About the Authors:
|Elyse Lambeth graduated from the University of Redlands with her master’s degree in communicative disorders in 2006, and received her board certification in fluency disorders earlier in 2017. She runs the fluency clinic at Seattle Children Hospital, co-facilitates the annual Seattle Stuttering Camp for Teens at the University of Washington, and has coordinated support groups and a FRIENDS workshop.|
|Lourdes Ramos-Heinrichs is a bilingual (Spanish-English) speech-language pathologist and has been a fluency specialist for the past 16 years. She works in the Boston Public Schools full time with culturally and linguistically diverse students. She has extensive experience working with interpreters, interprets during IEP meetings, and mentors colleagues on best practices in fluency disorders diagnostics and treatment.|
|Helen Selle is a bilingual (Spanish-English) speech language pathologist, who has worked in the Boston Public Schools for over 20 years. She has attended national and international conferences on fluency disorders. She improves her clinical skills through continuing education on current stuttering research and strategies for the preschool and school age populations.|
Collaborating with interpreters is an important part of evaluating people who stutter with limited English proficiency (LEP). Such collaboration elicits data that can direct diagnostic and treatment decisions. This paper provides background information, and suggests some strategies that promote improved collaboration with interpreters during fluency evaluations: (1) following best practices for use of interpreters, (2) briefing the Interpreter on evaluation procedures, and (3) communicating effectively with the interpreter and client. In addition, a form is provided which outlines the steps for better collaboration between the Speech-Language Pathologist (SLP) and the interpreter during the assessment process.
US Census information identified more than 63 million people, over the age of 5, who spoke a language other than English (American Community Survey, 2016). As the United States is becoming more linguistically diverse, the use of interpreters is becoming more common and essential.
Research has demonstrated that using interpreters while evaluating individuals with limited English proficiency (LEP) improves the accuracy of evaluations and quality of care (Priois, Riquelme, & Ganzfried, 2012; Karliner, Pérez-Stable, Gregorich, 2017; Villalobos, Bridges, Anastasia, Ojeda, Rodriguez, & Gomez 2016). However, SLPs receive inadequate little training on working with interpreters (Langdon, 2017-2020). SLPs reported that they lacked knowledge in working with students with LEP (Roseberry-McKibbin & Eicholtz, 1994). Other studies have shown that SLPs question the interpreters’ level of skill and training and their own ability to evaluate CLD clients (Caesar & Kohler, 2007; Hammer, Detwiler, Detwiler, Blood, & Qualls, 2004; Kritikos, 2003; Roseberry-McKibbin, Brice, & O’Hanlon, 2005).
Completing fluency evaluations utilizing interpreters likely compounds these issues as SLPs have frequently reported that fluency disorders is one of the areas within the profession in which they feel the least comfortable and confident (Brisk, Healey, & Hux, 1997; St. Louis & Durrenberger, 1993). Limited research on utilizing interpreters in fluency evaluations is available.
A special consideration in fluency evaluations is accurately judging stuttering in an unfamiliar language. A large body of research supports that stuttering behaviors (i.e., repetitions, tense pauses, prolongations) and the presence of physical concomitants are similar across multiple languages and cultural backgrounds (Shenker 2013; Boey, Wuyts, Van de Heyning, Bodt, & Hylen, 2007; Bernstein-Ratner & Benitez, 1985; Aron, 1962; Lemert, 1952; Lemert, 1962; Leavitt, 1974; Zimmerman, Liljeblad, Frank, & Cleeland, 1985). Low levels of interjudge agreement and intrajudge stability have been found when untrained and inexperienced judges assessed stuttering samples (Cordes & Ingham, 1994). Such poor judgement of stuttering by untrained listeners suggests that it may be inadvisable to use the interpreters’ judgements of stuttering.
