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should aim to address areas of the ICF framework that extend beyond the impairment level. Clinical issues and challenges As well as the broader context and challenges outlined above, there are several clinical issues that require attention and consideration for the delivery of effective and client- centred speech pathology services in an Australian context to people with aphasia who are bilingual or from a CALD background. While some aspects of speech pathology service provision to bilingual/CALD clients overlap with those of monolingual clients, there are also issues that are unique to the bilingual/CALD clients. Three main areas that SLPs may need to consider are: a) developing a better understanding of aphasia in bilingual/CALD individuals; b) identifying the most appropriate service delivery options for this caseload; and c) identifying and developing culturally and linguistically appropriate resources to enhance delivery of culturally relevant speech pathology services. Understanding aphasia in people who are bilingual or from a CALD background Currently, a wide range of terminology may be employed to describe the language ability of individuals who are not monolingual native English speakers including: bilingual, CALD, non-English Speaking Background (NESB), English as a Second Language (ESL), functional English, limited English proficiency. Although many of these terms may often be used interchangeably in common parlance, their meanings do not necessarily overlap. For example, a person may identify as CALD but not bilingual (e.g., Australian-born monolingual English speaker with Spanish parents) or a person may be bilingual but not CALD (e.g., Australian-born native English speaker of Anglo-Saxon origin who has learnt and is proficient in a second language). One analysis by the Australian Bureau of Statistics (2009) divides CALD status into four categories: a) born in Australia, mainly speaks English at home; b) born in Australia, mainly speaks a LOTE at home; c) born overseas, mainly speaks English at home; and d) born overseas, mainly speaks a LOTE at home. These categories illustrate the diverse range of individuals who may be classified as CALD. The notion of who can be termed “bilingual” is also a complex and multidimensional concept (see Lorenzen & Murray, 2008 for further discussion), with wide variation in the definition and measurement of bilingualism used within research studies. A systematic review of research investigating bilingual aphasia revealed that only 13 of the 77 studies included in the review provided a theoretical definition of bilingualism (Kane, Davidson, & Siyambalapitiya, 2014). The most commonly cited definition was Grosjean’s (1985; p. 467) definition of “the use of two or more languages or dialects in their daily lives”. Clinically, it is important that SLPs identify clear definitions of these terms and encourage their correct usage within the health system to ensure accurate communication about bilingual/CALD individuals and to avoid potential problems with their management. For example, a bilingual person who loses their ability to speak English following a stroke, and subsequently reverts to their native language, may be misidentified as a person who never spoke English to begin with (and possibly not receive the appropriate speech pathology management). Obtaining a comprehensive language history and current language profile, from the client and/or their significant others, is key first step in the process of describing, assessing, and diagnosing aphasia in individuals who are

bilingual or from a CALD background. Accurate information about a person’s pre-morbid language ability is essential for determining whether any language differences are due to pre-existing issues with proficiency versus the post- morbid effects of aphasia. There are several published tools that could be used or adapted as the basis of a language history questionnaire or interview (Marian, Blumenfeld, & Kaushanskaya, 2007; Muñoz, Marquardt, & Copeland, 1999; Paradis, Hummel, & Libben, 1989), which include information such as language acquisition history; educational history in each language; language use; self-rating of proficiency in each language (in both spoken and written modalities), etc. Information about language use, both pre- and post-stroke, is especially important for bilingual speakers, as they may utilise each of their languages in different sociolinguistic contexts (e.g., home language vs work language) and for different purposes (e.g., socialising vs occupational duties) (Centeno, 2005). These usage patterns may alter following a diagnosis of aphasia. For example, a bilingual speaker who loses their ability to communicate in English as a consequence of aphasia may no longer be able to communicate as effectively with English-speaking grandchildren and friends. As well as linguistic background, it is important to consider the influence of cultural variables on the management process and the way in which these may affect speech pathology practice. At the same time, clinicians need to take care not to culturally stereotype individuals from a particular background. A balance should be struck between identifying cultural variables that may impact upon the management process and determining the extent to which these variables are actually relevant on a case-by-case basis. Learning from the person with aphasia and his/her family about the impact of changed language on the person’s life and on family relationships is a first and critical step. This process will involve learning about cultural responses to illness, the individual’s role in the family, priorities of the person with aphasia for social participation, and their sense of self. This “insider perspective” (Brown, Worrall, Davidson, & Howe, 2010) can be explored as the therapist builds a relationship with the person from a CALD background and their family, and demonstrates a genuine interest in knowing about their patient’s culture, response to health issues, and experience of having aphasia. Understanding recovery patterns in bilingual individuals with aphasia is also pertinent in the rehabilitation of bilingual aphasia. Previous papers have reported the various types of language impairment and recovery patterns evidenced by individuals with bilingual aphasia (see Lorenzen & Murray, 2008; Roberts, 2008). Language impairment and recovery can occur in varied and complex patterns across a speaker’s languages so it is necessary to educate the client and family regarding the client’s relative strengths and weaknesses in each language. To accurately describe the nature of language recovery occurring in a bilingual person with aphasia, it is essential to take into account pre-morbid proficiency in each language as distinct from the post- morbid effects of aphasia. To provide effective management of aphasia in bilingual individuals, SLPs need a clear understanding of linguistic features that may present uniquely in bilingual aphasia and not monolingual aphasia. One example is code- switching, which occurs when a bilingual speaker alternates between their two languages (see Ansaldo, Marcotte, Scherer, & Raboyeau, 2008; Lorenzen & Murray, 2008). In neurologically normal bilingual speakers, code-switching may be used routinely when conversing with other bilingual speakers; however, following a diagnosis of aphasia this

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JCPSLP Volume 17, Number 1 2015

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