Childhood language disorders: Practice of Speech and Language Therapy with multilingual clients – Comparison of the service provision in Germany and the UK

Christine Lachmann, MSc

This paper is based on my own working experience as a Speech and Language Therapist (SLT) in the UK and in Germany.

I will first describe the general differences of the two SLT systems and then illustrate the practice of SLT with multilingual clients using two case studies. After the evaluation, the paper will include some suggestions for the training of SLTs and the practice with multilingual clients.

1.) Speech and Language Therapy in Germany

Speech and Language Therapy for children is generally delivered in private practices, special needs nurseries and day care centres, and at times in hospitals. Speech and Language Therapists do not work in mainstream schools and nurseries. A prescription is needed that can be obtained by a GP, a paediatrician or an ENT doctor. Paediatricians are responsible for the developmental checks and most children are sent to see a SLT between the ages of 4 to 6 years. The health insurance covers the cost of SLT up to a maximum of 60 sessions in a row, mostly delivered on an individual basis. In general, the parents do not attend the full session, but there is time for advice and/or homework at the end of each session.

2.) Speech and Language Therapy in the United Kingdom

Most of the children in the UK are seen by the National Health Service (NHS) SLT Service which is based at clinics and schools/nurseries. A referral is made by schools, nurseries, GPs, Health Visitors (HV) or the parents themselves. Most children are sent to the SLT service after developmental checks by the HV or the paediatrician; and school-aged children often get referred by the schools. In general, after an initial assessment, it is decided upon the treatment option: Group or individual therapy, parent training, advice/aims to schools/nurseries or just a follow-up assessment in 3-6 months. It is possible for the SLT to work in mainstream or special schools and link closely with the teachers. Children can also be seen in clinics during school time. The parents are attending the sessions most of the time. In general, therapy lasts about 6 weeks 1-2 weekly followed by a 3 months break and a follow-up assessment.

Speech and Language Therapy in Germany	Speech and Language Therapy in the United Kingdom
· covered by the Health Insurance · delivered in private practices and in special needs · SLTs not working in education · prescription needed by a doctor (GP, paediatrician or ENT) · up to 60 sessions in a row · parents are not attending full session	· covered by the National Health Service (NHS) · delivered in clinics and schools or nurseries · referral needed (HV, GP, school, nursery, parents) · therapy blocks of 6 weeks · parents are attending the full session

3.) Service provision for bilingual children in Germany

To demonstrate the possibilities for bilingual children to access Speech and Language Therapy in Germany, I will use a case study:

Furkan is a 4;6 year old boy of Turkish parents who has been attending a German nursery for a year. His parents are worried about his language skills because he does not speak any German yet. They also think that he speaks less Turkish than his siblings did at the same age. Therefore, they seek advice from the nursery teacher. She might recommend that the parents speak German at home to encourage and facilitate his German language development. This advice is still often given by teachers who have not received any training in bilingualism. However, it is not advisable for the parents to use another than their home language. Next, they go see their paediatrician. In Germany, the last two developmental checks are done by the paediatrician at age 4;0 and age 5;0. The doctor reassures the parents that due to the bilingual upbringing, Furkan might start speaking German a bit later. The parents are still worried though because their other children have not had these problems. But without a prescription from the doctor they cannot attend a Speech and Language Therapy Assessment. A year later, his German still being very poor, Furkan fails the school assessment and is unable to begin school at age 6. He is finally being sent to see an SLT.

Due to the poor German of both parents, the SLT has some difficulties to communicate with them and to take the case history. It is unclear whether the parents judge their son’s Turkish as age-appropriate or not. Migrant parents often try to hide language difficulties in their home language and are more concerned about German. Case history forms in various languages have been developed, but without the knowledge of the other language, they are found to be difficult to use and do not represent a big help. Sometimes relatives or friends attend the initial session to translate for the parents. However, there is a risk that the answers are biased due to the presence of the relatives.

The SLT then assesses his German language skills that are still very poor after two years of nursery. His results on standardised tests are far below his age group. Without the help of an interpreter or bilingual co-worker, the SLT cannot assess Furkans Turkish language skills but must rely on the parent’s information. Screenings have been developed with vocabulary items in various languages to assess mainly speech disorders. When used without the knowledge of the other language, there have been great difficulties due to regional variations of speech and words used.

There are no German assessments available with bilingual norms and most German standard SLT assessments poorly reflect language skills of bilingual children.

The SLT finally decides to provide some SLT sessions in German. However, this decision is not based on clear evidence. If, however, the SLT decides that he needs German lessons instead of SLT (second language acquisition difficulty), there is no service to refer the family to. There are several local initiatives that provide German classes in the nursery but this is not mandatory. The HIPPY program adapted from the States is a useful resource that helps parents and children to learn German together. Again, without a centralised service that provides the parents with all the important information, many parents do not get the help they need.

If in Furkans case, the SLT feels that he would benefit more from therapy in his mother tongue, unfortunately very few bilingual SLTs exist that speak Turkish. On the homepage of the dbl (Deutscher Bundesverband für Logopädie), parents can search for SLTs that treat in their home language. However the service is not very easy to access for parents with little German knowledge.

In Germany, SLTs are not generally trained in bilingualism since it is not a mandatory class. Unfortunately, most SLTs are monolingual and without training will not be able to judge the situation of multilingual clients sufficiently. Furthermore, most colleges do not provide training on cultural awareness which is very important when dealing with families of different cultural background.