In the limited research available about judging stuttering behaviors, there appear to be contradictory results. Some student and practicing clinicians had high inter- and intra-judge agreement, but they identified less than half of the stuttering moments that highly experienced clinicians noted (Brundage, Bothe, Lengeling, & Evans, 2006). Parents of children who stutter, by contrast, were found to have high levels of accuracy in judging stuttering in young children (Einarsdóttir & Ingham, 2009). Other studies indicated that SLPs were able to accurately judge the frequency and severity of stuttering in unfamiliar languages in both children and adults (Einarsdóttir & Ingham, 2009; Humphrey, 2004; Cosyns, Einarsdóttir, & Van Borsel, 2015; Bosshardt, Packman, Blomgren, & Kretschmann, 2016; Van Borsel, Leahy, & Britto Pereira, 2008; Lee, Robb, Ormond, & Blomgren, 2014). In contrast, two other studies that looked at reliability of rating found that clinicians demonstrated poor reliability in their native language and worse in an unfamiliar language (Hoffman, Wilson, Copley, Hewat, & Lim, 2014; Hoffman, Wilson, Hewat, & Huynh, 2017). Working with interpreters is important for obtaining the most accurate information during a fluency evaluation with individuals with LEP. Based on research in the use of interpreters in multiple professional settings, this paper proposes a framework for collaborating with interpreters during fluency evaluations.
Included are best practices for use of interpreters, outlines for the role of interpreters, and suggestions for effective communication among SLPs, interpreters and clients. A form is provided to guide this process.
Following Best Practices for Use of Interpreters
The SLP is the professional who decides whether an interpreter is necessary for a stuttering evaluation of a client who lacks English language proficiency. Langdon (2002) and ASHA’s Practice Portal on collaborating with interpreters indicate that the following are key considerations when selecting an interpreter:
- Proficiency in both languages
- Appropriate educational background
- Training which includes familiarity with medical, educational, and professional terminology
- Interpreter Certification (http://www.imiaweb.org/code/)
- Ability to convey the same information in different ways
- Skills to shift communication styles (e.g., professional language versus colloquial)
- Strong auditory memory to retain chunks of linguistic information while interpreting
As stated above, best practices include utilizing trained and certified interpreters. Before the evaluation, the clinician should write the full name of the interpreter and the agency they represent. The interpreter’s call identification number is valuable, in case of questions or issues related to the evaluation results. In l987, The International Medical Interpreters Association authored an Ethical Code of Conduct, specifically for medical interpreters. It was revised in 2006. The Code of Conduct outlines standards for interpreters to ensure accountability, responsibility, and development of trust. The SLP is responsible for managing the evaluation process within the code of ethics, to avoid any possible legal conflicts. Salient points within the professional code of ethics include the following:
- Interpreters will maintain confidentiality in all assignment-related information
- Interpreters will select the language and mode of interpretation that most accurately conveys the content and spirit of the messages of their clients
- Interpreters will refrain from accepting assignments beyond their professional skills, language fluency, and/or level of training
- Interpreters will not interject personal opinions or counsel patients
- Interpreters will engage in patient advocacy and in the intercultural mediation role of explaining cultural differences/practices to health care providers and patients only when appropriate and necessary for communication purposes, using professional judgement
- Interpreters will use skillful unobtrusive interventions so as not to interfere with the flow of communication in a triadic medical setting.
It is important to keep in mind that when working with interpreters, the SLP is responsible for all assessment decisions such as obtaining accurate information, collecting data and analyzing fluency samples. Best practices require that SLPs use culturally and linguistically appropriate materials during the assessment, and describe stuttering in a manner that is sensitive to the particular background of the client. The SLP has the responsibility to continually update their own professional training on how to best work with interpreters.
The interpreter can provide valuable feedback to enhance and improve each of these aspects of a fluency evaluation, but the SLP is the provider who ultimately bears the responsibility for accurate results and appropriate recommendations. Stuttering samples should be obtained in each of the languages spoken by the PWS (Shenker, 2013). The clinician should then judge stuttering frequency and severity in each sample with input from the PWS and parents (if applicable). Descriptive discussion of length of stuttering moments, avoidance of words and talking, word switching, and types of stuttering with the PWS and their family will be important. The interpreter may be able to provide valuable information regarding whether words that contain reduplications of sounds or syllables were present in the sample or are common in the language. Finn and Cordes (1997) suggested that it was likely that clinicians would be able to distinguish between words that contained repetitions and stuttering.
