock & Muñoz-Sandoval, 1996a)

Spanish test of academic skills for all agesthrough geriatric

Woodcock-Muñoz: Pruebas de habilidad cognitiva—Revisada(Woodcock & Muñoz-Sandoval, 1996b)



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