4.) Service provision for bilingual children in the UK

A similar case study will be used to demonstrate the access of SLT in the UK:

Sandeep’s parents are speaking Punjabi at home. They started to worry about his language skills when he was two years old as he was not developing language at the same speed as his siblings. They went to see their Health visitor to discuss the issue. Most of the NHS trusts have HVs from various cultural and lingual backgrounds so often parents can access a service in their home language. The HV checks on the boy’s home language as well as his English and recommends further assessment. She refers Sandeep to the SLT service. Meanwhile, she will advise the parents on general language development and how the parents can support their son’s language skills.

The SLT department will offer an initial assessment session and is generally able to invite an interpreter for the parents if needed. With the help of the interpreter, the SLT takes the case history and advises the parents. Interpreters can also be used to assess the home language. Although not ideal, this will allow the SLT do get a clearer picture of Sandeep’s language skills in Punjabi. Some SLT services (Newham PCT e.g.) have bilingual co-workers that are trained in SLT and are able to do assessment and treatment under supervision in the home language of the client. If no bilingual co-worker or interpreter is available, the SLT will have to rely on the English language assessments. Same as in Germany, most of the assessments do not have bilingual norms and standardised assessments have to be judged with caution when used with bilingual clients in their weaker language. However, it was felt that the range of assessments available in the UK do reflect the language skills of multilingual clients better and many trusts have developed non-standardised assessment formats that seem quite accurate.

If Sandeeps language skills are judged to be sufficient in his home language, he will be transferred to the ESL service (English as a Second Language) where his family will receive further help in improving his English language skills. If however, his home language is also delayed, SLT is recommended and will be delivered either by the bilingual co-worker or by the SLT. An interpreter can be invited to the sessions in order to help the SLT to advise the parents on language development etc.

By the age of 4;6 years, Sandeep’s parents have received a parent training for early language skills via the bilingual co-worker and Sandeep has attended an early language group for six weeks. Furthermore, the SLT gave some advice and aims to the nursery teacher in order to enhance his English language skills. Sandeep was able to improve his language skills and is able to start reception class at school without any further difficulties. Since children in the UK begin school at an earlier age than in Germany, immigrant children do have a better chance to learn English and receive the help they need.

Same as in Germany, bilingualism is not a mandatory course in the training of SLT students. Many NHS trusts do have SLTs specialised on bilingualism and I personally received a cultural awareness and bilingualism training session when starting my job in Newham PCT.

When looking for a SLT working in another language than English, they can check with their local NHS SLT service or access the service of independent SLTs (ASLTIP).

SLT service provision for multilingual children in Germany	SLT service provision for multilingual children in the UK
· no possibility for the parents to attend SLT without a prescription · children are seen at a later age than in the UK · no interpreters available for the parents · no bilingual co-workers · no service for German as a second language to refer parents to	· parents can self-refer to the SLT service · children are sent earlier than in Germany · possibility to invite interpreter to SLT sessions · some trust have bilingual co-workers in the main immigrant languages · ESL service available

5.) Evaluation of the two systems

Overall the UK appears more prepared for bilingual clients and a network of support is already in place. There is still a need to recruit more bi- and multilingual SLT students from various cultural backgrounds. Clients do benefit from possibilities to receive help in their home language and a Health Visitor appears to be a good link between the NHS and the parents of different backgrounds.

The possibility to invite interpreters and/or bilingual co-workers has always been regarded as positive by the parents. Unfortunately not all the NHS trusts have bilingual co-workers. Trained in SLT by the trust, they are not only able to perform assessments in the client’s home language, but are also able to advise the SLT of cultural differences. They represent a link for the parents to access the service.

In the UK, bilingual children with speech and language difficulties are accessing the SLT service earlier than in Germany. Due to the check ups from the HV, they are generally referred earlier. Furthermore parents are able to self refer their children to the SLT service when concerned about their language development.

Since UK children attend school already at age 4, more help in learning English is provided in reception classes than in regular German nurseries. However, there are new initiatives in order to enhance language skills and phonology skills in German nurseries as well.

In Germany, Speech and Language Therapists have no possibility to access interpreters for assessment and treatment sessions.

I have still encountered many professionals working with bilingual families in Germany that recommend not speaking the family’s home language when children have speech and/or language difficulties. SLT students are still often taught that bilingualism might be a cause for SLT difficulties even though this is clearly not the case.

In the UK, it is part of the professional standards for SLTs to consider bilingualism as an advantage and to not advise clients and carers “to give up speaking in their home language as a means of supporting language progress in English” (Communicating Quality 2,p 150).

6.) Conclusion and suggestions

SLT assessment packs are needed that take into account the bilingual background. Vocabulary tests should have two sections: One that uses words that children will learn in nursery and one that contains general vocabulary items.

There is a need to recruit more SLT students from various lingual and cultural backgrounds since so far SLTs are mainly monolingual in both countries.

Bilingual co-workers or SLT assistants are a good option to be able to deliver therapy and assessments/advice to the parents in their home language.

Courses in multilingualism and cultural awareness should become mandatory during the training of SLTs.

In Germany, there is a need for a central service for immigrant children that do not need SLT but language courses. The parents need to be made aware of the possibilities.

Moreover, nursery teachers in Germany need further training in bilingualism and in enhancing language skills. This could prevent speech and language and second language acquisition difficulties.

References:

- C. Baker: The care and education of young bilinguals – An introduction for professionals; Multilingual Matters 2002

- Communicating Quality 2: Professional standards for speech and language therapists; RCSLT 1996 2^nd edition

- Deutscher Bundesverband für Logopädie (dbl): www.dbl-ev.de

- The Association of Speech and Language Therapists in Independent Practice (ASLTIP); www.helpwithtalking.com

- V. Triarchi-Herrmann: Mehrsprachige Erziehung – Wie Sie Ihr Kind fördern; Reinhardt Verlag 2003