Briefing the Interpreter on Evaluation Procedures
SLPs often use interpreters trained in the medical or law fields, and these interpreters are often not trained to work in the area of communication impairment. This can cause issues when assessing communication disorders in individuals who speak limited English. For example, a speech and language evaluations aims to understand not just the content, but also the syntax (i.e., word order), grammar, fluency, and speech intelligibility of what has been said. Interpreters in the medical field are trained to interpret for content related to the client’s health related concerns. On the other hand, SLPs must ensure that interpreters are not inadvertently invalidating the test by providing clues, prompts, or scaffolds. Having time to brief the interpreter prior to the evaluation is important to discuss the clinician’s expectations for the interpreter during the evaluation. Additionally, terms for stuttering and what is considered stuttering may vary widely between individuals and, more broadly, languages and cultures. It is important to discuss the terminology that will be utilized during the fluency evaluation with the interpreter to ensure understanding and, therefore, accurate interpretation. One of the authors recently had a family from China that described their son’s communication difficulties as stuttering. The teenager also reported that he stuttered and that he avoided talking at times and was self-conscious because of his stuttering. It was not until the author saw the child for an evaluation that it became clear that he had a significant speech sound disorder and not a fluency disorder. Utilizing examples of types of disfluencies may be helpful in describing stuttering and avoiding confusion.
In order for the interpreter to be well prepared for interpreting the evaluation, he/she needs to be informed about key assessment objectives, be familiarized with protocols and diagnostic tools, and be provided with clear directions on how to act in the clinical setting. During the briefing, the SLP should convey to the interpreter that any errors in grammar and speech sound must be relayed to the clinician. Differences in voice, fluency, and pragmatics are also helpful things for the interpreter to note. Ensure that the interpreter understands that the clinician would like him/her to feel comfortable asking for clarification whenever it would be helpful. It may be helpful to discuss with the interpreter that this particular evaluation is looking at whether the child stutters, but to keep alert about other possible coexisting communication impairments. A full stuttering evaluation looks at strengths and weaknesses in all aspects of communication to determine the impact in daily life.
Communication Tips that Lead to Successful Outcomes
To ensure the most effective communication between the clinician, the interpreter, and the client during the session, Novikoff, Porto, & Haynes (2012) suggested the following guidelines which are based on the professional code of ethics for interpreters:
- Encourage the client and family to ask for explanations and clarifications through the interpreter throughout the evaluation
- The clinician should talk directly to the client or family as if they can speak English.
- Maintain eye contact with the client and family, not the interpreter
- Speak directly to the client and family not to the interpreter (e.g., “What brought you here today?” rather than “Can you ask the client what brought him in today?”)
- Refrain from technical jargon that the client, family, and interpreter will not understand
- Provide examples as much as possible
- At the end of the session, summarize the results and recommendations
Tips on How to Prepare the Interpreters
Novikoff, Porto, & Haynes (2012) suggest that developing rapport with the interpreter is essential for a positive collaborative experience.
- Briefing the interpreter before the evaluation including going over forms and clarifying roles for during the clinical encounter
- Maintaining a professional but friendly interaction during the evaluation/session while the client is present
- Debriefing by talking about how the evaluation went, discuss any cultural or linguistic concerns that arose, review and discuss the information or data collected during the session, and confer on how to improve interpreting experiences in the future
ASHA’s Practice Portal on collaborating with interpreters suggests similar guidelines for laying the foundation for good communication during the session:
- Scheduling additional time in the session to discuss the session with the interpreter and to account for the added time needed to interpret what is said
- Verifying the cultural appropriateness of assessment and treatment materials with the interpreter
- Arranging for documents written in unfamiliar languages to be translated, to ensure that they, as clinicians, are aware of the content of the documents
We hope that these guidelines will help you to have a successful collaboration with an interpreter during a stuttering assessment. We know from personal experience that working with interpreters helps immensely to bridge language and cultural gaps. Working with an interpreter allows us to develop rapport with the client, gather authentic data, and receive verbatim translations. When you combine all these benefits, it is logical to employ the services of a qualified interpreter, in order to get an in-depth and well-balanced assessment result.
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